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Removal of embedded biliary uncovered self-expandable metal stents (uSEMS) is regarded as difficult or even impossible when the duration of indwell exceeds a couple of weeks, because of the ingrowth of tissue. The presence of diffuse and severe ingrowth is the main feature limiting SEMS removal [1]. In the esophagus, placement of a self-expanding plastic stent (SEPS) inside the SEMS has been shown to induce pressure necrosis of this tissue hyperplasia, allowing subsequent removal of the stent. We applied this technique in a 58-year-old patient with a history of alcohol abuse, obstructive jaundice, and suspected malignancy, in whom an uSEMS 10 mm wide and 6 cm long (Wallflex; Boston Scientific, Natick, Massachusetts, USA) had been mistakenly inserted more than 1 year before. The patient had experienced recurrent cholangitis due to stent obstruction caused by tissue ingrowth. Stent removal was therefore considered, but was unsuccessful using conventional maneuvers. A covered SEMS (Wallflex) was then placed inside the uSEMS

Application of the “covered-stent-in-uncovered-stent” technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth