Appendiceal perforation due to biliary stent migration in a neutropenic patient with lung cancer receiving chemotherapy: A case report

Abstract

The use of biliary stents has become a common and usually safe procedure. However, the migration of biliary stents is an uncommon but well-recognized event after endoscopic retrograde cholangiopancreatography. The migration of plastic stents usually does not result in complications and are spontaneously eliminated from the gastro-intestinal tract. Additionally, <1% of migrated stents result in intestinal perforation, which typically occurs at the duodenum. Chemotherapeutic agents may cause gastrointestinal toxicity and hematologic toxicity predisposing to neutropenic enterocolitis. The current study reports a patient with an unprecedented case of biliary stent migration resulting in appendiceal gangrene and perforation in a neutropenic patient under chemotherapy for metastatic small cell lung cancer.

Is surgical exploration mandatory in pneumatosis intestinalis with portomesenteric gas? Lesson learned in a neutropenic patient under chemotherapy

“…The development of pylephlebitis occurs when this translocation advances to the portomesenteric and intrahepatic veins. However, it seems that neutropenia does not induce full‐thickness injury with necrosis of the bowel wall 2,4 . Therefore, the absence of perforation may warrant medical therapy as the first‐line option, especially in a stable patient.…”

“…Acute mesenteric ischemia is an emergency for surgery 1 . However, the findings of neutropenia and hematologic toxicity in a cancer patient under chemotherapy favor the diagnosis of neutropenic enteritis versus acute (or chronic) mesenteric ischemia 2,3 . Indeed, the latter is a vascular disease often accompanied by severe and rapid progression and it bears different physiopathology than gastrointestinal toxicity due to neutropenia from cytostatics.…”

“…However, it seems that neutropenia does not induce fullthickness injury with necrosis of the bowel wall. 2,4 Therefore, the absence of perforation may warrant medical therapy as the first-line option, especially in a stable patient. The medical treatment of the neutropenic status itself appears to be a key factor that confers improvement of the clinical conditions.…”

“…1 However, the findings of neutropenia and hematologic toxicity in a cancer patient under chemotherapy favor the diagnosis of neutropenic enteritis versus acute (or chronic) mesenteric ischemia. 2,3 Indeed, the latter is a vascular disease often accompanied by severe and rapid progression and it bears different physiopathology than gastrointestinal toxicity due to neutropenia from cytostatics. In our patient, the normal serum lactate, the absence of gastrointestinal bleeding, and the presence of moderate abdominal symptoms that did not worsen during a course of 10 days further reduce the possibility of acute mesenteric ischemia within the differential diagnosis.…”

Colonic diverticular perforation by a migrated biliary stent

“…Chou 2017 [27] F/85 N/A CBD stone N/A N/A Sigmoid Endoscopic removal and clip closure Siaperas 2017 [28] F/75 Diverticulosis Post-op CBD stricture Straight 1 mo Sigmoid Hartmann procedure with colostomy Riccardi 2019 [29] F/79 Diverticulosis CBD stone Straight 10 Fr x 10 cm, Double pigtail 7 Fr 4 wks Sigmoid Hartmann procedure with colostomy Marcos 2020 [6] F/65 Diverticulosis CBD stone Straight 10 Fr x 5 cm 1 yr Sigmoid Surgical primary closure Pengermä 2021 [30] F/66 N/A Chronic pancreatitis with distal biliary stricture Straight, 10 Fr x 5 cm 4 d Appendix Appendectomy…”