Successful Nonoperative Management of a Sigmoid Colon Perforation Caused by a Migrated Biliary Stent

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CASE REPORT Endoscopic biliary stents have been routinely used for the treatment of various hepatobiliary diseases. Complications from biliary stent placement may include cholangitis, bleeding, stent migration, or perforation. A 94-year-old woman with a history of gallstones presented with nausea, vomiting, and abdominal pain for 1 day with markedly elevated liver enzymes. Magnetic resonance cholangiopancreatography was consistent with choledocholithiasis and biliary duct dilation. The patient underwent an uneventful endoscopic retrograde cholangiopancreatography for sphincterotomy, stone extraction, and 10 F × 7 cm common bile duct (CBD) stent placement. Repeat endoscopic retrograde cholangiopancreatography for CBD stent retrieval failed to identify the previously placed CBD stent. A computed tomography scan revealed that the stent perforated the lateral wall of the sigmoid colon. Emergent flexible sigmoidoscopy was undertaken. Endoscopically, the distal edge of the stent seemed to have perforated the sigmoid colon, as evidenced by nonvisible flanges (Figure 1). The flanges on the proximal edge were seen but seemed to have caused mild mucosal injury. The stent was retrieved endoscopically in its entirety. An over-the-scope clip was attempted for both defects; however, the proximal site injury was significantly fibrotic, which instead required 8 through-the-scope clips to ensure a high degree of closure in this elderly patient to avoid the need for surgical intervention. An over-the-scope clip at the distal injury site was successfully placed. Postendoscopic contrast examination did not show any extravasation (Figure 1). The patient was treated with empiric antibiotics and discharged the following day in stable condition.Figure 1.: Flexible sigmoidoscopy showed the stent had perforated the sigmoid colon (a). After successful retrieval of the stent (b), an over-the-scope clip was placed at the distal injury site (c). Postendoscopic contract examination showed no extravasation.Bowel injury is a rare complication of biliary stent placement occurring in less than 1% of migrated stents. Stent migration should be suspected when a previously placed stent is not identified on endoscopic examination, and a cross-sectional imaging should be promptly ordered for investigation. Multidisciplinary evaluation including surgical consultation should be pursued, yet situational awareness is critical. In select situations, endoscopic clip closure may resolve colonic perforation. Flexible sigmoidoscopy stent retreival and endocopic clip closure. Watch the video at https://links.lww.com/ACGCR/A33 and https://links.lww.com/ACGCR/A34. DISCLOSURES Author contributions: E. Kwong edited the video, collected data, and wrote the manuscript. K. Jones collected data and edited the video. S. Park and K. Kwok edited the manuscript and video. K. Kwok is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.