KEYWORDS
Biliary stent
-
duodenal perforation
-
endoscopic retrograde cholangiopancreatography
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is widely
used as a well-established procedure for benign or malignant biliary tract obstruction.
Although the migration of plastic biliary stents has been reported, stent-induced
perforation of the intestinal wall is an uncommon complication. Computed tomography
(CT) is the diagnostic procedure of choice that locates the stent, the presence of
perforation, and other complications, and also helps in establishing the treatment
options. This report presents a rare case of migrated biliary stent where the cranial
part of the stent remained in the common bile duct (CBD) stone and the caudal part
perforated the second part of duodenum, causing a retroperitoneal abscess.
Case Report
A 64-year-old male presented with abdominal pain, vomiting, and yellow discoloration
of his eyes and urine over a week prior to presentation. He reported no significant
history of weight loss, and there was no alteration in the color of his stool. All
blood investigations were within the reference range except a serum bilirubin level
of 8 mg/dL and a serum alkaline phosphatase level of 800 U/L. Abdominal ultrasonography
(USG) revealed a CBD stone measuring 10 mm in size with multiple gallbladder stones.
Written and informed consent for ERCP was obtained after explaining possible complications
associated with ERCP such as pancreatitis, bleeding, infection, and perforation. We
performed an ERCP to remove the CBD stone. Cholangiogram revealed mild dilatation
of the CBD with a small filling defect at the lower end of CBD. We performed sphincterotomy
in this case to remove the stone. After sphincterotomy, over the guidewire, we introduced
standard ERCP balloon and passed it beyond the stone till the upper end of bile duct.
We inflated a balloon at this point and dragged it down to remove the stone. We inserted
a 10F 10-cm straight plastic stent. The stent can be avoided in this particular case,
but as the patient was not willing for post-ERCP immediate surgery on the next day,
we decided to keep the stent to prevent similar complication in the future. His serum
bilirubin level was 2.0 mg/dL at the time of discharge on the 4th postoperative day.
He required re-admission on the 8th postoperative day for severe abdominal pain and
sepsis with elevated serum pancreatic enzymes. Abdominal USG revealed moderate ascites
with pancreatic edema. CT could not be performed due to altered renal function. The
patient was diagnosed with post-ERCP pancreatitis and treated with nasojejunal tube
feeding, administration of broad-spectrum antibiotics, and percutaneous drainage of
fluid collections. On the 17th postoperative day, while his sepsis persisted, renal
function was shown to have improved. Therefore, abdominal CT was performed which showed
that the caudal end of the stent had perforated the lateral wall of the second part
of the duodenum with leakage of oral contrast into the right anterior pararenal space
[Figure 1]. Further exploration revealed the presence of an abscess in the right retroperitoneal
area and the psoas muscle, as well as an 8-mm laceration in the second part of the
duodenum with protrusion of the stent through it [Figure 2]. The stent was removed, and a 16F T-tube duodenostomy was performed, followed by
insertion of a Jackson–Pratt drain and abdominal tube drain, and a feeding jejunostomy
was constructed. The patient required 30 days of hospitalization including 7 days
in the Intensive Care Unit. He has had an uneventful course over 6-month follow-up
other than the development of an incisional hernia.
Figure: Computed tomography of the abdomen showing migration of the biliary stent causing
perforation of the second part of duodenum, with protrusion of the stent into the
right anterior pararenal space
Figure: Duodenal perforation secondary to the migrated stent through an 8-mm laceration into
the right anterior pararenal space
Discussion
Reportedly, the incidence of a perforation associated with an ERCP is <1%.[1] A perforation could occur secondary to extension of a sphincterotomy beyond the
transmural portion of the bile or pancreatic duct, or extramural passage or migration
of the guidewire or stent.[1] Risk factors for a perforation include altered surgical anatomy, an inappropriately
performed sphincterotomy, stricture dilation, and a lengthy procedure.[2] Howard et al. have classified ERCP-related perforations into three distinct varieties:
guidewire induced, peri-ampullary, and duodenal remote from the papilla.[3] Stapfer et al. have classified ERCP-related perforations into four types based on
etiology, location of the perforation, and severity of injury as follows:[4] Type I: lateral- or medial-wall duodenal perforations, Type II: peri-ampullary,
Type III: injury to the bile duct secondary to the guidewire/basket instrumentation,
and Type IV: radiological evidence of free air without any obvious perforation or
contrast extravasation.
Arhan et al. have observed that the overall migration rate for plastic stents in patients
with benign and malignant diseases is 8.58% (proximal 4.58% and distal 4.00%) and
that stent migration was more commonly associated with benign disease.[5] Although intestinal migration of biliary stents is not uncommon, stent-induced perforation
of the intestinal wall is a rare complication. Being a C-shaped structure with a fixed
retroperitoneal location, the duodenum is predisposed to higher risk of stent perforation.[6] Other conditions associated with increased risk of stent perforation are the presence
of duodenal diverticula and abdominal wall hernias.[5] This case is different in that the cranial part of the stent remained in the CBD
and the caudal part perforated the duodenum, causing complete biliary diversion into
the retroperitoneal cavity leading to retroperitoneal abscess formation. We have observed
that most reported cases of luminal perforation with biliary stents have been associated
with a straight biliary stent.[6], [7], [8], [9], [10] From the available literature, we suggest that double pigtail stents are to be used
to prevent such disastrous complication. Pigtail stents are less likely to migrate
distally. They are placed slightly differently than straight plastic stents since
duodenoscope has to be partially withdrawn during final deployment to allow the pigtail
to form in the second part of the duodenum.
Conclusion
Migration of a plastic biliary stent causing a duodenal perforation is rare. We propose
that clinicians should consider this entity among the differential diagnoses in patients
presenting with abdominal pain and sepsis after an ERCP with stent placement. This
diagnosis should be considered in those presenting with a high index of suspicion.
A suspected perforation should be investigated using a CT scan of the abdomen with
oral contrast even in cases of altered renal function.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgement
We would like to acknowledge the help provided by Dr. Sushil Dawka (professor of surgery,
Mauritius) for his kind suggestions and helps in editing the manuscript.
Financial support and sponsorship
Nil.
