3161 A Rare Cause of Duodenal Perforation From Migrated Biliary Stent Managed Endoscopically

Abstract

INTRODUCTION: Biliary stent migration is not uncommon (6-10%). A resultant duodenal perforation is however a rare complication (<1%) often associated with significant morbidity and can require surgery. Here we present a rare case of a duodenal perforation from plastic stent migration which was successfully managed endoscopically with through-the-scope (TTS) clips. CASE DESCRIPTION/METHODS: A 75 years old lady with history of painless obstructive jaundice, CT imaging with a hilar soft tissue mass and intrahepatic biliary dilation underwent endoscopic ultrasound (EUS) and endoscopic retrograde cholangiography (ERCP). A 7 Fr × 15 cm plastic biliary stent was placed into the right system after sphincterotomy and stricture dilation. The left system could not be accessed. Post procedure liver chemistries improved and she was discharged on antibiotics with close follow up. Patient developed lower abdominal pain and presented to the emergency department approximately 48 hours after ERCP. CT abdomen revealed biliary stent migration with concern for duodenal perforation and extraluminal air with heterogenous free fluid. Emergent upper endoscopy (EGD) showed migration of plastic biliary stent with distal tip protruding through the lateral wall of the second portion of the duodenum. The stent was removed using rat-tooth forceps revealing a 3 mm mucosal defect which was closed with TTS clips. Hospital course was complicated by fevers and repeat imaging showed increasing size of air and fluid collection. Repeat EGD showed a visible area of leakage on one edge of the previously repaired perforation. This was closed with hemostatic clips. Small bowel follow through studies at day 3 and 7 post procedure confirmed no contrast extravasation to suggest a persistent duodenal leak. Her diet was advanced and she was discharged with clinic follow up. DISCUSSION: Duodenal perforation from biliary stent migration is rare and limited case reports present the use of TTS clips in endoscopic management. In our patient the plastic biliary stent was endoscopically visualized protruding through the opposite wall of the duodenum while the proximal end was still in the biliary tree, likely creating enough force to cause a perforation. Although the initial attempted closure with TTS clips revealed no leakage immediately post procedurally, there was persistent leakage requiring repeat endoscopy and further clips for closure. A high morbidity surgical procedure can be avoided by this endoscopic approach even if there is a recurrence of leakage.