Endoscopic biliary stent migration with small bowel perforation in a liver transplant recipient

Bowel Perforation Caused by Biliary Stent Migration After ERCP: A Systematic Review

GOALS

This systematic review aims to evaluate the risk factors, clinical features, and outcomes of bowel perforation caused by stent migration after endoscopic retrograde cholangiopancreatography (ERCP).

BACKGROUND

Distal migration of biliary stents can occur after ERCP. Upon migration, most stents pass through the intestine without adverse events; however, bowel perforation has been reported.

STUDY

A comprehensive literature search of PubMed, EMBASE, and Cochrane databases was conducted through October 2023 for articles that reported bowel perforation because of stent migration. Cases of incomplete stent migration and proximal stent migration were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify full-length articles in English reporting.

RESULTS

Of 2041 articles retrieved on the initial search, 92 met the inclusion criteria. A total of 132 cases of bowel perforation occurred due to stent migration after ERCP (56.1% female; average age: 66 y). The median time from initial ERCP to perforation was 44.5 days (IQR 12.5-125.5). Most cases of perforation occurred in the small bowel (64.4%) compared with the colon (34.8%). Stents were mostly plastic (87.1%) with a median diameter of 10 Fr (IQR 8.5-10) and median length of 10.3 cm (IQR 715). Surgical management was pursued in 52.3% and endoscopic management in 42.4%. Bowel resection was required for 25.8% of patients. The overall mortality rate was 17.4%.

CONCLUSION

In summary, this study demonstrates that bowel perforation after ERCP stent migration primarily occurs within 44.5 days and most frequently with a 10 Fr plastic biliary stent. The overall mortality rate was 17.4%. It is important for endoscopists to be mindful of this rare but serious adverse event.

Migration of a biliary stent causing duodenal perforation and biliary peritonitis

Migration of endoscopically placed biliary stents is a well-recognized complication of endoscopic retrograde cholangiopancreatography. Less than 1% of migrated stents however cause intestinal perforation. We present a case of a migrated biliary stent that resulted in duodenal perforation and biliary peritonitis.

Endoscopic treatments of endoscopic retrograde cholangiopancreatography-related duodenal perforations

Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.

Biliary stent migration presenting with leg pain

Although the therapeutic benefits of endoscopic retrograde cholangiopancreatography (ERCP) usually outweigh the risks, there can be rare complications, including stent migration leading to perforation, intestinal obstruction or penetration. An 87-year-old woman presented with symptomatic choledocholithiasis. Two previous endoscopic attempts at stone removal were unsuccessful. On repeat ERCP at our institution, multiple large stones were removed, but complete duct clearance could not be achieved. A plastic biliary stent was placed with plans to reattempt in 6 weeks. Postoperatively, she had mild back pain radiating into her right leg that gradually worsened to the point where she was unable to ambulate. An abdominal CT scan showed the distal aspect of the biliary stent extending through the wall of the duodenum with the tip positioned within the right psoas muscle. The stent was successfully removed via a rat-toothed forceps. Our case illustrates an extremely rare complication of biliary stent placement.

Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers

BACKGROUND

Proximal or distal migration of a plastic biliary stent is uncommon, but its management can be a technical challenge to the pancreatobiliary endoscopist.

PATIENTS AND METHODS

All cases (n=51) of proximally and distally migrated plastic biliary stents over an 8-year period at 3 referral pancreaticobiliary centers were included in this retrospective study. Indications for stenting, risk factors for migration, presentation of migration, and various techniques used for stent's retrieval are herein analyzed.

RESULTS

Twenty-one proximal and 30 distal bile duct-migrated stents were identified. All patients with proximally and 17 (56.7%) with distally migrated stents were symptomatic. Choledocholithiasis, dilated common bile duct, short and large size stent were the main risk factors. The retrieval of proximally migrated stents was successful in 15 patients (71.4%) and in all symptomatic patients with distal migration. The retrieval techniques included forceps, Dormia basket, snare, Soehendra stent retriever, and balloon. One patient died of sepsis due to peritonitis from duodenal perforation from a distally migrated stent.

CONCLUSIONS

Retrieval of a proximally migrated stent requires experience with different endoscopic devices. Moreover, distal migration needs attention because it can cause severe complications.

An unusual cause of ileal perforation: Report of a case and literature review

An ileal perforation resulting from a migrated biliary stent is a rare complication of endoscopic stent placement for benign or malignant biliary tract disease. We describe the case of a 59-year-old woman with a history of abdominal surgery in which a migrated biliary stent resulted in an ileal perforation. Patients with comorbid abdominal pathologies, including colonic diverticuli, parastomal hernia, or abdominal hernia, may be at increased risk of perforation from migrated stents.

Percutaneous retrieval of a biliary stent after migration and ileal perforation

We present a case of a migrated biliary stent that resulted in a distal small bowel perforation, abscess formation and high grade partial small bowel obstruction in a medically stable patient without signs of sepsis or diffuse peritonitis. We performed a percutaneous drainage of the abscess followed by percutaneous retrieval of the stent. The entero-peritoneal fistula closed spontaneously with a drain in place. We conclude, migrated biliary stents associated with perforation distal to the Ligament of Trietz (LOT), may be treated by percutaneous drainage of the abscess and retrieval of the stent from the peritoneal cavity, even when associated with a large intra-abdominal abscess.

Complications and treatment of migrated biliary endoprostheses: A review of the literature

Endoscopic biliary stent insertion is a well-established procedure. It is especially successful in treating postoperative biliary leaks, and may prevent surgical intervention. A routine change of endoprostheses after 3 mo is a common practice but this can be prolonged to 6 mo. We reported a colonic perforation due to biliary stent dislocation and migration to the rectosigmoid colon, and reviewed the literature.

Implantation of migrated biliary stents in the digestive tract

BACKGROUND

Biliary stents constitute an alternative for the palliative treatment of benign or malignant biliary obstruction, biliary strictures, choledocholithiasis, biliary fistulas from lateral lesions of the biliary duct or cystic duct leaks due to slippage of clip closure. Obstruction resulting in cholangitis is common. Proximal migration to the biliary duct or distal migration to the duodenum with subsequent passage per rectum are relatively frequent, but impaction and perforation of the bowel are rare.

CASE OUTLINES

Two cases are reported. In one patient a migrated stent impacted in the caecal wall, and in the other the impaction produced a perforation of an adherent small bowel loop. Both patients were treated surgically and made an uneventful recovery.

DISCUSSION

Biliary stents migrate in 8-10% of patients and are generally eliminated by natural means. Occasionally they impact and perforate the digestive tract, usually in the duodenum or other fixed areas or in bowel affected by adhesions due to a previous operation. Although endoscopy is the treatment of choice to retrieve them, operation should be performed whenever there is suspicion of perforation of the intestinal wall.

An unusual complication of a biliary stent-small bowel perforation of an incarcerated hernia sac

We present a case of small bowel perforation after migration of an endoscopically inserted biliary stent inside an incarcerated hernia sac. A review of the literature revealed no other report of stent morbidity associated with hernias. The management and implications are discussed.