Prevalence of and risk factors for stent migration-induced duodenal perforation

Abstract

Background and study aims The safety of transpapillary biliary drainage by stent placement through endoscopic retrograde cholangiography (ERC) may be compromised by the occurrence of stent migration-induced perforation of the duodenal wall (SMDP). We aimed to assess the prevalence rate, risk factors and clinical course of SMDP. Patients and methods This retrospective cohort study included all patients who underwent an ERC with biliary plastic stent placement, between January 2014 and December 2018. Patients with an SMDP were identified from our endoscopy complication registry. Results 1227 patients underwent an ERC, of whom 629 patients (51 %) with biliary plastic stent placement; in 304 patients (25 %) stents were placed for perihilar strictures. Thirteen patients with SMDP were identified. The prevalence was 2.1 % for patients with biliary plastic stent placement and 4.3 % for patients stented for a perihilar stricture. All SMDPs occurred in patients with a perihilar stricture and with stents ≥ 12 cm (range 12–20 cm). Another potential risk factor was stent insertion into the left liver lobe, which was present in 10 of 13 patients. In 10 of 13 patients, SMDP was clinically suspected. Three of 13 patients were asymptomatic and diagnosed at elective stent retrieval. Eight patients could be endoscopically treated with an over-the-scope clip. Four patients died due to abdominal sepsis despite repeated interventions. Conclusion SMDP is a rare but potentially life-threatening complication of ERC after transpapillary drainage for perihilar biliary strictures. Stents ≥ 12 cm and stent insertion into the left liver lobe may be associated risk factors.

The Pierced Colon: When Biliary Stents Go the Wrong Way

“…Colonic perforation is a rare complication of biliary stenting. Reviewing reported cases of colonic perforations of biliary stents from 2000 to 2022 (Table 1 ), we found that unlike in duodenal perforation, which carries a high risk of mortality, 6 , 7 mortality in reported cases of colonic perforation is low (1 of 32). Of note, only 1 perforation was confirmed to be due to a pigtail stent while 31 of 32 perforations were caused by straight stents (25 of 32) or the type of stent was not mentioned (5 of 32).…”

“…Duodenal perforation vis-à-vis of the papilla by straight biliary stents ranges from 1 in 2,293 6 to 2.1%. 7 The majority was managed with endoscopic removal and closure, with however high mortality (3 of 11 6 vs 4 of 13 cases 7 ). While migration to unusual sites, such as the pericardium, 8 – 10 bronchial system, 11 and perforation of small bowel, 12 , 13 is limited to few case reports, colonic perforation has been reported in 32 cases since 2000 (Table 1 ), with only 5 cases outside the rectosigmoid colon, in which most perforations occurred because of impaction in thin-walled diverticula.…”

Endoscopic treatment for duodenal perforation due to biliary stent dislocation: A case report and brief review of the literature

“…Surgical intervention should be considered in cases with failure of endoscopic therapy and/or persistent abdominal infection. [3] Regarding closure methods, using an OTSC is better than using hemoclips; however, OTSCs are more expensive than hemoclips and the procedure is somewhat complicated. When the perforated hole caused by plastic stent migration is small, hemoclips are sufficient for closing the hole.…”

“…Stassen et al reported that stent length > 12 cm, perihilar stricture, and stent insertion into the left liver lobe were risk factors for stent migration-induced perforation of the duodenal wall. [3] Although pigtail stents may be less traumatic than straight stents, as they are associated with a low rate of stent migration, we experienced duodenal perforation caused by dislocation of the proximal tip of a pigtail PS. Mismatch between the shapes of the bile duct and PS rarely caused dislocation of the proximal tip of a biliary PS.…”

“…The clinical presentation can sometimes be asymptomatic and nonspecific with symptoms that mimic those of cholecystitis or pancreatitis, thereby obscuring early detection. [3] As a result, a high index of suspicion is required to diagnose this complication. We experienced 3 successfully treated cases of duodenal perforation caused by a biliary stent.…”