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Wilson N, Ezeani C, Ismail A, Abdalla M, Mohammed S, Abdalla A, Elawad A, Beran A, Jaber F, Abosheaishaa H, Loon E, Abdallah M, Vargo J, Bilal M, Chahal P. Bowel Perforation Caused by Biliary Stent Migration After ERCP: A Systematic Review. J Clin Gastroenterol 2025; 59:472-478. [PMID: 39008570 DOI: 10.1097/mcg.0000000000002029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/05/2024] [Indexed: 07/17/2024]
Abstract
GOALS This systematic review aims to evaluate the risk factors, clinical features, and outcomes of bowel perforation caused by stent migration after endoscopic retrograde cholangiopancreatography (ERCP). BACKGROUND Distal migration of biliary stents can occur after ERCP. Upon migration, most stents pass through the intestine without adverse events; however, bowel perforation has been reported. STUDY A comprehensive literature search of PubMed, EMBASE, and Cochrane databases was conducted through October 2023 for articles that reported bowel perforation because of stent migration. Cases of incomplete stent migration and proximal stent migration were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify full-length articles in English reporting. RESULTS Of 2041 articles retrieved on the initial search, 92 met the inclusion criteria. A total of 132 cases of bowel perforation occurred due to stent migration after ERCP (56.1% female; average age: 66 y). The median time from initial ERCP to perforation was 44.5 days (IQR 12.5-125.5). Most cases of perforation occurred in the small bowel (64.4%) compared with the colon (34.8%). Stents were mostly plastic (87.1%) with a median diameter of 10 Fr (IQR 8.5-10) and median length of 10.3 cm (IQR 715). Surgical management was pursued in 52.3% and endoscopic management in 42.4%. Bowel resection was required for 25.8% of patients. The overall mortality rate was 17.4%. CONCLUSION In summary, this study demonstrates that bowel perforation after ERCP stent migration primarily occurs within 44.5 days and most frequently with a 10 Fr plastic biliary stent. The overall mortality rate was 17.4%. It is important for endoscopists to be mindful of this rare but serious adverse event.
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Affiliation(s)
- Natalie Wilson
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Chukwunonso Ezeani
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Abdellatif Ismail
- Department of Internal Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, MD
| | - Monzer Abdalla
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL
| | | | - Abubaker Abdalla
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA
| | - Ayman Elawad
- Department of Internal Medicine, Howard University Hospital, Washington, DC
| | - Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO
| | | | - Erica Loon
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Mohamed Abdallah
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - John Vargo
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Alkhawaldeh IM, Shattarah O, AlSamhori JF, Abu‐Jeyyab M, Nashwan AJ. Late small bowel perforation from a migrated double plastic biliary stent: A case report and a review of literature of 85 cases from 2000 to 2022. Clin Case Rep 2023; 11:e7425. [PMID: 38028080 PMCID: PMC10658557 DOI: 10.1002/ccr3.7425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message This case highlights the importance of considering stent migration as a possible cause of intestinal perforation and the need for prompt surgical intervention. Abstract Endo-biliary stent displacement is rare but can cause intestinal perforation. An 85-year-old woman with a history of ERCPs and biliary stents experienced stomach pain and vomiting. She was diagnosed with small bowel perforation from migrated stents and underwent emergency laparotomy, bowel resection, and tension-free stapled anastomosis.
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Affiliation(s)
| | - Osama Shattarah
- General Surgery Department, School of MedicineMutah UniversityAl‐KarakJordan
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Walradt T, Ryou M, Shah R. A Unique Management Strategy for Migrated Biliary Stent Causing Duodenal Perforation. ACG Case Rep J 2023; 10:e01192. [PMID: 37899955 PMCID: PMC10602489 DOI: 10.14309/crj.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Distal stent migration leading to duodenal perforation is an uncommon complication of endoscopic biliary plastic stent placement. We present a case in which a patient with a migrated biliary plastic stent that perforated through the duodenum was managed expectantly until a duodenocolic fistula formed prior to endoscopic removal.
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Affiliation(s)
- Trent Walradt
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
| | - Marvin Ryou
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
| | - Raj Shah
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA
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Zorbas KA, Ashmeade S, Lois W, Farkas DT. Small bowel perforation from a migrated biliary stent: A case report and review of literature. World J Gastrointest Endosc 2021; 13:543-554. [PMID: 34733414 PMCID: PMC8546564 DOI: 10.4253/wjge.v13.i10.543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/10/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%. CASE SUMMARY We report a case of a 54-year-old Caucasian woman with a history of Human Immunodeficiency virus with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, portal vein thrombosis and extensive past surgical history who presented with acute abdominal pain and local peritonitis. On further evaluation she was diagnosed with small bowel perforation secondary to migrated biliary stents and underwent exploratory laparotomy with therapeutic intervention. CONCLUSION This case presentation reports on the unusual finding of two migrated biliary stents, with one causing perforation. In addition, we review the relevant literature on migrated stents.
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Affiliation(s)
| | - Shane Ashmeade
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
| | - William Lois
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
| | - Daniel T Farkas
- Department of Surgery, Bronx Care Health System, New York, NY 10457, United States
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Tominaga T, Nonaka T, Fukuda A, Moriyama M, Oyama S, Ishii M, Nishimuta M, Fujise Y, Sawai T, Nagayasu T. Complete closure of a colo-duodenal fistula in a patient with advanced ascending colon cancer after pembrolizumab combined with radiation therapy: a case report. Surg Case Rep 2021; 7:168. [PMID: 34269952 PMCID: PMC8285456 DOI: 10.1186/s40792-021-01248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background A colo-duodenal fistula is a very rare complication of colon cancer that presents with not only severe clinical symptoms, but a poor prognosis due to locally advanced cancer. A novel immune checkpoint inhibitor for colon cancer patients provides a high objective response rate. Recently, radiation therapy combined with immune checkpoint inhibitor therapy has been reported to have a synergistic antitumor effect. A case of complete closure of a colo-duodenal fistula in a patient with locally advanced colon cancer after combined pembrolizumab and radiation therapy is reported. Case presentation A 66-year-old man presented with abdominal distention. Abdominal contrast-enhanced computed tomography (CT) showed a 80-mm bulky mass in the right upper quadrant. The tumor created a fistula to the second portion of the duodenum. Upper gastrointestinal endoscopy showed a colo-duodenal fistula. Gastro-jejunal bypass and ileostomy were performed to prevent bowel obstruction, followed by systemic chemotherapy. MSI-high was diagnosed on examination of the biopsy specimen. Treatment was then changed to immunotherapy using pembrolizumab; after six courses, the tumor markers were decreased to within normal ranges, but the main tumor increased. Radiation therapy was then given for local control of the main tumor, after which CT showed that all of the tumor, including the main tumor, lymph node metastases, and the colo-duodenal fistula, had gradually shrunk. Follow-up upper gastrointestinal endoscopy showed that the colo-duodenal fistula had closed completely. PET–CT showed no abnormal uptake in all tumors, and clinical complete response was diagnosed. Now, 21 months after diagnosis, the tumor is well controlled without evidence of regrowth. Conclusions Pembrolizumab combined with radiation therapy has a potentially dramatic therapeutic effect for advanced colon cancer.
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Affiliation(s)
- Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Akiko Fukuda
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masaaki Moriyama
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shosaburo Oyama
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Mitsutoshi Ishii
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masato Nishimuta
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yuta Fujise
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Terumitsu Sawai
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Majeed TA, Gaurav A, Shilpa D, Preeti J, Sanjay S, Manisha S, Kumar SJ, Bhushan PB. Malignant coloduodenal fistulas-review of literature and case report. Indian J Surg Oncol 2011; 2:205-9. [PMID: 22942613 DOI: 10.1007/s13193-011-0099-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 10/24/2011] [Indexed: 11/29/2022] Open
Abstract
Colo-duodenal fistula is an uncommon complication of malignant and inflammatory bowel disease. Presentation varies from upper abdominal pain, feculent vomiting and diarrhea associated with foul eructation's. Occasionally patients presents with gastro-intestinal bleed. The contact of duodenal bile salts with colonic mucosa frequently leads to diarrhea, so also duodenal colonization with colonic pathogens frequently leads to malabsorption and severe foul eructations. The diagnosis is established either by gastrointestinal contrast studies or contrast enhanced C. T. Scan. Gastroduodenoscopy can demonstrate the fistulous communication or direct invasion and it can also be helpful in obtaining a histological diagnosis. Surgical treatment includes Right Radical hemicolectomy combined with Pancreatico duodenectomy in operable patients and Intestinal bypass for inoperable ones. Right Radical hemicolectomy combined with wedge excision of Duodenum is a suitable alternative in select cases. We report an unusual case of locally advanced carcinoma hepatic flexure of colon with direct invasion of duodenum. Extended right radical hemicolectomy with wedge excision of second part of duodenum was done as an alternative to combined radical hemicolectomy with Pancreatico duodenectomy.
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Miloudi N, Hefaiedh R, Mzoughi Z, Ben Abid S, Mestiri H, Ghorbel A, Khalfallah T. Accidental insertion of biliary endoprosthesis in the portal vein: a case report. Clin Res Hepatol Gastroenterol 2011; 35:144-7. [PMID: 21809491 DOI: 10.1016/j.clinre.2010.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Uzzaman MM, Nair MS, Myint F. An unusual complication encountered incidentally at laparoscopic cholecystectomy: a case series. J Gastrointest Surg 2010; 14:1608-12. [PMID: 20652438 DOI: 10.1007/s11605-010-1238-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 05/25/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This is a case series of erosion of the common bile duct by an in situ stent found incidentally during laparoscopic cholecystectomy (LC). To the best of our knowledge, this is one of the first reported incidences of this nature. METHOD Four individual case reports. RESULTS Thirty nine patients with an in situ CBD stent underwent LC for symptomatic gallstones in our institution over a 4-year time period (2005 to 2009). Four patients were found to have the stent eroding through the wall of the CBD. In these four patients, endoscopic retrograde cholangiopancreatography (ERCP) had previously been performed - extracting stone(s) - followed by sphincterotomy and insertion of a 7 Fr pigtail stent (measuring 4 cm). The operation was converted to open in two patients, and the procedure was abandoned in one of these cases. In the other two patients, the anatomy of Calots triangle was delineated well, and the operator was able to complete LC. The duration between initial pigtail stent insertion and LC ranged from 32 to 400 days. None of our patients required a definitive surgical repair of the CBD or T-tube placement. The stent was removed during surgery in one case, removed endoscopically at a later date in two patients, and passed spontaneously in one patient. All four patients made a good postoperative recovery. CONCLUSION CBD erosion is a complication of plastic biliary stent insertion. CBD stent erosion will make surgery more hazardous especially if it remains in situ for a significant period of time. CBD erosion can generally be managed conservatively without the need for surgical repair. Awareness of this complication should prompt earlier surgery or earlier removal of plastic pigtail stents.
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Affiliation(s)
- Mohammed Mohsin Uzzaman
- Department of General Surgery, North Middlesex University Hospital, 62 Kensington Avenue, London E12 6NP, UK.
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9
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Elective laparoscopic cholecystectomy in the presence of common bile duct stent. Surg Endosc 2010; 25:429-36. [DOI: 10.1007/s00464-010-1185-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 06/01/2010] [Indexed: 11/26/2022]
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Bagul A, Pollard C, Dennison AR. A review of problems following insertion of biliary stents illustrated by an unusual complication. Ann R Coll Surg Engl 2010; 92:W27-31. [PMID: 20501006 DOI: 10.1308/147870810x12659688852239] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The management of obstructive jaundice resulting from both benign and malignant causes relies heavily on minimally invasive techniques and particularly with the insertion of biliary endoprostheses. Migration of these biliary stents is a well-documented problem and can result in a variety of complications including perforation, intra-abdominal sepsis, fistulae formation, obstruction and appendicitis. METHODS A literature search was performed using PubMed examining case reports, published abstracts and reviews to date (2009). In addition, we report a left groin abscess as a previously unreported complication following migration of a biliary endoprosthesis. FINDINGS Stent migration can lead to serious complications and produce significant morbidity and mortality. Symptomatic patients especially those with other co-morbid abdominal pathologies such as colonic diverticulae, parastomal hernia or abdominal hernias may be at an increased risk of perforation especially when straight plastic stents are used.
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Affiliation(s)
- Atul Bagul
- HPB Department, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, UK.
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Losanoff JE, Vanha TG, Testa G, Ahmed EB, Millis JM. Endoscopic biliary stent migration to the iliopsoas muscle in a liver transplant recipient: percutaneous removal. Dig Dis Sci 2007; 52:2508-2511. [PMID: 17436093 DOI: 10.1007/s10620-006-9725-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 12/03/2006] [Indexed: 01/14/2023]
Affiliation(s)
- Julian E Losanoff
- Department of Surgery, Section of Transplantation, MC 5026, Room J 517, University of Chicago, 5841 South Maryland Avenue Chicago, Illinois 60637, USA.
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Ha JPY, Leung LH, Tang CN, Li MKW. Silent duodenocolic fistula secondary to biliary stent migration. SURGICAL PRACTICE 2007. [DOI: 10.1111/j.1744-1633.2007.00362.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Soulsby R, Leung E, Williams N. Malignant colo-duodenal fistula; case report and review of the literature. World J Surg Oncol 2006; 4:86. [PMID: 17147825 PMCID: PMC1698919 DOI: 10.1186/1477-7819-4-86] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 12/05/2006] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Colo-duodenal fistula is a rare complication of malignant and inflammatory bowel disease. Cases with malignant colo-duodenal fistulae can present with symptoms from the primary, from the fistula or from metastatic disease. The fistula often results in diarrhoea and vomiting with dramatic weight loss. Upper abdominal pain is usually present as is general malaise both from the presence of the disease and from the metabolic sequelae it causes. The diarrhoea relates to colonic bacterial contamination of the upper intestines rather than to a pure mechanical effect. Vomiting may be faeculant or truly faecal and eructation foul smelling but in the case reports this 'classic' symptomatology was often absent despite a fistula being present and patent enough to allow barium through it. Occasionally patients will present with a gastro-intestinal bleed. CASE PRESENTATION We present an unusual case of colorectal carcinoma, where a 65 year old male patient presented with diarrhoea and vomiting secondary to a malignant colo-duodenal fistula near the hepatic flexure. Adenocarcinoma was confirmed on histology from a biopsy obtained during the patient's oesophageogastroduodenoscopy, and the fistula was demonstrated in his barium enema. Staging computed tomography showed a locally advanced carcinoma of the proximal transverse colon, with a fistula to the duodenum and regional lymphadenopathy. The patient was also found to have subcutaneous metastasis. Following discussions at the multidisciplinary meeting, this patient was referred for palliation, and died within 4 months after discharge from hospital. CONCLUSION We present the case, discuss the management and review the literature. Colo-duodenal fistulae from colonic primaries are rare but early diagnosis may allow curative surgery. This case emphasises the importance of accurate staging and repeated clinical examination.
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Affiliation(s)
- Ruth Soulsby
- Department of General Surgery, University Hospitals Coventry, Clifford Bridge Road, Walsgrave, CV2 9DX, UK
| | - Edmund Leung
- Department of General Surgery, University Hospitals Coventry, Clifford Bridge Road, Walsgrave, CV2 9DX, UK
| | - Nigel Williams
- Department of General Surgery, University Hospitals Coventry, Clifford Bridge Road, Walsgrave, CV2 9DX, UK
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Diller R, Senninger N, Kautz G, Tübergen D. Stent migration necessitating surgical intervention. Surg Endosc 2003. [PMID: 14508668 DOI: 10.1007/s00464-002-9163-5.] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Internal drainage with transhepatically or endoscopically placed endoprostheses has been used for many years as a temporary or definitive treatment for biliary tract obstruction. As a late complication, stent migration may occur. METHODS We reviewed our records to identify patients who were operated on for a migrated endoprosthesis that was causing complications. In all, five such patients were identified. RESULTS One patient had a large bowel perforation. Bowel penetration led to an interenteric fistula in one patient and to a biliocolic fistula formation in another. Small bowel distension was found in two patients. Surgical treatment consisted of local excision in three patients, segmental resection in one patient, and a bypass operation in the patient with biliocolic fistula. Postoperatively, four patients recovered without problems, but one patient died during a complicated postoperative course. CONCLUSION If a stent becomes stuck in the gastrointestinal tract and is not accessible for endoscopic removal, early operative revision is mandatory to prevent further complications.
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Affiliation(s)
- R Diller
- Department of General Surgery, University Clinic of Muenster, Waldeyerstrasse 1, D-48149 Münster, Germany.
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