Asymptomatic duodenal perforation from obstructed and migrated biliary stent

Endoscopic biliary stenting has become a principal management option in the treatment of pancreaticobiliary disease. Long-term complications include occlusion, migration, and dislocation [1] [2] [3]. Duodenal perforations caused during stent migration are rare but life-threatening [4], with complications including peritonitis, sepsis, retroperitoneal abscess, and duodenal fistulization [4] [5]. This report describes an asymptomatic case of duodenal perforation caused by distal stent migration and successful retrieval of the migrated stent using an endoscope.

A 70-year-old man with a short history of jaundice underwent placement of an 8.5-Fr biliary stent for drainage at a local hospital. Meanwhile cholangiography disclosed evidence of hepatic portal filling defects. Several days later he underwent laparotomy, during which the biliary stent was neither found nor extracted. Frozen section detection did not show malignant tumor cell. Cholecystectomy was then performed, and a T-tube was placed in the common bile duct (CBD). The patient made a good recovery. Twenty days later, T-tube tract cholangiography and computed tomography (CT) scan revealed the distal end of the biliary stent located 10 mm into the duodenal lumen ([Fig. 1]).

Fig. 1 T-tube tract cholangiography revealed the distal end of the biliary stent located 10 mm into the duodenal lumen.

This patient presented without any symptoms of stent perforation or gallstones during a 2-year period. More recently, he was admitted to our department to determine whether or not the stent had migrated.

Under endoscopy, the distal part of the stent was found to penetrate the contralateral bowel wall of the duodenal papilla ([Fig. 2]).

Fig. 2 The distal part of the stent was found to protrude through the contralateral bowel wall of the duodenal papilla.

The proximal stent was in the CBD. The stent was retrieved using a rat tooth grasping forceps and found to be obstructed. The perforation wound was clamped with a hemostatic clip ([Fig. 3] [Fig. 4] [Fig. 5]).

Fig. 3 The stent was retrieved using a rat tooth grasping forceps.

Fig. 4 The plastic stent was found to be obstructed.

Fig. 5 The perforation wound was clamped with a hemostatic clip.

Cholangiography disclosed severe filling defects in the CBD ([Fig. 6]).

Fig. 6 Cholangiography disclosed severe filling defects in the common bile duct.

The stones were retrieved with a wire-guided basket.

In this case, the stent was obstructed before migration, so the bile could not evacuate to the abdominal cavity. This might explain why the patient was without symptoms after stent migration resulted in perforation. This novel consequence suggests that regular follow-up and CT scans are needed for asymptomatic patients with biliary stenting.

Endoscopy_UCTN_Code_CPL_1AK_2AD

References

• 1 Libby E D, Leung J W. Prevention of biliary stent clogging: a clinical review.  Am J Gastroenterol. 1996;  91 1301-1308
• 2 Arhan M, Odemiş B, Parlak E et al. Migration of biliary plastic stents: experience of a tertiary center.  Surg Endosc. 2009;  23 769-775
• 3 Storkson R H, Edwin B, Reiertsen O et al. Gut perforation caused by biliary endoprosthesis.  Endoscopy. 2000;  32 87-89
• 4 Saranga B R, Rao P, Ghosh K. Iatrogenic duodenal perforations caused by endoscopic biliary stenting and stent migration: an update.  Endoscopy. 2006;  38 1271-1274
• 5 Basile A, Macri A, Lamberto S et al. Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent.  Gastrointest Endosc. 2003;  57 136-138