Side-by-side plastic stent insertion for refractory post-endoscopic sphincterotomy bleeding after covered metal stent placement

Post-endoscopic sphincterotomy (ES) bleeding is a common adverse event following endoscopic retrograde cholangiopancreatography (ERCP [ 1 ]). The placement of a covered self-expandable metal stent (CSEMS) has been reported as an effective rescue hemostatic technique by providing mechanical compression at the duodenal papilla [ 2 ] [ 3 ]. However, bleeding can occasionally persist despite the CSEMS placement [ 4 ] [ 5 ]. Herein, we report a novel rescue hemostatic method for such challenging cases ([ Video 1 ]). Download Video Rescue hemostasis with side-by-side plastic stent insertion for post-endoscopic sphincterotomy bleeding refractory to covered metal stent placement.Video 1 An 86-year-old woman with a history of Billroth I reconstruction underwent ERCP for distal biliary obstruction. After cholangiography, ES was performed ([ Fig. 1 ]), and continuous bleeding from the duodenal papilla occurred thereafter ([ Fig. 2 ] a ). Initial endoscopic hemostasis using a balloon tamponade and hemostatic gel failed. A 5-Fr pancreatic plastic stent was placed to prevent post-ERCP pancreatitis, followed by deployment of a CSEMS (HANAROSTENT, 10 mm × 10 cm; M.I. Tech Co., Seoul, Korea). However, profuse bleeding persisted, and the source was unclear ([ Fig. 2 ] b ). Subsequently, a 7-Fr plastic stent (ADFlap Stent, 14 cm; SILUX, Saitama, Japan) was inserted side-by-side with the CSEMS, providing additional compression to the duodenal papilla and achieving hemostasis ([ Fig. 3 ]). No rebleeding or adverse events occurred. Fig. 1 Endoscopic images before endoscopic sphincterotomy. a The duodenal papilla before endoscopic sphincterotomy. b Sphincterotome positioned at the papillary orifice just before incision. Fig. 2 Endoscopic images after endoscopic sphincterotomy. a Active bleeding from the duodenal papilla after endoscopic sphincterotomy. b Persistent bleeding despite the placement of a covered self-expandable metal stent. Fig. 3 Endoscopic images after additional plastic stent placement. a An endoscopic view showing the side-by-side placement of a plastic stent (arrow) beside the covered self-expandable metal stent, following the placement of a pancreatic plastic stent (arrowhead). b Hemostasis achieved after additional plastic stent placement. In this case, the additional plastic stent was positioned on the anal side of the CSEMS, opposite to the sphincterotomy incision ([ Fig. 4 ]). This likely altered the angle and tension of the CSEMS, enhancing direct mechanical compression at the bleeding site. This simple modification may serve as a practical rescue technique when the CSEMS placement alone is insufficient, expanding its hemostatic potential in challenging post-ES bleeding. Fig. 4 A fluoroscopic image after the procedure. A fluoroscopic view showing the side-by-side placement of covered self-expandable metal and plastic stents. Endoscopy_UCTN_Code_CPL_1AK_2AC Publication History Article published online: 09 February 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