Percutaneous retrieval of a biliary stent after migration and ileal perforation
© Culnan et al; licensee BioMed Central Ltd. 2009
Received: 12 December 2008
Accepted: 31 January 2009
Published: 31 January 2009
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.
Endoscopic biliary stent placement is a well established, safe and minimally invasive modality for the treatment of biliary diseases such as choledocholithiasis.[1, 2] Over the past decade the use of this modality has increased in prevalence and utility. Despite the overall safety of this modality, on rare occasions these stents may migrate from the biliary tract. A small percentage of those stents perforate the gut and require surgical intervention.[4, 5] We present an unusual case of biliary stent migration with distal small bowel perforation and abscess formation which was successfully treated using interventional radiology techniques, including percutaneous drainage and fluoroscopic removal of the stent.
A 76-year-old woman was admitted with cholecystitis and choledocholithiasis diagnosed via computed tomographic (CT) scan. Her past medical and surgical history was significant for paroxysmal atrial fibrillation, a right hemicolectomy and right oophorectomy for colon cancer, pulmonary embolism requiring inferior vena cava filter placement, endovascular abdominal aortic aneurysm repair, and a stroke resulting in vascular dementia. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed with removal of an impacted common bile duct stone and placement of an uncoated 10F plastic endostent, though the duct was radiographically clear. Four days later, after her liver function test normalized, she underwent a laparoscopic cholecystectomy during which an intra-peritoneal abscess was found surrounding a markedly inflamed and necrotic appearing gallbladder. The cholecystectomy was performed without complication and the abscess was drained adequately. The remainder of her post-operative course was unremarkable and she was discharged home on post-operative day five.
Her drainage continued at a stable and low level. She was discharged home with the drain with the intent of removing it after 6 weeks if there was no further an enteric or purulent content. Oral ciprofloxicin and metronidazole was prescribed three weeks.
Migration of endoscopically placed biliary stents is a well recognized complication of ERCP. Less than 1% of migrated stents cause intestinal perforation. Of those that do perforate the bowel, the vast majority occur proximal to the ligament of Trietz (LOT). There have been a several case reports of intestinal perforation distal to the LOT, generally in the colon. [6–9] There have also been case reports describing small bowel perforation. [10–13]
Generally speaking, a double pigtail stent (7F) is preferable in cases involving choledocholithiasis. A straight stent may migrate since there is nothing to hold it in place, even though there are side flaps. An exception might be an impacted stone that is tight on the stent and prevents migration. Dislodged straight stents are more likely to perforate bowel whereas perforation with a pigtail is much more rare. Furthermore, straight 10 F plastic stents should generally be used for conditions such as strictures and tumours. The rationale for a double pigtail stent (7F) in this case is not known to the authors.
Migrated stents causing complications have either been retrieved endoscopically or via laparotomy.[4, 7, 14] There is at least one documented case of a percutaneous intervention to remove a biliary stent causing a retroperitoneal duodenal perforation and bilioma. However, there has not been a documented case involving percutaneous methods to retrieve a migrated stent beyond the LOT.
The existing literature on this subject would advocate prompt and aggressive surgical intervention because of gross contamination, intraperitoneal abscess, and bowel perforation.[4, 5] Prompt surgical intervention is generally indicated for small bowel perforations, especially in the setting of a highly contaminated field, bowel obstruction and generalized abdominal pain. Historically, bowel perforation from migrated bilary stents has been treated either by endoscopic retrieval or laparotomy should endoscopic means fail. There are reports in which endoscopy is used to retrieve stents and close bowel perforations via clip application, but this only applies to areas that are accessible to endoscopic instrumentation. In our case, endoscopic means was not possible because the perforation was in the distal small bowel and associated with a partial small bowel obstruction. Additionally, percutaneous interventions were undertaken in cases involving retroperitoneal bilomas. Such bilomas were likely sterile, or at least not as heavily contaminated as an abscess.
Given the patient's past medical history, including advanced age, prior abdominal surgery, and cardiac status, we surmised that percutaneous drainage of the abscess posed a lower risk than a laparotomy. We concluded that drainage of the abscess would alleviate her small bowel obstruction, allow her inflammatory changes to resolve, and provide the time necessary for her to become nutritionally replete. In essence, we chose to treat this patient in a fashion similar to a complicated diverticular abscess or a perforated appendicitis with abscess formation. Prior reports involving biliary stent migration have advocated aggressive surgical intervention for patients with large infected intra-abdominal collections, delayed or critically ill clinical presentations, or a low physiologic reserve.[4, 5] We had considered operative removal of the biliary stent after the patient had recovered clinically. However, the stent was able to be removed percutaneously during a drain upsizing. The patient had a 15 day hospital course and an extended period of percutaneous drainage. Of note, she initially refused operative intervention via laparoscopy or laparotomy to resect the enteroperitoneal fistula and preferred this treatment path.
As percutaneous interventional techniques improve, cases that now require emergent surgical intervention may soon be better served by these less invasive techniques. In this circumstance, fluoroscopically guided percutaneous removal of a migrated biliary stent distal to the LOT, coupled with traditional conservative management principles in the treatment of enterocutaneous fistulas obviated the need for aggressive surgical intervention. This approach has not been previously documented. We conclude that fluoroscopic retrieval of migrated biliary stents associated with perforation distal to the LOT, along with percutaneous abscess drainage, may be a safe and effective treatment alternative to laparotomy for stable patients, even when associated with a large intra-abdominal abscess.
This activity was screened by our Institutional Review Board for exempt status according to the policies of this institution and the provisions of applicable regulations and was found not to require formal IRB review because it did not meet the regulatory definition of research.
- The following abbreviations were used in this manuscript:
LOT: Ligament of Trietz
Endoscopic retrograde cholangiopancreatography.
- Lammer J, Neumayer K: Biliary drainage endoprostheses: experience with 201 placements. Radiology. 1986, 159 (3): 625-629.View ArticlePubMedGoogle Scholar
- Mueller PR, Ferrucci JT, Teplick SK, vanSonnenberg E, Haskin PH, Butch RJ, Papanicolaou N: Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology. 1985, 156 (3): 637-639.View ArticlePubMedGoogle Scholar
- Johanson JF, Schmalz MJ, Geenen JE: Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc. 1992, 38 (3): 341-346. 10.1016/S0016-5107(92)70429-5.View ArticlePubMedGoogle Scholar
- Diller R, Senninger N, Kautz G, Tubergen D: Stent migration necessitating surgical intervention. Surg Endosc. 2003, 17 (11): 1803-1807. 10.1007/s00464-002-9163-5.View ArticlePubMedGoogle Scholar
- Saranga Bharathi R, Rao P, Ghosh K: Iatrogenic duodenal perforations caused by endoscopic biliary stenting and stent migration: an update. Endoscopy. 2006, 38 (12): 1271-1274. 10.1055/s-2006-944960.View ArticlePubMedGoogle Scholar
- Anderson EM, Phillips-Hughes J, Chapman R: Sigmoid colonic perforation and pelvic abscess complicating biliary stent migration. Abdom Imaging. 2007, 32 (3): 317-319. 10.1007/s00261-006-9067-2.View ArticlePubMedGoogle Scholar
- Elliott M, Boland S: Sigmoid colon perforation following a migrated biliary stent. ANZ J Surg. 2003, 73 (8): 669-670. 10.1046/j.1445-2197.2003.02698.x.View ArticlePubMedGoogle Scholar
- Figueiras RG, Echart MO, Figueiras AG, Gonzalez GP: Colocutaneous fistula relating to the migration of a biliary stent. Eur J Gastroenterol Hepatol. 2001, 13 (10): 1251-1253. 10.1097/00042737-200110000-00021.View ArticlePubMedGoogle Scholar
- Marsman JW, Hoedemaker HP: Necrotizing fasciitis: fatal complication of migrated biliary stent. Australas Radiol. 1996, 40 (1): 80-83. 10.1111/j.1440-1673.1996.tb00353.x.View ArticlePubMedGoogle Scholar
- Akimboye F, Lloyd T, Hobson S, Garcea G: Migration of endoscopic biliary stent and small bowel perforation within an incisional hernia. Surg Laparosc Endosc Percutan Tech. 2006, 16 (1): 39-40. 10.1097/01.sle.0000202198.74569.5a.View ArticlePubMedGoogle Scholar
- Esterl RM, St Laurent M, Bay MK, Speeg KV, Halff GA: Endoscopic biliary stent migration with small bowel perforation in a liver transplant recipient. J Clin Gastroenterol. 1997, 24 (2): 106-110. 10.1097/00004836-199703000-00014.View ArticlePubMedGoogle Scholar
- Lanteri R, Naso P, Rapisarda C, Santangelo M, Di Cataldo A, Licata A: Jejunal perforation for biliary stent dislocation. Am J Gastroenterol. 2006, 101 (4): 908-909. 10.1111/j.1572-0241.2006.00509.x.View ArticlePubMedGoogle Scholar
- Storkson RH, Edwin B, Reiertsen O, Faerden AE, Sortland O, Rosseland AR: Gut perforation caused by biliary endoprosthesis. Endoscopy. 2000, 32 (1): 87-89. 10.1055/s-2000-87.View ArticlePubMedGoogle Scholar
- Roses LL, Ramirez AG, Seco AL, Blanco ES, Alonso DI, Avila S, Lopez BU: Clip closure of a duodenal perforation secondary to a biliary stent. Gastrointest Endosc. 2000, 51 (4 Pt 1): 487-489. 10.1016/S0016-5107(00)70454-8.View ArticlePubMedGoogle Scholar
- Bui BT, Oliva VL, Ghattas G, Daloze P, Bourdon F, Carignan L: Percutaneous removal of a biliary stent after acute spontaneous duodenal perforation. Cardiovasc Intervent Radiol. 1995, 18 (3): 200-202. 10.1007/BF00204152.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.