Holmium:yttrium–aluminum–garnet laser–assisted retrieval of an embedded fully covered self-expandable metallic stent for benign biliary strictures

Acronyms and abbreviations BBS: Benign biliary strictures FCSEMS: Fully covered self-expandable metallic stents POCS: Peroral cholangioscopy Ho:YAG: Holmium:yttrium-aluminum-garnet Benign biliary strictures (BBSs) are commonly encountered after hepatobiliary surgery and require endoscopic stent placement. Fully covered self-expandable metallic stents (FCSEMSs) are increasingly used for this indication.[ 1​ ] However, FCSEMSs may become embedded in the bile duct wall, particularly after prolonged placement or disruption of the covering membrane. In such cases, stent removal can be extremely challenging. The holmium:yttrium–aluminum–garnet (Ho:YAG) laser is effective for lithotripsy of pancreaticobiliary stones and tissue ablation.[ 2​ ] We report a case in which peroral cholangioscopy (POCS)-guided Ho:YAG laser ablation enabled the removal of an embedded FCSEMS. A 48-year-old man underwent right hepatectomy for hepatocellular carcinoma and subsequently developed a postoperative BBS. An FCSEMS was placed to treat the BBS. Six months later, FCSEMS removal was attempted but was unsuccessful because of severe epithelial hyperplasia and partial stent embedding ([ Fig. 1 ]). Because repeated plastic stent exchange every 3–4 months was required to maintain biliary drainage, we decided to attempt the removal of the embedded FCSEMS using laser ablation ([ Video 1 ]). Fig. 1 The fully covered self-expandable metallic stent (FCSEMS) caused focal biliary narrowing, with no passage of contrast medium. Video 1 An embedded fully covered self-expandable metallic stent was successfully removed using peroral cholangioscopy-guided holmium:yttrium–aluminum–garnet laser ablation and lithotripsy. Download Video After biliary cannulation, a guidewire was advanced to the distal end of the stent. A POCS system (SpyGlass DS II; Boston Scientific, Marlborough, MA, USA) was inserted and revealed that epithelial hyperplasia had buried the stent. Ho:YAG laser ablation was then performed using a laser system (Litho EVO; EDAP TMS S.A., Vaulx-en-Velin, France) to dissect and ablate the ingrown hyperplastic tissue and expose the FCSEMS wires ([ Fig. 2 ]). The exposed metal mesh was fragmented using the laser and removed with forceps under direct POCS visualization. Fig. 2 Peroral cholangioscopy-guided holmium:yttrium–aluminum–garnet laser lithotripsy was used to fragment the FCSEMS. The BBS was recanalized after complete stent removal, which was achieved over three sessions without procedure-related adverse events ([ Fig. 3 ]). This technique may represent an effective salvage option for recanalizing the BBS and retrieving the embedded FCSEMS. Fig. 3 The FCSEMS was removed, and good contrast flow through the bile duct was observed. Endoscopy_UCTN_Code_TTT_1AR_2AL Publication History Received: 24 May 2026 Accepted after revision: 10 June 2026 Article published online: 08 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany