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Swied MY, Al Turk Y, Maitar M. Migrated Plastic Biliary Stent Causing Cecal Perforation. ACG Case Rep J 2024; 11:e01424. [PMID: 38988715 PMCID: PMC11236398 DOI: 10.14309/crj.0000000000001424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 05/31/2024] [Indexed: 07/12/2024] Open
Abstract
Plastic biliary stents can spontaneously dislodge from the common bile duct and migrate distally into the bowels. Most migrated plastic biliary stents get passed with stools without any complication. However, in rare cases, migrated biliary stents can cause bowel perforation requiring urgent intervention. We report a rare case of a 53-year-old woman presenting with severe lower abdominal pain secondary to migrated plastic biliary stent causing cecal perforation. Computed tomography revealed a radiopaque linear foreign body within the cecum. The patient underwent emergent laparoscopy with stent removal and was discharged 2 days later without long-term complications.
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Affiliation(s)
| | - Yahia Al Turk
- Southern Illinois University School of Medicine, Springfield, IL
| | - Michael Maitar
- Southern Illinois University School of Medicine, Springfield, IL
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2
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Kale A, Sundaram S, Aggarwal M, Giri S, Darak H, Jain G, Ansari AAA, Mane P, Khan N, Shinde L, Kawli K, Shukla A. Predictors of proximal migration of straight biliary plastic stents. Indian J Gastroenterol 2024; 43:592-600. [PMID: 38015380 DOI: 10.1007/s12664-023-01469-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/04/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND/AIMS Proximal biliary plastic stent migration (PSM) remains a challenging complication. The study aims at determining the PSM rate, retrieval outcomes and factors associated with PSM. METHODS Endoscopy database was analyzed from January 2016 to January 2021 to identify 1137 patients, who underwent stent removal or repeat endoscopic retrograde cholangiopancreatography (ERCP). Demography, methods of stent retrieval, outcomes and complications were noted. Logistic regression was performed to determine risk factors for PSM. Propensity score matching was done in a 1:1 manner using age, sex, comorbidities and indication to assess endoscopy-related factors. Clinical trial registration done (CTRI/2022/02/040516). RESULTS PSM was noted in 74 (6.5%) cases. Stent retrieval was successful in 94.59% (70/74) of cases. A balloon catheter (46/74) was commonly used. Technical failure was due to an impacted stent (2) and stent above the stricture (2). Complications were seen in 2.7% of cases. On multi-variate regression, sphincteroplasty at index ERCP (Odds ratio [OR] = 5.68, 95% confidence interval [CI] = 2.7-11.89), stent length < 10 cm (OR = 8.53, 95% CI = 3.2-22.47), 7-Fr stent (OR = 18.25, 95% CI = 6.5-50.64), dilated bile duct (mean diameter- 9.2 ± 3.94 mm) (OR = 0.384, 95% CI = 0.18-0.72) and delayed ERCP by > 3 months from index ERCP (OR = 15.28, 95% CI = 8.1-28.49). After performing propensity score matching for age, sex, comorbidities and indication to determine endoscopy-related factors, 7-Fr stent size (OR 3.495; 95% CI-1.23-9.93) and duration of indwelling stent for more than three months (OR-3.37; 95% CI-1.646-6.76) were significantly associated with proximal stent migration. CONCLUSION Proximally migrated straight stents can be successfully retrieved using standard accessories. The use of 7-Fr size stent, stents indwelling for more than three months, sphincteroplasty at index ERCP, stent length < 10 cm and dilated bile duct were associated with increased risk of proximal migration of straight biliary plastic stents. After propensity score matching, the use of 7-Fr size stents and stent indwelling for over three months were endoscopy-related factors associated with proximal migration.
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Affiliation(s)
- Aditya Kale
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India.
| | - Sridhar Sundaram
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Mohit Aggarwal
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Suprabhat Giri
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Harish Darak
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Gautam Jain
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Abu Aasim Akhtar Ansari
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Prajakata Mane
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Nagma Khan
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Leela Shinde
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Kashmira Kawli
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Akash Shukla
- Department of Gastroenterology, Seth G S Medical College and K E M Hospital, 9Th Floor, Ward 32 A, Multistory Building, Acharya Donde Marg, Parel, Mumbai, 400 012, India
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Zhou F, Zhan X, Hu D, Wu N, Hong J, Li G, Chen Y, Zhou X. Evaluation of ERCP-related perforation: a single-center retrospective study. Gastroenterol Rep (Oxf) 2024; 12:goae044. [PMID: 38766494 PMCID: PMC11099543 DOI: 10.1093/gastro/goae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 02/05/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is a rare and serious adverse event. The aim of our study was to evaluate the risk factors and management of ERCP-related perforation, and to further determine the predictive factors associated with perforation outcome. Methods A total of 27,018 ERCP procedures performed at the First Affiliated Hospital of Nanchang University (Nanchang, China) between January 2007 and March 2022 were included in the investigation of ERCP-related perforation. Medical records and endoscopic data were extracted to analyse the risk factors, management, and clinical outcome of ERCP-related perforation. Results Seventy-six patients (0.28%) were identified as having experienced perforation following ERCP. Advanced age, Billroth II anatomy, precut sphincterotomy, and papillary balloon dilatation were significantly associated with ERCP-related perforation. Most patients with perforation (n = 65) were recognized immediately during ERCP whereas 11 were recognized later on. The delay in recognition primarily resulted from stent migration (n = 9). In addition, 12 patients experienced poor clinical outcome including death or hospice discharge (n = 3), ICU admission for >3 days (n = 6), and prolonged hospital stay for >1 month due to perforation (n = 3). Cancer and systemic inflammatory response syndrome (SIRS) are associated with a higher risk of poor outcome. Conclusions Advanced age, Billroth II anatomy, precut sphincterotomy, and balloon dilation increase the risk of ERCP-related perforation whereas cancer and SIRS independently predicted poor clinical outcome.
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Affiliation(s)
- Feng Zhou
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Xiaoyun Zhan
- Department of Gastroenterology, The Third Hospital of Nanchang, Nanchang, Jiangxi, P. R. China
| | - Dan Hu
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Nanzhen Wu
- Department of Gastrointestinal Surgery, Fengcheng People's Hospital, Fengcheng, Jiangxi, P. R. China
| | - Junbo Hong
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Guohua Li
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Youxiang Chen
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Xiaojiang Zhou
- Department of Gastroenterology, Digestive Disease Hospital, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, P. R. China
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4
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Kamezaki H, Yoshikawa H, Iwanaga T, Tokunaga M, Maeda T, Senoo J, Ohyama H, Kato N. Endoscopic papillary large balloon dilatation-assisted retrieval of a proximally migrated double pigtail stent from the bile duct: A case report. DEN OPEN 2024; 4:e272. [PMID: 37441154 PMCID: PMC10333721 DOI: 10.1002/deo2.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/21/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
Double-pigtail stents are commonly used for drainage in cholangitis to prevent stent migration. We report a case in which a double pigtail stent had migrated proximally into the bile duct and was successfully retrieved after endoscopic papillary large balloon dilatation (EPLBD). An 86-year-old man underwent endoscopic papillary sphincterotomy for cholangitis due to common bile duct stones and had a double-pigtail stent placed in the common bile duct. The patient presented a week later for endoscopic biliary stone removal, but the stent had migrated proximally and could not be visualized during the endoscopy. Endoscopic papillary large balloon dilatation was performed to dilate the papilla to a diameter of 12 mm, following which the stent was grasped and removed. The biliary calculi were subsequently extracted, and the procedure was completed without any complications. This case highlights the potential usefulness of endoscopic papillary large balloon dilatation for retrieving a double-pigtail stent that has migrated to the bile duct.
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Affiliation(s)
- Hidehiro Kamezaki
- Department of GastroenterologyEastern Chiba Medical CenterChibaJapan
| | - Hiroshi Yoshikawa
- Department of General MedicineEastern Chiba Medical CenterChibaJapan
| | - Terunao Iwanaga
- Department of GastroenterologyEastern Chiba Medical CenterChibaJapan
| | - Mamoru Tokunaga
- Department of GastroenterologyEastern Chiba Medical CenterChibaJapan
| | - Takahiro Maeda
- Department of GastroenterologyEastern Chiba Medical CenterChibaJapan
| | - Junichi Senoo
- Department of GastroenterologyEastern Chiba Medical CenterChibaJapan
| | - Hiroshi Ohyama
- Department of GastroenterologyGraduate School of MedicineChiba UniversityChibaJapan
| | - Naoya Kato
- Department of GastroenterologyGraduate School of MedicineChiba UniversityChibaJapan
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5
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Christensen SH, Roga NF, Kirkegaard J, Nygaard J. Migrated biliary stent into the portal vein: a case report. J Surg Case Rep 2024; 2024:rjae065. [PMID: 38370583 PMCID: PMC10871764 DOI: 10.1093/jscr/rjae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/24/2024] [Indexed: 02/20/2024] Open
Abstract
Biliary stent insertion is a well-established treatment of bile duct obstruction. Stent migration is a late-onset complication and can be life-threatening. We present a case of proximal biliary stent migration to the portal vein. An upper endoscopy was performed, and the biliary stent was retracted. Bleeding was seen from the papilla of Vater. The hepatoduodenal ligament was explored, and the common bile duct was found fully adherent to the portal vein, with a fistula between the common bile duct and the portal vein. The patient underwent surgery with extrahepatic bile duct resection and hepaticoduodenostomy. The patient survived and was discharged without surgical postoperative complications on postoperative Day 8.
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Affiliation(s)
- Sanne H Christensen
- Department of Surgery, University Hospital Aarhus, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Nawal F Roga
- Department of Surgery, University Hospital Aarhus, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jakob Kirkegaard
- Department of Surgery, University Hospital Aarhus, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jacob Nygaard
- Department of Surgery, University Hospital Aarhus, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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6
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Ghirardelli L, Beneduce AA, Gusmini S. A Rare Case of Small Bowel Obstruction due to Migration of a Percutaneous Biliary Stent. J Investig Med High Impact Case Rep 2024; 12:23247096241238527. [PMID: 38646799 PMCID: PMC11036911 DOI: 10.1177/23247096241238527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 04/23/2024] Open
Abstract
Biliary endoprostheses are widely used in the treatment of biliary lithiasis, malignant and benign strictures, and occasionally in long-lasting biliary fistulas. They can be placed endoscopically during endoscopic retrograde cholangiopancreatography and radiologically (percutaneous) when the endoscopic route is not feasible. Complications associated with the endoscopic placement of biliary endoprostheses are well described in the literature, with migration being the most common. Intestinal obstruction is a rare complication associated with the migration of these devices. There are no reports in the literature of this complication occurring after percutaneous placement. We present a case of a patient who arrived at the emergency department with ileal obstruction secondary to the migration and concurrent embedding of a covered stent placed radiologically to treat a biliary leak after surgery. The patient underwent diagnostic laparoscopic and ileal resection, revealing a lithiasic concretion at the tip of the stent, causing the small bowel obstruction.
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7
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Frattaroli F, Varanese M, Esposito A, Lauro A, Frattaroli S. Sems Sensibility: Biliary Stent Migration into the Oesophagus. Dig Dis Sci 2023; 68:4321-4325. [PMID: 37889378 DOI: 10.1007/s10620-023-08068-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 10/28/2023]
Abstract
Endoprostheses are commonly used in the treatment of biliary and pancreatic disorders. Fully-covered metal stents are intended for the palliation of malignant strictures in the biliary tree. We report a case of a patient affected by cancer of the pancreas who was treated with a proximal metallic biliary stent. The stent migrated to the oesophagus and was endoscopically removed. Proximal migration, although rare, should be kept in mind as a potential complication of the procedure.
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Affiliation(s)
| | - Marzia Varanese
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Anna Esposito
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Stefano Frattaroli
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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8
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Amaral AC, Hussain WK, Han S. Cholangioscopy-guided salvage retrieval of a migrated stent at a hepaticojejunostomy anastomosis using a colonoscope. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:416-417. [PMID: 37849781 PMCID: PMC10577397 DOI: 10.1016/j.vgie.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Video 1Cholangioscopy-guided retrieval of a migrated biliary stent at the hepaticojejunostomy anastomosis.
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Affiliation(s)
- Anna Cecilia Amaral
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Waleed K Hussain
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Samuel Han
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, Ohio
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9
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Walradt T, Ryou M, Shah R. A Unique Management Strategy for Migrated Biliary Stent Causing Duodenal Perforation. ACG Case Rep J 2023; 10:e01192. [PMID: 37899955 PMCID: PMC10602489 DOI: 10.14309/crj.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Distal stent migration leading to duodenal perforation is an uncommon complication of endoscopic biliary plastic stent placement. We present a case in which a patient with a migrated biliary plastic stent that perforated through the duodenum was managed expectantly until a duodenocolic fistula formed prior to endoscopic removal.
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Affiliation(s)
- Trent Walradt
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
| | - Marvin Ryou
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
| | - Raj Shah
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
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10
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Patil G, Dalal A, Kamat N, Vadgaonkar A, Shah A, Vora S, Maydeo AP. Endoscopic management of a migrated biliary stent in the pleura: a rare complication. Endoscopy 2023; 55:E436-E437. [PMID: 36796443 PMCID: PMC9935077 DOI: 10.1055/a-2011-5480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Gaurav Patil
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Ankit Dalal
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Nagesh Kamat
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Amol Vadgaonkar
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Animesh Shah
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Sehajad Vora
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Amit P. Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
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11
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Proximal Biliary Stent Migration Causing Cardiac Tamponade. ACG Case Rep J 2023; 9:e00924. [PMID: 36628372 PMCID: PMC9820785 DOI: 10.14309/crj.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/31/2022] [Indexed: 01/07/2023] Open
Abstract
Plastic biliary stents are commonly placed during endoscopic retrograde cholangiopancreatography for various indications, and stent-related complications are uncommon. We describe a case in which a plastic biliary stent migrated proximally through the liver capsule and diaphragm after endoscopic retrograde cholangiopancreatography, leading to pericardial effusion and cardiac tamponade. It is important for clinicians managing patients with biliary stents to be aware of this significant adverse event.
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12
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Simeon K, Wright A, Browne V. Cardiac tamponade and septic pericarditis caused by biliary stent migration. Am J Emerg Med 2023; 63:181.e1-181.e3. [PMID: 36270959 DOI: 10.1016/j.ajem.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
In patients with biliary or pancreatic disease, endoscopic retrograde cholangiopancreatography (ERCP) is a common and important therapeutic and diagnostic procedure. Stent migration is a possible complication occurring in approximately 5-10% of cases. This case presents a 47-year-old male with chest pain and found to have biliary stent migration to the pericardial sac causing septic pericarditis and cardiac tamponade. Highlighting this devastating complication, this case demonstrates an opportunity for emergency physicians (EP) to diagnose and monitor patients for post-operative and post-procedural complications. In the emergency department, EPs are well positioned to use ultrasound as a diagnostic and monitoring tool for cardiac tamponade.
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Affiliation(s)
- Kate Simeon
- University of Colordao Hospital, Department of Emergency Medicine, USA; Denver Health Medical Center, USA.
| | - Angela Wright
- University of Colordao Hospital, Department of Emergency Medicine, USA
| | - Vaughn Browne
- University of Colordao Hospital, Department of Emergency Medicine, USA
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13
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Chatterjee A, Garg R, Simons-Linares R, Chahal P. Cognitive ERCP: decision making during successful retrieval of proximally migrated biliary stent. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2022; 8:73-74. [PMID: 36820258 PMCID: PMC9938156 DOI: 10.1016/j.vgie.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Video 1Cognitive ERCP: decision making during successful retrieval of proximally migrated biliary stent.
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Affiliation(s)
- Arjun Chatterjee
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rajat Garg
- Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Roberto Simons-Linares
- Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Prabhleen Chahal
- Gastroenterology and Hepatology Department, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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14
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Risk of Stent Migration in Intended Long-Term Biliary Plastic Stents: Is Being Straight Good? Dig Dis Sci 2022; 67:4330-4331. [PMID: 35318551 DOI: 10.1007/s10620-022-07465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 12/09/2022]
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15
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Akshintala VS, Singh A, Singh VK. Prevention and Management of Complications of Biliary Endoscopy. Gastrointest Endosc Clin N Am 2022; 32:397-409. [PMID: 35691688 DOI: 10.1016/j.giec.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA.
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16
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Przybysz MA, Stankiewicz R. Rare post-endoscopic retrograde cholangiopancreatography complications: Can we avoid them? World J Meta-Anal 2022; 10:122-129. [DOI: 10.13105/wjma.v10.i3.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/11/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Regarded as a minimally invasive procedure, endoscopic retrograde cholangiopancreatography (ERCP) is commonly used to manage various pancreaticobiliary disorders. The rate of complications is low and starts from 4% for diagnostic interventions. The group of most frequent negative outcomes is commonly known and includes pancreatitis, cholecystitis, and hemorrhage. Rare adverse effects occur occasionally but carry a significant risk of unexpected and potentially dangerous results. In some cases, including splenic injury, the knowledge of pre-existing conditions might be helpful in avoiding the unwanted outcome, while in others, the risk factors are not clearly defined. Such situations demand increased caution in the post-ERCP period. The appearance of abdominal pain, peritoneal symptoms, or instability of the patient’s hemodynamic condition should alert the physician and lead to further investigation of the possible causes. The diagnostic process usually involves imaging tests. The implementation of the appropriate treatment should be immediate, as many of the rare complications carry the risk of dangerous, even potentially lethal, results.
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Affiliation(s)
- Marta Aleksandra Przybysz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw 02-097, Poland
| | - Rafał Stankiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw 02-097, Poland
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Successful endoscopic closure with an over-the-scope clip for sigmoid colon perforation due to bile duct stent migration. Clin J Gastroenterol 2021; 15:157-163. [PMID: 34716544 PMCID: PMC8858274 DOI: 10.1007/s12328-021-01544-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/22/2021] [Indexed: 10/26/2022]
Abstract
An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.
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Zorbas KA, Ashmeade S, Lois W, Farkas DT. Small bowel perforation from a migrated biliary stent: A case report and review of literature. World J Gastrointest Endosc 2021; 13:543-554. [PMID: 34733414 PMCID: PMC8546564 DOI: 10.4253/wjge.v13.i10.543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/10/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%. CASE SUMMARY We report a case of a 54-year-old Caucasian woman with a history of Human Immunodeficiency virus with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, portal vein thrombosis and extensive past surgical history who presented with acute abdominal pain and local peritonitis. On further evaluation she was diagnosed with small bowel perforation secondary to migrated biliary stents and underwent exploratory laparotomy with therapeutic intervention. CONCLUSION This case presentation reports on the unusual finding of two migrated biliary stents, with one causing perforation. In addition, we review the relevant literature on migrated stents.
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Affiliation(s)
| | - Shane Ashmeade
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
| | - William Lois
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
| | - Daniel T Farkas
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
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19
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Fujimori N, Yasumori S, Oono T. Successful endoscopic retrieval of an embedded biliary stent using an intra-stent balloon inflation technique assisted by direct per-oral cholangioscopy. Dig Endosc 2021; 33:e97-e99. [PMID: 33856707 DOI: 10.1111/den.13981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/23/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Yasumori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takamasa Oono
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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20
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Abstract
BACKGROUND AND PURPOSE The frequency, risk factors as well as the sites of biliary stent migration are variable in the literature. This retrospective study investigated the frequency of biliary stent migration, why biliary stents migrated, how the migrated stents affected the patients, and what are the different techniques retrieved the migrated stents. PATIENTS AND METHODS Out of 876 stented patients, 74 patients (8.4%) had their stents migrated. Patients with and without migrated stents were compared regarding endoscopy and stent-related parameters. The sequels of stent migrations were reported. Furthermore, the methods used for stent retrieval were reviewed. RESULTS Proximal and distal stent migration occurred at a rate of 3 and 5.5%, respectively. The independent predictors for stent migration were moderate to marked common bile duct (CBD) dilation, complete sphincterotomy, the use of balloon dilation, and stent insertion for more than 1 month. Cholangitis and stent obstruction was the most commonly reported adverse event (n = 18, 24.3%). Distal stent migration associated with two cases of bleeding due to duodenal wall injury, and two cases of duodenal perforation. All the retained migrated stents in the current study were retrieved by endoscopy using extraction balloon, Dormia basket, snares, and foreign body forceps. CONCLUSION Biliary stent migration occurs at a rate of 8.4%. Stents do migrate because of dilated CBD, wide sphincterotomy, and biliary balloon dilation. Furthermore, wide, straight stents inserted for more than 1 month easily migrate. The migrated stents migrated intraluminal in the CBD, duodenum or the colon. All the retained migrated stents were retrieved endoscopically.
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Affiliation(s)
- Mohamed H Emara
- Hepatology, Gastroenterology and Infectious Diseases Department, Faculty of Medicine, Kafrelsheikh University, Kafr El-Shaikh
| | - Mohammed Hussien Ahmed
- Hepatology, Gastroenterology and Infectious Diseases Department, Faculty of Medicine, Kafrelsheikh University, Kafr El-Shaikh
| | - Ahmed S Mohammed
- Tropical Medicine Department, faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed I Radwan
- Tropical Medicine Department, faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Aya M Mahros
- Hepatology, Gastroenterology and Infectious Diseases Department, Faculty of Medicine, Kafrelsheikh University, Kafr El-Shaikh
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21
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Brown D, Naidu J, Thomas R. Bowel perforation: a 'not so rare' complication of biliary stent migration. ANZ J Surg 2021; 91:E784-E786. [PMID: 33949077 DOI: 10.1111/ans.16902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Damien Brown
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Jeevinesh Naidu
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rebecca Thomas
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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22
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Tabone R, Yuide P, Burstow M. Jejunal perforation secondary to migrated biliary stent. J Surg Case Rep 2021; 2021:rjab057. [PMID: 33758653 PMCID: PMC7963451 DOI: 10.1093/jscr/rjab057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 12/16/2022] Open
Abstract
An 80-year-old female presented with acute left-sided abdominal pain. Cross-sectional imaging demonstrated a contained perforation around a migrated biliary stent within a large incisional hernia. Significant surgical background included an open cholecystectomy complicated by bile leak and insertion of a biliary stent 2.5 years prior. The stent had migrated at the time of attempted retrieval 10 weeks post-insertion. A decision was made to pursue conservative management after which time she remained asymptomatic until her acute presentation. Emergency laparotomy, adhesiolysis, stent removal, small bowel resection and abdominal wall closure were successfully performed in this case. In the setting of the biliary stent migration, it is important to consider individual patient’s risk factors for acute perforation, such as intra-abdominal adhesions or diverticular disease, when deliberating conservative management versus elective surgical intervention for stent retrieval.
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Affiliation(s)
- Renee Tabone
- General Surgery, Queensland Health, Logan Hospital, Meadowbrook, Queensland 4131, Australia
| | - Peter Yuide
- General Surgery, Queensland Health, Logan Hospital, Meadowbrook, Queensland 4131, Australia
| | - Matthew Burstow
- General Surgery, Queensland Health, Logan Hospital, Meadowbrook, Queensland 4131, Australia
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23
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Wang X, Qu J, Li K. Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature. BMC Gastroenterol 2020; 20:149. [PMID: 32398025 PMCID: PMC7216602 DOI: 10.1186/s12876-020-01294-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic retrograde biliary drainage (ERBD) is the most frequently performed procedure for treating benign or malignant biliary obstruction. Although duodenal perforations secondary to the biliary plastic stent are quite rare, they can be life-threatening. The treatment strategies for such perforations are diverse and continue to be debated. CASE PRESENTATION We report three cases of duodenal perforation due to the migration of biliary plastic stents that were successfully managed using an endoscope. The three patients were admitted on complaints of abdominal pain after they underwent ERBD. Abdominal computerized tomography (CT) revealed migration of the biliary plastic stents and perforation of the duodenum. Endoscopy was immediately performed, and perforation was confirmed. All migrated stents were successfully extracted endoscopically by using snares. In two of the three cases, the duodenal defects were successfully closed with haemostatic clips after stent retrieval, and subsequently, endoscopic nasobiliary drainage tubes were inserted. After the endoscopy and medical treatment, all three patients recovered completely. CONCLUSIONS Duodenal perforations due to the migration of biliary stents are rare, and the treatment strategies remain controversial. Our cases and cases in the literature demonstrate that abdominal CT is the preferred method of examination for such perforations, and endoscopic management is appropriate as a first-line treatment approach.
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Affiliation(s)
- Xiaopeng Wang
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China
| | - Junwen Qu
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China
| | - Kewei Li
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China.
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24
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Migrating biliary stent in an older woman with choledocholithiasis. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-00669-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Yuan XL, Ye LS, Liu Q, Wu CC, Liu W, Zeng XH, Zhang YH, Guo LJ, Zhang YY, Li Y, Zhou XY, Hu B. Risk factors for distal migration of biliary plastic stents and related duodenal injury. Surg Endosc 2020; 34:1722-1728. [PMID: 31321537 PMCID: PMC7093356 DOI: 10.1007/s00464-019-06957-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The risk factors of duodenal injury from distal migrated biliary plastic stents remain uncertain. The aim of this study was to determine the risk factors of distal migration and its related duodenal injury in patients who underwent placement of a single biliary plastic stent for biliary strictures. METHODS We retrospectively reviewed all patients with biliary strictures who underwent endoscopic placement of a single biliary plastic stent from January 2006 to October 2017. RESULTS Two hundred forty-eight patients with 402 endoscopic retrograde cholangiopancreatography procedures were included. The incidence of distal migration was 6.2%. The frequency of duodenal injury was 2.2% in all cases and 36% in cases with distal migration. Benign biliary strictures (BBS), length of the stent above the proximal end of the stricture (> 2 cm), and duration of stent retention (< 3 months) were independently associated with distal migration (p = 0.018, p = 0.009, and p = 0.016, respectively). Duodenal injury occurred more commonly in cases with larger angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body (p = 0.018) or in cases with stent retention < 3 months (p = 0.031). CONCLUSIONS The risk factors of distal migration are BBS and the length of the stent above the proximal end of the stricture. The risk factor of duodenal injury due to distal migration is large angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body. Distal migration and related duodenal injury are more likely to present during the early period after biliary stenting.
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Affiliation(s)
- Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Qin Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xian-Hui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu-Hang Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Lin-Jie Guo
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu-Yan Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xin-Yue Zhou
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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26
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Celii FG, Zvavanjanja RC. Percutaneous transhepatic use of rigid bronchial forceps as bailout in difficult biliary stent retrieval. Radiol Case Rep 2019; 14:246-250. [PMID: 30479681 PMCID: PMC6250801 DOI: 10.1016/j.radcr.2018.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022] Open
Abstract
Endoscopic retrieval of embedded, proximally migrated, or fractured plastic biliary stents may be technically challenging and sometimes unsuccessful. Percutaneous transhepatic techniques have previously been described to assist in such challenging cases. Here in, we describe a difficult case in which all commonly described endoscopic and percutaneous techniques failed to retrieve a proximally migrated, fractured, and looped plastic biliary stent. We finally successfully retrieved the plastic forceps after off-label utilization of rigid bronchial forceps via a percutaneous transhepatic approach. We describe the technique utilized in detail and this appears to be the first description of this off-label use in this challenging scenario.
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Affiliation(s)
- Francis G. Celii
- University of Texas-Houston McGovern Medical School, 6431 Fannin Street, Suite 2.132, Houston, TX 77030, USA
| | - Rodrick C. Zvavanjanja
- Department of Diagnostic and Interventional Imaging, University of Texas-Houston McGovern Medical School, 6431 Fannin Street, Suite 2.132, Houston, TX 77030, USA
- Corresponding author.
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27
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Calcara C, Broglia L, Comi G, Balzarini M. Plastic Biliary Stent Migration During Multiple Stents Placement and Successful Endoscopic Removal Using Intra-Stent Balloon Inflation Technique: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:65-9. [PMID: 26847214 PMCID: PMC4745661 DOI: 10.12659/ajcr.896076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patient: Male, 77 Final Diagnosis: Biliary neoplasm Symptoms: — Medication: — Clinical Procedure: Biliary stent removal using intra-stent balloon inflation techniqueextraction Specialty: Gastroenterology and Hepatology
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Affiliation(s)
| | - Laura Broglia
- Unit of Gastroenterology, SS Trinità Hospital, Borgomanero, Italy
| | - Giovanni Comi
- Unit of Gastroenterology, SS Trinità Hospital, Borgomanero, Italy
| | - Marco Balzarini
- Unit of Gastroenterology, SS Trinità Hospital, Borgomanero, Italy
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