Biliary Stent Migration Causing Duodenal Perforation: An Uncommon Complication of a Common Procedure

Abstract

Therapeutic endoscopy has advanced substantially and biliary stenting is considered to be a relatively safe procedure. We present a rare case of duodenal perforation with a migrated plastic biliary stent. A 79 y.o. male with history of CAD, type 2DM and RA treated with Methotrexate and Etanercept referred by rheumatologist for elevated liver enzymes. Upon presentation patient denied any complaint. Initial work up revealed Alb 3.5, AST 240, ALT 768, Alk ph. 549, total bilirubin 5.3. U/S abdomen showed markedly distended GB with mildly distended CBD. Upper EUS and ERCP showed Dilated GB with impacted stone compressing the CBD (Mirizzi syndrome). A 10 F x9 cm plastic stent was deployed successfully in the CBD. Eventually, patient underwent open cholecystectomy. Few days later, patient start developing sepsis with signs consistent with peritonitis requiring ICU level of care. Repeat CT abdomen with contrast revealed stent migration through duodenal wall with retroperitoneal abscess formation. Subsequent EGD confirmed the plastic stent migration through the duodenal wall resulting a 5 mm perforation in the opposite wall of the duodenum causing retroperitoneal abscess. The stent was removed and three hemoclips were applied to close the perforation. IR guided abscess drainage was done later. Upper GI series and HIDA scan were negative for signs of extravasation and bile leak. However, it shows absent excretion of material by the liver. Patient underwent repeat ERCP with a new stent to the CBD was done successfully. Discussion: ERCP is a procedure used to manage a variety of pancreaticobiliary disorders and it is usually very effective and safe and has a clear advantage over surgical intervention. In a retrospective review of 12,427 patients undergoing ERCP, 75 (0.6%) had perforation. The most common causes were guidewire manipulation (32%), sphincterotomy (15%), endoscope manipulation (11%), cannulation (11%), stent placement (9%), or stricture dilation (7%). In 15% of patients, the exact cause for perforation was unknown. This case represents a rare situation in which the perforation was secondary to the migrating plastic stent few days after the procedure in the opposite side of the duodenum in absence of precipitating factors. The patient was treated with a combination of endoscopic removal of the stent with clipping of the perforation and IR guided abscess drainage.2124_A Figure 1. Migrated stent penetrating the duodenal wall2124_B Figure 2. Duodenal wall perforation after removing the stent2124_C Figure 3. Clipping the perforation with Hemoclips