1425 A Stent Long-Forgotten: Obstructive Jaundice and Acute Cholangitis Due to Migrated Biliary Stent

Abstract

INTRODUCTION: Long-term biliary stenting may be beneficial in high risk elderly patients or patients with multiple comorbidities with irretrievable CBD stones. However, the rate of complications increases with the longer duration that the stent has been placed and replacement or removal of biliary stents are recommended after 3-6 months. Little information exists on consequence of long-term biliary stents and management of its complications. CASE DESCRIPTION/METHODS: A 73-year-old Pakistani female with chief complaint of worsening right upper quadrant pain for 3 days, jaundice and intermittent fevers. Patient had a complex medical and surgical history of necrotizing gallstone pancreatitis complicated by bowel perforation status post partial pancreatectomy, common biliary duct stent placement and right-sided colectomy in 2009. Computed tomography revealed a dilated gallbladder with cholecystocutaneous fistula and dilated common bile duct and prior CBD stent which was migrated in the distal CBD. External drainage was performed by Interventional Radiology, followed by ERCP with the cholangiogram revealing choledocholithiasis and the migrated CBD stent lodged in common bile duct and common hepatic duct. Significant opacity was also noted suggesting that the stent was enclosed and cemented within the biliary duct. A few biliary sweeps with inflated balloon catheter to retrieve the migrated stent was attempted without success. Patient was then subsequently transferred to a tertiary facility for advanced endoscopic intervention with successful retrieval of the migrated biliary stent and various advanced endoscopic techniques with placement of metallic stent and nasobiliary drainage. DISCUSSION: Endoscopic management should be the primary management option prior to surgery, especially in those patients with significant comorbidities unfit for surgery. In our patient the ERCP was technically difficult and complex due to a large amount of stone burden in the setting of an up-migrated lodged stent placed 10 years ago within the bile duct. Multiple tools and interventions including biopsy forceps, adult and pediatric raptor forceps, web baskets, extraction balloons, cholangioscope, and electrohydraulic lithotripsy, metal stent placement and nasobiliary drainage. This specific case adds to current literature the various advanced endoscopic techniques that can be used in management of complications which can occur with biliary stenting.