Usefulness of a long hood for the detection of bleeding sites in colonic diverticular hemorrhage: A randomized controlled trial.

Background and Aim: The use of a hood at the tip of a colonoscope enables aspiration, inversion of the diverticulum, and observation of the inside of the diverticulum. In most previous studies, a short hood was used; however, observation of the diverticulum is often inadequate. Long food is promising by previous research, but it was a retrospective study using propensity matching and has some limitations. We compared the identification rate of stigmata of recent hemorrhage (SRH) between the long and standard hoods in cases of suspected colonic diverticular hemorrhage (CDH) to confirm the usefulness of long hood by prospective randomized controlled trial. Methods: Eighty patients (42 in the long hood group [L group] and 38 in the short hood group [S group]) who visited the Saitama Medical University Hospital and Tokai University Hachioji Hospital between December 2018 and July 2021 with a chief complaint of bloody stool and suspected CDH, based on the clinical course and imaging studies, were included. Patients were randomly assigned to the L or S group. Results: Regarding patient background, age was significantly higher in the L group; however, no significant differences were found in medical history or history of antithrombotic medication or nonsteroidal anti-inflammatory drug use. Identification rate of SRH was significantly higher in the L group (58.5%, 24/42 patients) than in the S group (26.3%, 10/38 patients) (P < 0.05). All patients were treated using the clip method, and the rate of rebleeding within 1 month was not significantly different between the two groups. Conclusion: A long hood was more useful compared with a short hood in identifying SRH of CDH (UMIN000034603).

Hemostasis with Metallic Stent for Multiple Metastatic Pancreatic Tumors Complicated with Hemobilia.

Introduction: Hemobilia, which refers to bleeding from the bile duct, is rare and difficult to treat. We report a case of successful hemostasis of a pancreatic tumor complicated by hemobilia. Case Presentation: A 76-year-old man was referred to our hospital with a pancreatic head tumor. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography-FNA were performed, and the patient was diagnosed with pancreatic metastasis of renal cell carcinoma. After discharge, the patient noted worsening jaundice and progressive anemia and was readmitted. ERCP reveals active bleeding from the duodenal papillae. The patient was placed on a fully covered metallic stent and discharged after confirming hemostasis. Conclusion: Renal cell carcinoma is a tumor with abundant blood flow. If hemobilia occurs, bleeding from pancreatic metastatic tumors should be considered. Additionally, hemostasis using a fully covered metallic stent is useful for treating hemobilia in tumors.

The pretreatment method in marine organisms and sediment for microplastics analysis by FTIR using "Cylindrical microplastics fractionator".

For the detection of microplastics (MPs) in aquatic biota using Fourier transform infrared spectroscopy (FTIR), the ability to remove organic matter (OM) in pretreatment steps is essential to increase the time efficiency of MPs measurement and method uniformity. In principle, decreasing OM can be achieved by increasing the number of pretreatment steps. However, MPs are lost in proportion to the number of transfers between each step. Therefore, we have created a "Cylindrical MPs Fractionator" composed of commercially available materials. This container allows for a six-step pretreatment process that is designed to increase the removal capacity of OM with only one transfer to prevent the loss of MPs.•Biological or sediment samples are placed in the extractor and subjected to chemical treatment and density separation.•Residues containing MPs are obtained on filters by vacuum filtration.•After additional chemical treatment of the obtained residue, the components of the residue are identified by microscopic FTIR.This method removed 99.3% of OM and recovered 88.5% of MPs. The presenting method confirmed that this can be used with the same process for 11 organisms and sediments from estuarine ecosystem in Japan as models.

Microplastic pollution in the gastrointestinal tract of giant river catfish Sperata seenghala (Sykes, 1839) from the Meghna River, Bangladesh.

Freshwater rivers are considered the major route for microplastics (MPs), yet limited studies have been reported on MPs in freshwater river fish, especially in Bangladesh. This research reveals the intake of MPs by the giant river catfish Sperata seenghala, collected from the Meghna River, which is the only outlet of the Ganges-Brahmaputra River. Three locations, namely, Chandpur Sadar, Bhola Sadar, and Char Fasson, along the Meghna River, were selected in order to investigate the gastrointestinal tracts (GIT) of the fish. Ninety percent (n=27) of fish (n=30) were contaminated, with fragment-shaped MPs (65%) as the most abundant among the four types. A total of 179 MP particles were detected using micro-Fourier transformed infrared spectroscopy (µ-FTIR), with an average of 5.96 ± 1.32 MP particles per fish. Among the four size groups, the highest proportion of MPs (54%) occurred in the 45-100 µm group; the dominant color among the seven color groups was white (30%). The highest quantity of MPs was found in the relatively densely populated Chandpur Sadar region. Polypropylene-polyethylene copolymer (PP-PE, 23%) was proportionally dominant among the 15 types. No significant relationship was found between the total number of observed MPs and the GIT weight. This study will help us to understand MP pollution in S. seenghala that may transmit to the human body through the food chain.

Bilateral Humeral Retrotorsion Angle Measured Using an Ultrasound-Assisted Technique in Asian Baseball Players.

Background: Repetitive pitching is thought to restrict the physiological derotation process of the humeral head. Some studies have reported that side-to-side differences in the humeral retrotorsion angle (ΔHRA) occur between the ages of 9 and 11 years in baseball players. However, it remains unclear whether the ΔHRA in Asian baseball players depends on pitching skill or competitive level. Purpose: To evaluate the ΔHRA in Asian collegiate and professional baseball players and to determine the effects of pitching activity on the physiological derotation process of the humeral head. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We evaluated 128 shoulders in 64 Asian baseball players who were stratified into 4 groups as follows: 13 professional pitchers; 9 professional fielders; 8 collegiate pitchers; and 34 collegiate fielders. The throwing and nonthrowing side HRA was assessed using an ultrasound-assisted technique, and the ΔHRA was compared among the 4 groups. In addition, Pearson correlation analysis was used to assess the relationship between ΔHRA and glenohumeral range of motion, baseball starting age, and fastball velocity in pitchers. Results: The HRA was significantly greater in the throwing arm than in the nonthrowing arm in each group, with no significant differences among the groups. There was no correlation between ΔHRA and range of motion or fastball velocity. There was a significant negative correlation between baseball starting age and ΔHRA in professional fielders (r = -0.633; P = .036). Conclusion: The findings of the present study provide evidence that in Asian baseball players, the HRA was significantly greater in the throwing arm than in the nonthrowing arm. There were no clear associations between HRA and pitching ability or competitive level.

Sex reversal of pejerrey (Odontesthes bonariensis), a species with temperature-dependent sex determination, in a seminatural environment.

This study examined the changes in sex ratios and sex reversal rates in pejerrey Odontesthes bonariensis that occur with the progression of the spawning season in a seminatural setting. Four groups of hatchery-produced pejerrey larvae were stocked in floating cages in La Salada de Monasterio lake (Pampas region), a natural habitat of this species, and reared from hatching beyond gonadal sex determination with minimum human interference. Cage 1 was stocked at the beginning of the spring spawning season and the other cages were stocked with monthly delays until cage 4 in early summer. The genotypic (amhy+, XY/YY; amhy-, XX) and phenotypic (testis, male; ovary, female) sex ratios and proportions of genotype/phenotype mismatched individuals were estimated and their relation to water temperature and daylength during the experiment was analysed by generalized linear modelling. Water temperature varied between 11 and 30.5°C, and daylength duration between 11 h 22 min and 14 h 35 min. Sex genotyping revealed nearly balanced sex ratios of XY/YY (46%-49.1%) and XX (50.9%-54%) fish in cages 2-4 whereas the genotypic sex ratio in cage 1 was clearly biased towards XY/YY fish (60.6%). Phenotypic males ranged from 42% to 54.4% in cages 1-3. Cage 4, in turn, had significantly more phenotypic males (66%). The percentage of XX males (phenotypic male/genotypic female) was 23.1% in cage 1, decreased to a minimum of 5.4% in cage 2 and gradually increased in cages 3 and 4 to a maximum of 40.7% in the latter. The percentages of XY/YY females (phenotypic female/genotypic male) were highest in cage 1 (30%) and decreased progressively in the other cages to a significantly lower value (4.3%) in cage 4. These results generally support the findings of laboratory studies on the effect of temperature on the sex determination of this species and also provide novel evidence of a XX genotype-specific masculinizing effect of short daylength.

A Case of Lupus Enteritis in Which Multiple Colorectal Ulcers Were the Only Signs of Relapse.

The patient was a 62-year-old woman. She had been treated for systemic lupus erythematosus (SLE) for 15 years and had a stable clinical course with cyclosporine, prednisolone, and ticlopidine. She experienced anal pain, diarrhea, and bloody stools for four months. Colonoscopy showed scattered large and small punchedout ulcers in the colon and deep longitudinal ulcers in the sigmoid colon. Blood test results indicated low SLE activity. Culture of mucosal biopsy did not reveal any findings. Computed tomography showed intestinal membrane arteriovenous dilatation (comb sign), therefore lupus enteritis was suspected. After initiating endoxan pulse therapy, symptoms improved rapidly. Disappearance of ulcers was confirmed by endoscopic images.

Analysis of Comorbidity for Patients with Pancreatic Cysts in Medical Checkup Screening.

OBJECTIVES: We investigated whether there is a difference in the frequency of comorbidity between patients with pancreatic cysts and those without pancreatic cysts by abdominal ultrasonography in patients undergoing medical checkup screening. METHODS: The subjects were 6,627 patients who underwent abdominal ultrasonography at Tokai University Hachioji Hospital's Health Screening Center between April 2019 and March 2020. RESULTS: Of the total 6,627 patients, 158 (2.4%) were pointed out to have pancreatic cysts. Multivariate analysis revealed that the related factors were female sex, age 60 years or older, diabetes, lung cancer, and uterine/ovarian cancer. CONCLUSION: Unlike pancreatic cancer, pancreatic cysts are more common in women. In addition, it is known that pancreatic cysts have a high complication rate of cancers of other organs; lung cancer and uterine/ovarian cancer were identified as high-risk factors in this study.

Implantation of autogenous meniscal fragments wrapped with a fascia sheath induces fibrocartilage regeneration in a large meniscal defect in sheep: A histological and biomechanical study.

INTRODUCTION: Currently, various studies have been reported to regenerate the meniscus tissue in a large defect after partial meniscectomy using biological or synthetic scaffolds with or without fibrochondrocytes. However, the clinical utility of those treatments has not been established as of yet. HYPOTHESIS: Purposes of this study were to develop a sheep model to evaluate feasibility of this new surgical strategy to treat the irreparable meniscus injury, and to test the hypothesis that implantation of autogenous meniscal fragments wrapped with a fascia sheath may significantly induce fibrocartilage regeneration in a large meniscal defect in the sheep model. METHODS AND METHODS: Twenty Suffolk sheep were used. In each animal, an anterior 10-mm width of the right medial meniscus was resected. Then, the animals were divided into the following 2 groups. In Group I, the defect was enveloped with a fascia from the left thigh. In Group II, the resected meniscus fragmented into small pieces was grafted into the defect. Then the defect was enveloped with a fascia. In each group, 5 of 10 sheep were used for histological and biomechanical evaluations, respectively, at 12 weeks after surgery. RESULTS: In Group I, the defect was incompletely filled with thin fibrous tissues, while fibrocartilage tissues rarely regenerated in the tissue. In Group II, all defects were completely filled with thick fibrocartilage tissues, which were richly stained with the safranin O staining. Both the gross and histological observation score of Group II was significantly (p=0.0005, p=0.0005) greater than that of Group I. Concerning the cross-sectional area of the regenerated tissue, Group II was significantly (p=0.0002) greater than Group I. In the biomechanical evaluation, the maximal load and the linear stiffness of the meniscus-tibia complex were significantly (p=0.0015, p=0.0283) greater in Group II than in Group I. DISCUSSION: Implantation of autogenous meniscal fragments wrapped with a fascia sheath significantly induces fibrocartilage regeneration into a large meniscal defect in the sheep model. LEVEL OF EVIDENCE: Not applicable; Controlled Laboratory Study, Experimental in vivo study.

Inclusion of shape parameters increases the accuracy of 3D models for microplastics mass quantification.

As microplastics may bring about adverse effects on living organisms, it is important to establish more precise quantification approaches to better understand their dynamics. One method to determine the concentration of microplastics is to estimate their mass using three-dimensional (3D) models, but its accuracy is not well known. In this study, we evaluated the shape of the particles and verified the accuracy of a 3D model-based mass estimation using samples from a tidal flat facing Tokyo Bay. The particle shape evaluation suggested that the microplastics were flat and irregular in shape; based on these data, we created two types of models to estimate their mass. As a result, an accuracy of mass estimation by our model was higher than other models that consider the slenderness and flatness of particles. The optimization of mass estimation methods based on 3D models may improve the reliability of microplastic evaluation in monitoring studies.

Stress-Distribution Pattern Across the Glenohumeral Joint in Collegiate and Professional Baseball Players: A Computed Tomography Osteoabsorptiometry Study.

BACKGROUND: The influence of long-term loading conditions on the articular surfaces of the glenohumeral joint can be determined by measuring stress-distribution patterns. Long-term pitching activity changes the stress distribution across the glenohumeral joint surface; however, the influence of competitive level on stress-distribution patterns remains unclear. PURPOSE: To use computed tomography (CT) osteoabsorptiometry (CTOAM) to evaluate the distribution of subchondral bone density across the glenohumeral joint in collegiate and professional baseball players as well as to determine the effects of pitching activity on the articular surfaces. STUDY DESIGN: Descriptive laboratory study. METHODS: We evaluated 73 shoulders in 50 baseball players. CT imaging data were obtained from the dominant-side shoulder of 12 professional pitchers (PP group) and 15 professional fielders (PF group). CT imaging data were also obtained from both shoulders of 12 asymptomatic collegiate pitchers (CP group) and 11 collegiate fielders (CF group). The pattern of distribution of subchondral bone density across the articular surfaces of each glenohumeral joint was assessed by CTOAM. As a measure of bone density, the mean Hounsfield units (HU) were obtained for each joint surface, and the absolute values of the dominant shoulder were compared for each group. RESULTS: Stress-distribution patterns over the articular surfaces differed between the dominant and nondominant sides in the CP group as well as between both collegiate groups versus the PP group. In the CP group, the mean HU of the humeral head surface were greater on the nondominant versus dominant side (P = .035). On the dominant side, the mean HU of the humeral head surface and glenoid were greater in the CP versus the PP group (P = .001 and .027, respectively). CONCLUSION: Stress distribution on the articular surface of the glenohumeral joint was affected by pitching ability and competitive level. Our analysis indicates that the traction force on the glenohumeral joint surface might be greater than compression force during pitching. CLINICAL RELEVANCE: The present findings suggest that pitching activity results in low stress to the articular surfaces of the glenohumeral joint. This supports the notion that mechanical conditions play a crucial role in the etiology of disorders specific to pitching activity.

Intraspecific genetic variation matters when predicting seagrass distribution under climate change.

Seagrasses play a vital role in structuring coastal marine ecosystems, but their distributional range and genetic diversity have declined rapidly in recent decades. To improve conservation of seagrass species, it is important to predict how climate change may impact their ranges. Such predictions are typically made with correlative species distribution models (SDMs), which can estimate a species' potential distribution under present and future climatic scenarios given species' presence data and climatic predictor variables. However, these models are typically constructed with species-level data, and thus ignore intraspecific genetic variability, which can give rise to populations with adaptations to heterogeneous climatic conditions. Here, we explore the link between intraspecific adaptation and niche differentiation in Thalassia hemprichii, a seagrass broadly distributed in the tropical Indo-Pacific Ocean and a crucial provider of habitat for numerous marine species. By retrieving and re-analysing microsatellite data from previous studies, we delimited two distinct phylogeographical lineages within the nominal species and found an intermediate level of differentiation in their multidimensional environmental niches, suggesting the possibility for local adaptation. We then compared projections of the species' habitat suitability under climate change scenarios using species-level and lineage-level SDMs. In the Central Tropical Indo-Pacific region, models for both levels predicted considerable range contraction in the future, but the lineage-level models predicted more severe habitat loss. Importantly, the two modelling approaches predicted opposite patterns of habitat change in the Western Tropical Indo-Pacific region. Our results highlight the necessity of conserving distinct populations and genetic pools to avoid regional extinction due to climate change and have important implications for guiding future management of seagrasses.

Posterior reversible encephalopathy syndrome (PRES) caused by chemotherapy containing S-1 against diffuse type gastric cancer.

A 23-year-old woman who complained of abdominal distension and anorexia was referred to our hospital. Computed tomography showed ascites, a huge hepatic tumor and ovarian tumor. Gastroscopy revealed type 4 gastric cancer and biopsy examination showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. We diagnosed her with stage IV advanced gastric adenocarcinoma. She received the chemotherapy with S-1 and CDDP regimen. After two courses, this regimen was changed to the SOX (S-1 + OHP) regimen because of acute kidney injury. After one course of the SOX regimen, she developed general muscle cramp. Magnetic resonance imaging showed a 15 mm, round, high-intensity signal at the parietal lobe on T2-weighted images. She was hospitalized for with the suspicion of brain metastasis. Anticonvulsants improved her muscle cramp, but she had consciousness disturbance on the 9th hospital day. T2WI showed high-intensity signals within the cerebral white matter at both sides of the occipital lobe. We suspected leukoencephalopathy caused by S-1 and discontinued the SOX regimen. We also treated her hypertension and hyponatremia. Her consciousness disturbance improved in several days, and the T2WI finding was markedly improved on the 20th hospital day. We diagnosed her with posterior reversible encephalopathy syndrome caused by chemotherapy containing S-1.

Phenotypic/genotypic sex mismatches and temperature-dependent sex determination in a wild population of an Old World atherinid, the cobaltcap silverside Hypoatherina tsurugae.

Several New World atheriniforms have been recognized as temperature-dependent sex determined (TSD) and yet possess a genotypic sex determinant (amhy) which is primarily functional at mid-range temperatures. In contrast, little is known about the sex determination in Old World atheriniforms, even though such knowledge is crucial to understand the evolution of sex determination mechanisms in fishes and to model the effects of global warming and climate change on their populations. This study examined the effects of water temperature on sex determination of an Old World atheriniform, the cobaltcap silverside Hypoatherina tsurugae, in which we recently described an amhy homologue. We first assessed the occurrence of phenotypic/genotypic sex mismatches in wild specimens from Tokyo Bay for three years (2014-2016) and used otolith analysis to estimate their birth dates and approximate thermal history during the presumptive period of sex determination. Phenotypic sex ratios became progressively biased towards males (47.3%-78.2%) during the period and were associated with year-to-year increases in the frequency of XX-males (7.3%-52.0%) and decreases in XY/YY-females (14.5%-0%). The breeding season had similar length but was delayed by about 1 month per year between 2014 and 2016, causing larvae to experience higher temperatures during the period of sex determination from year to year. Larval rearing experiments confirmed increased likelihood of feminization and masculinization at low and high temperatures, respectively. The results suggest that cobaltcap silverside has TSD, or more specifically the coexistence of genotypic and environmental sex determinants, and that it affects sex ratios in wild populations.

Crowding stress during the period of sex determination causes masculinization in pejerrey Odontesthes bonariensis, a fish with temperature-dependent sex determination.

The pejerrey is an atherinopsid species from South America that presents a combination of genotypic and environmental (temperature-dependent) sex determination whereby low and high temperatures induce feminization and masculinization, respectively. Masculinization involves a heat-induced stress response leading to increased circulating cortisol and androgens. We tested whether crowding would elicit a similar response as high temperature and affect the sex ratios of pejerrey. Larvae with XX and XY genotypes were reared at 15, 62 and 250 larvae/L in 0.4, 1.6, and 6.4 L containers during a period considered critical for sex determination at 25 °C, a mixed-sex promoting temperature. Fish were analysed at 3-7 weeks for whole-body cortisol and 11-ketotestosterone (11-KT) titer and hydroxy-steroid dehydrogenase (hsd11b2) mRNA transcript abundance, and after completion of gonadal sex differentiation (10-14 weeks) for determination of phenotypic and genotypic sex mismatches. Crowding was associated with depressed growth, higher cortisol and 11-KT titers, increased hsd11b2 transcription, and increased frequency of masculinization compared to intermediate and/or low rearing densities. Perceived crowding (by rearing in containers with mirror-finish, reflecting walls) also caused masculinization. These results suggest the possibility that other environmental factors besides temperature can also affect sex determination in pejerrey and that a stress response leading to increased cortisol and androgen levels, which is potentially perceived by the brain, may be a common feature among different forms of environmental sex determination in this species.

To invade or not to invade? Exploring the niche-based processes underlying the failure of a biological invasion using the invasive Chinese mitten crab.

Invasive alien species represent a serious threat to global biodiversity, causing considerable damage to native ecosystems. To better assess invasion risks, it is essential to better understand the biological processes that determine the success or failure of invasions. The catadromous Chinese mitten crab Eriocheir sinensis, whose native distribution is the Pacific Coast of China and Korea, has successfully invaded and established populations in North America and Europe. In Japan, where E. sinensis is also regarded as potentially invasive and multiple introduction vectors exist, the species is not yet established. These settings can be used to explore niche-based processes underlying the apparent failure of a biological invasion. We first quantified native and invasive realized niches of E. sinensis in freshwater habitats using geometrical n-dimensional hypervolumes. Based on the assumption of niche conservatism, we then projected habitat suitability of this species in Japan using species distribution models (SDMs) calibrated with distinct sets of distribution data: native occurrences, invasive occurrences, and both. Results showed that E. sinensis has undergone either niche shifts or niche contractions during invasions in different areas of the world. Projections from SDMs indicate that although part of Japan is suitable for E. sinensis, this does not include the freshwater habitats around the Ariake Sea, which is considered to be a suitable marine environment for E. sinensis larvae. The mismatch between suitable freshwater and marine environments provides a possible explanation for the failure of establishment of E. sinensis in Japan to date. Our findings have useful general implications for the interpretation of biological invasions.

Eosinophilic Cholecystitis Associated with Eosinophilic Granulomatosis with Polyangiitis.

We report a case of eosinophilic cholecystitis associated with eosinophilic granulomatosis with polyangiitis (EGPA) complicated by cerebral hemorrhage. A 60-year-old man presented to a local hospital with a diagnosis of acute cholecystitis, with persistent fever and epigastric pain for 2 weeks. His symptoms persisted despite 3-week hospitalization; therefore, he was transferred to our hospital for further evaluation. Laboratory investigations upon admission showed white blood cells 26,300/µL and significant eosinophilia (eosinophils 61%). Abdominal computed tomography revealed no gallbladder enlargement but a circumferentially edematous gallbladder wall. Additional blood test results were negative for antineutrophil cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies; however, immunoglobulin (Ig)G and IgE levels were high at 1,953 mg/dL and 3,040/IU/mL, respectively. He improved following endoscopic transnasal gallbladder drainage for cholecystitis and was diagnosed with EGPA and received corticosteroid and immunosuppressant combination therapy. The eosinophil count decreased immediately after treatment, and abdominal pain and numbness resolved. He returned with left-sided suboccipital hemorrhage likely attributed to EGPA 6 months after discharge. EGPA is characterized by inflammation of small blood vessels and clinically manifests with an allergic presentation of bronchial asthma, as well as renal dysfunction, interstitial pneumonia, enteritis, and cerebral hemorrhage. Few reports have described cholecystitis as a presenting symptom of EGPA. We report a rare case of such a presentation with added considerations.

A Case of Endoscopic Mucosal Resection of Carcinoma in Adenoma at the Minor Duodenal Papilla.

Here, we describe a case of minor papillary adenocarcinoma in adenoma that was treated with endoscopic mucosal resection (EMR). In a 67-year-old woman, sigmoid colon cancer was incidentally detected on preoperative upper gastrointestinal endoscopy. Endoscopy revealed a slightly elevated lesion at the minor duodenal papilla. The findings of a histopathologic examination were suggestive of adenocarcinoma. Computed tomography and magnetic resonance images identified a minute tumor, whereas endoscopic ultrasonography revealed that the tumor did not spread to the pancreas. We performed EMR of this lesion. There were no complications, and relapse has not occurred in 3 years. Cases of minor papillary adenocarcinoma treated with EMR are quite rare.

Successful Endoscopic Removal of a Biliary Stent with Stent-Stone Complex after Long-Term Migration.

A 49-year-old man was referred to our hospital for an abnormality of the hepatobiliary enzyme. The patient was diagnosed with primary sclerosing cholangitis 9 years ago, and he had a biliary stent with a string placed as an inside stent. We attempted to remove the stent 6 months later, but the string was cut off, so the stent could not be removed. Removal was attempted again, but the patient cancelled the outpatient appointments. During the examination performed at the present visit, we discovered that the biliary stent had migrated into the bile duct, and a stone had formed around the stent. We attempted to remove the stent-stone complex by endoscopic retrograde cholangiopancreatography, but it was difficult; thus, we decided to implant a new biliary stent and remove the other stent later. When we performed endoscopic retrograde cholangiopancreatography again 2 days later, the bile duct axis was linearized thanks to the additional stent, enabling us to grab the migrated stent with stent-stone complex using grasping forceps and to successfully pull it out. By implanting an additional plastic stent temporarily, we were able to straighten the biliary axis and endoscopically remove the biliary stent that migrated and caused the development of stent-stone complex in a 2-staged approach.