Intra-peritoneal duodenal perforation caused by delayed migration of endobiliary stent: a case report

Abstract

Endoscopic biliary stenting is an accepted modality of palliation of malignant biliary obstructions. Delayed stent migration causing intra-peritoneal perforation of duodenum, is a rare life threatening complication. Proximal adhesion of stent to the tumor is believed to increase the intensity of distal trauma produced by the intra-duodenal segment, preventing its adaptation to intestinal peristalsis and causing perforation. Low bacterial load and containment of leak by gut and omentum blunts the clinical features. Unexplained abdominal discomfort in stented patients should alert the clinician to its possibility, irrespective of the delay between stent placement and onset of symptoms. Early diagnosis and treatment is desirable but aggressive surgical management with gastro-biliary diversion, tube duodenostomy, antibiotics, bowel rest and parenteral alimentation followed by distal alimentation, may make up for the delay in those presenting late. A case of 7 days old intra-peritoneal duodenal perforation following delayed migration (3 months) of endobiliary stent presenting with atypical features is reported. Stent's distal end was protruding through the duodenum with its proximal end in CBD. Mortality, fistulization, abscesses and sepsis are known complications but were not observed in our case. Much of the management can be done minimally invasively, if recognized early.

Duodenal perforation as a consequence of biliary stent migration can occur regardless of stent type or duration

“…Notably, patients can present with nonspecific symptoms; therefore, a high index of suspicion for perforation should be maintained when evaluating these patients, irrespective of the duration of the stent placement [3,4]. Our two cases demonstrate that duodenal perforation can occur in both benign and malignant settings, regardless of the type of stent or its length of time in place.…”

Risk factors for distal migration of biliary plastic stents and related duodenal injury

“…The rate of duodenal injury in cases with distal migration was relatively high in the present study (up to 36%). However, only limited case reports reported distal migration-induced duodenal perforation thus far [6,7,17,[22][23][24]; hence, the risk factors of duodenal injury due to distal migrated stents remain uncertain. Sanchez-Tembleque et al [17] suggested that the inflexibility of the stent may influence migration and related duodenal injury.…”

Small Bowel Perforation Secondary to Biliary Stent Migration in an Incarcerated Inguinal Hernia

“…Risk factors for distal stent migration include benign strictures and ampullary stenosis [10]. The most likely site for perforation is in the duodenum or bowel containing herniae [3,14].…”