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DOI: 10.1055/s-0034-1365790
Duodenal perforation as a consequence of biliary stent migration can occur regardless of stent type or duration
Publication History
Publication Date:
06 June 2014 (online)
Biliary stents are the preferred method of managing malignant and benign biliary obstruction [1]. However, they are not without potential complications, including occlusion, migration, and intestinal perforation [1]. We report two cases of duodenal perforation as a result of migration of metal and plastic biliary stents.
A 70-year-old man with biliary obstruction secondary to an adenocarcinoma of the pancreatic head and gastric outlet obstruction that prevented transpapillary biliary access underwent antegrade placement of a 6-cm fully covered metal biliary stent (Wallflex 10 mm × 60 mm; Boston Scientific, Natick, Massachusetts, USA) using an endoscopic ultrasound (EUS)-guided antegrade technique ([Fig. 1]).
He presented 3 months later with diabetic ketoacidosis. An abdominal computed tomography (CT) scan revealed evidence of a mild pneumoperitoneum ([Fig. 2]). An exploratory laparotomy identified an intraperitoneal perforation of the third portion of the duodenum. The stent was removed, gastrointestinal flow was diverted with an antrectomy and gastrojejunostomy, and a percutaneous biliary tube was inserted for biliary diversion. Following this, the patient recovered and he was discharged after 7 days.
A 67-year-old man underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and insertion of a 10-Fr × 12-cm straight plastic biliary stent (Cotton-Leung; Wilson-Cook, Winston-Salem, North Carolina, USA) for management of an anastomotic biliary stricture ([Fig. 3]) after an orthotopic liver transplant.
The patient presented 1 week after the ERCP with fevers and elevated values on liver function testing. A CT scan revealed signs of a sealed perforation in the second portion of the duodenum ([Fig. 4]). An intraoperative ERCP was performed ([Fig. 5]), followed by an exploratory laparotomy with repair of the duodenal perforation with a Graham patch and a jejunal serosal patch. A percutaneous biliary drain was inserted. The patient died 4 weeks later because of sepsis and multiorgan failure.
Migration of biliary stents, whether metal or plastic, has been reported to occur in 8 % – 10 % of cases; however, subsequent perforation is a rare event [2]. Notably, patients can present with nonspecific symptoms; therefore, a high index of suspicion for perforation should be maintained when evaluating these patients, irrespective of the duration of the stent placement [3] [4]. Our two cases demonstrate that duodenal perforation can occur in both benign and malignant settings, regardless of the type of stent or its length of time in place.
Endoscopy_UCTN_Code_CPL_1AL_2AD
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References
- 1 Issa H, Nahawi M, Bseiso B et al. Migration of a biliary stent causing duodenal perforation and biliary peritonitis. World J Gastrointest Endosc 2013; 5: 523-526
- 2 Cerisoli C, Diez J, Gimenez M et al. Implantation of migrated biliary stents in the digestive tract. HPB (Oxford) 2003; 5: 180-182
- 3 Bharathi RS, Rao PP, Ghosh K. Intra-peritoneal duodenal perforation caused by delayed migration of endobiliary stent: A case report. Int J Surg 2008; 6: 478-480
- 4 Miller G, Yim D, Macari M et al. Retroperitoneal perforation of the duodenum from biliary stent erosion. Curr Surg 2005; 62: 512-515