Research Article: Endoscopic or Conservative Management of Iatrogenic Duodenal Perforations Caused by Long Plastic Biliary Stent Distal Migration

Date Published: July 30, 2020

Publisher: Wolters Kluwer

Author(s): Namisha Thapa, Michael Loudin, Kaveh Sharzehi, Silvio W. de Melo, Brintha K. Enestvedt.


Plastic biliary stents are associated with rare but potentially life-threatening distal stent migration. We present 4 patient cases with distal migration, whereas the proximal aspect remained in the bile duct. Time to stent migration ranged from 1 week to 2 months. Stent migration caused contralateral duodenal wall perforation; 2 underwent endoscopic over-the-scope clip placement for defect closure. All required previous stent removal and stent exchange. This case series highlights that proximal stricture and longer stents have higher migration risk, also shown in the literature. We also show that duodenal perforation can successfully be managed endoscopically with an over-the-scope clip.

Partial Text

Biliary stents are used for internal drainage of malignant and benign biliary obstruction during endoscopic retrograde cholangiopancreatography (ERCP). Intestinal perforation is a rare but potentially life-threatening adverse event associated with plastic biliary stents and has been described with distal stent migration out of the biliary tree, occurring in less than 6% of all plastic biliary stents with less than 1% actually causing intestinal perforation.1,2 Endoscopic management of iatrogenic duodenal perforations with endoscopic clips to close the defect is gaining momentum.3 We present a case series of 4 patients with biliary stricture and duodenal perforation from long in situ plastic biliary stents, managed conservatively or with endoscopic management.

We discuss 4 biliary stricture cases in which patients sustained a duodenal perforation related to partial distal migration of long plastic biliary stents. In this present case series, the time frame between stent placement and reported adverse events ranged from 7 days to 3 months. In previous literature, the time frame has varied from 2 weeks to 3 years with majority ranging from 1 to 6 months.4 In all our cases, the stents were either 10 or 12 cm long, were all from the same manufacturer, and the strictures were proximal common hepatic duct or hilar strictures.5 In addition, in all our cases, the removed stents were exchanged immediately for double pigtail biliary stents to limit any duodenal damage from the distal aspect of the stent.

Author contributions: N. Thapa wrote the manuscript and reviewed the literature. M. Loudin, K Sharzehi, and SW de Melo edited the manuscript, reviewed the literature, and approved the final version. BK Enestvedt wrote the manuscript, reviewed the literature, approved the final version, and is the article guarantor.




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