Long Biliary Stent Causing Sigmoid Colon Perforation

Abstract

Distal biliary stent migration occurs in 5–10% of the cases; usually, the stent passes spontaneously through the rectum. Cholangitis, perforation, obstruction, and fistula formation are the reported complications. In our patient, biliary stent migration resulted in sigmoid colon perforation. We describe the clinical presentation, associated risk factors for colon perforation and review the published literature. Case report: 70-Year-old male with Hepatitis C, Childs classA cirrhosis and unresectable hepatocellular carcinoma was referred for ERCP and stenting of segmental biliary obstruction caused by the tumor. Radio frequency ablation (RFA) was planned later in the week, but it was thought that the segmental biliary obstruction should be drained to prevent cholangitis after RFA. He has past history of open cholecystectomy 38 years ago, sigmoid diverticulosis and left inguinal hernia repair. Patient underwent ERCP and stent placement across the area of obstruction in the left intrahepatic ductal system. A10-Fr and 15 cm plastic biliary stent with a single external flap and single internal flap was inserted uneventfully. 2 days after the stent placement, patient underwent RFA. 10 days later patient presented to the ER with worsening abdomen pain for 6 days and with signs of peritonitis. CT scan revealed free air in the abdomen, sigmoid diverticulae and a migrated stent in the abdomen outside the lumen of the sigmoid colon. Patient underwent laparotomy, which revealed ascites with fecal staining, a sigmoid resection with colostomy and peritoneal toilet was performed. The stent was found to be floating freely in the peritoneum and was removed. The patient's postoperative course was complicated by hypotension, respiratory failure, renal failure, and sepsis. Despite aggressive therapy he did not improve and was made comfort measures. Patient died on post operative day 8. Conclusion: Although rare, intestinal perforation should be considered in patients presenting with acute abdomen and radiology findings confirming stent migration. In our review of literature, most of colon perforations occurred between 1–3 weeks after the biliary stent placement. Straight stents, papillary stenosis, adhesions, diverticular disease, colonic strictures and hernias were associated conditions. Our case illustrates the point that long (>7 cm) straight biliary stents may not spontaneously pass with feces should they become dislodged and double pigtail biliary stents should be considered to minimize the risk of perforation.