Double sigmoid colon perforation following a migrated biliary stent

Abstract

A 76-year-old woman was admitted to our hospital with abdominal pain, distension, nausea and fever. Three weeks earlier the patient was jaundiced and the medical check-up with ERCP revealed slight dilatation of the common bile duct due to an impacted stone in its distal part. The stone was extracted, and a plastic stent 10French/11cm was inserted for internal biliary drainage. The routine clinical investigations revealed diverticulosis of the colon. The patient had been scheduled for elective laparoscopic cholecystectomy and resection of the sigma. Based on that past medical history, the clinical signs and the radiological findings her current condition was diagnosed as local peritonitis due to perforated diverticulitis of the left colon. A midline laparotomy was performed. There were no signs of peritonitis in the abdomen. The gall bladder was chronically inflamed with a stone in the infundibulum. Neither stones, nor a stent were found in the common bile duct. A cholecystectomy was perfomed. The sigmoid colon was hyperaemic and edematous, with numerous small diverticula sized up to 8mm. After mobilization of the left colon, a covered double perforation on the posterior wall of the sigma was discovered. It was caused by the biliary stent, which had migrated per via naturalis and perforated the wall of the distal sigmoid colon both medially and laterally. A sigmoid colon resection with primary hand-sewn end-to-end colo-colostomy was performed. The patient is now doing well at home, after an uneventful postoperative period of 10 days at the ward. Long-term complications from biliary stents, such as migration and perforation, are uncommon but potentially life-threatening. If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications. In the absence of peritonitis a primary anastomosis is the method of choice, while in cases of contaminated peritoneal cavity and unprepared bowel, a Hartmann's procedure should be performed. With the increasing use of biliary stents, perforation of the intestine is a diagnosis to consider in anyone with acute abdominal pain and radiology demonstrating a migrated biliary stent.