A Tale of a 4-year-old Biliary Stent: Lessons to Learn

Abstract

FigureComplications associated with biliary stents are rare and include stent occlusion, stent migration and cholangitis. Despite the high success rate, limited data is available about their long term complications. We report the case of a 47 y.o. woman presenting with biliary colic secondary to an impacted forgotten BS. Only few cases were reported in the English literature where biliary duct obstruction resulted from forgotten BSs that promoted the formation of new bile stones. A 47 y.o. woman presented for 2 week history of postprandial right upper quadrant abdominal pain that radiated to her back. Medical history was significant for a benign common bile duct (CBD) stricture that was treated with balloon dilatation and a 10 Fr x 7.5 cm CBD stent placement 53 months ago. The patient was asymptomatic since and never followed up. Laboratory tests showed cholestasis. A contrast abdominal Magnetic Resonance Imaging showed central intrahepatic and CBD dilatation up to 1.2 cm. Attempts to remove the old BS were unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a non mobile filling defect consistent with small stones causing moderate distal CBD obstruction. The retained BS appeared to be embedded in the filling defect. A new 7FR x 12cm BS was placed. Another ERCP was performed. A 6mm x 4cm biliary balloon was used to dilate the CBD under fluoroscopic guidance. After dilation, the retained BS was successfully removed with a snare. Small stone fragments and gravel were also removed by a wire guided biliary basket. Spyglass cholangioscopy demonstrated large solid casting of stones in the CBD where the distal end of the old stent resided. A wireguided 10Fr x 10cm plastic BS was placed to facilitate biliary drainage. The remaining stones were removed with electrodynamic lithotripsy in 2 sessions. The ultimate goal of biliary endoprosthesis is the prevention of cholangitis through the maintenance of an uninterrupted biliary flow. However patients usually fail to follow up view the resolution of their symptoms. The most feared complication of retained biliary stents remains cholangitis therefore plastic stents need to be removed or replaced every 3-6 months to prevent flow disruption and superimposed bacterial infection. Management of retained stents includes endoscopic stent retrieval, especially in uncomplicated cases However in case of stent impaction and development of large stentolith, surgical intervention may be the only therapeutic choice.