Augmentation of immunosuppression using steroids is dictated by clinical, biochemical and histological severity of AR and represents the main way of treatment. “
“Endoscopic intervention with metallic biliary stenting is increasingly being performed for the management of variety of pancreatic and hepatobiliary disorders. A rare complication of metallic biliary stent insertion is stent embedment. Although a recognized complication, there is limited literature available addressing the treatment

of this complication. This report demonstrates the effectiveness of a “stent-in-stent” technique to remove an embedded biliary metal stents. A 50-year-old man with chronic alcoholism presented with biliary obstruction related to a chronic pancreatitis and a benign biliary stricture. The initial ERCP (Endoscopic Retrograde Cholangio Pancreatography) showed a 5 mm benign biliary stricture that was treated with sequential insertion of plastic buy PD98059 biliary stents. Despite two attempts with plastic stents, the stricture did not improve radiologically. The patient was subsequently treated by insertion of a self-expanding covered metal stent (WallFlex Biliary RX Fully Covered 10 mm × 60 mm, Boston Scientific,

Natural Product Library high throughput Marlborough, MA, USA). Post-procedure the patient was lost to follow up but re-presented 14 months following the metal stent insertion with cholangitis. Repeat ERCP showed a blocked stent with complete embedment of the distal end due to in-growth of epithelial tissue (Fig. 1a). Stent removal was not possible despite vigorous attempts including the use of Jumbo forceps to remove epithelial in-growth. A new self-expanding covered metal stent (WallFlex

Biliary RX Fully Covered 10 mm × 60 mm, Boston Scientific) was inserted within the embedded stent to induce pressure necrosis of ingrown epithelial tissue (Fig. 1b,c). Repeat ERCP was performed 2 weeks later. At this procedure, the recently inserted inner stent was removed without difficulty and the outer embedded stent could now be removed with minimal resistance. Post-ERCP cholangiogram showed resolution of the stricture. The Carbachol patient has remained asymptomatic post-procedure during 6 months during outpatient follow up. Self-expanding metal stents are safe devices for patients with obstructive jaundice secondary to benign as well as malignant biliary strictures. With their large and prolonged patent lumen, they have superior drainage capacity relative to plastic stents. Despite the good safety profile of fully covered self-expanding covered metal stents, serious complications such as stent embedment may occur, particularly if they are left in for prolonged time periods. The majority of embedded metal stent removal techniques involve mechanical modalities using accessories such as grasping Dormia baskets, forceps and snares as well as YAG laser (Neodymium-doped yttrium aluminum garnet). Most these mechanical techniques carry potential risks of perforation and bleeding.