Small bowel perforation from a migrated biliary stent: A case report and review of literature

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.

Key Words: Biliary stent; Biliary stent migration; Small bowel perforation; Endoscopic retrograde cholangiopancreatography; Case report

Core Tip: Bowel perforation from biliary stent migration is a serious potential complication of biliary stents, but fortunately has an incidence of less than 1%. From this review of literature, we can see that most common types of migrated stents entailing bowel perforation are the plastic stents and the most common site of perforation is duodenum. A significant finding is the mortality after bowel perforation from biliary stent which is as high as 10.3%. The main treatment is surgical stent removal, but a growing body of literature shows that endoscopic removal and mucosal repair is feasible in select cases. This has still not been accomplished in the mid portion of the bowel.

INTRODUCTION

Endoscopic biliary stents placement is a well-established therapeutic intervention in the era of modern medicine. It has been used either for temporary or permanent decompression of biliary system, for benign or malignant diseases. Biliary stents are classified by material into two categories: plastic and metallic stents, with the former being less expensive and easier to remove or change[1]. However, this technologically advanced treatment has not been free from complications. The complication rate ranges between 8% and 10% and serious common complications are stent occlusion, cholangitis, bleeding, pancreatitis, duodenal perforation and stent migration[2]. Biliary stent migration is well known with a rate of 5%-10% and can be either proximal or distal[2].

A serious potential consequence of stent migration is bowel perforation which can happen at any part of the small or large bowel, but fortunately has an incidence of less than 1%[3,4]. The majority of the case reports with bowel perforation secondary to migrated biliary stent describe duodenal or colonic perforations, with very few cases of small bowel perforations. Herein we report a case of a patient with multiple comorbidities and surgical interventions, who presents with two migrated biliary stents, one of which was perforating through the small bowel. Both stents were removed uneventfully with laparotomy and a single small bowel resection.

CASE PRESENTATION

Chief complaints

Diffuse abdominal pain.

History of present illness

We present the case of a 54-year-old Caucasian female, who presented in the emergency department of our hospital with diffuse abdominal pain for one week, which had become severe in the last day.

History of past illness

She initially presented in October 2019 with hyperbilirubinemia. At the time she had an ultrasound that showed gallstones as well as a dilated common bile duct of 10 mm. She underwent an magnetic resonance cholangiopacreatography (MRCP) which showed an 8mm duct, but no definite filling defects. Following this she underwent a diagnostic ERCP, at which time a distal stricture was noted, and a plastic stent [7 French (Fr) 7 cm single external and single internal flap] was placed. A second ERCP was done in February 2020, at which time choledocholithiasis was identified and felt to be the cause of the stricture. At that time a new plastic stent was placed (8.5 Fr 7 cm). The original stent was not seen at that time. In August 2020 she went for another ERCP at which time she had a normal cholangiogram, and the stent was not seen at that time. She presented to our Emergency Department in November 2020.

Personal and family history

Her past medical history was significant for human immunodeficiency virus (HIV) infection with acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, alcoholic liver cirrhosis, and portal vein thrombosis. Her past surgical history was significant for colectomy with end ileostomy for toxic megacolon from Clostridium difficile, followed later by a re-exploration and ileorectal anastomosis with proximal diverting loop ileostomy, which was still in place.

Physical examination

On initial evaluation the patient had temperature 98.2 °F (36.7 °C), pulse 87 per minute, blood pressure 115/83 mmHg. Her clinical examination revealed diffuse abdominal tenderness and focal peritonitis in the left lower quadrant of the abdomen.

Laboratory examinations

From laboratory evaluation the patient had WBC 6.1 k/μL and total bilirubin 0.7 mg/dL.

Imaging examinations

Computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast showed two migrated biliary stents. The first was in an ileal loop and was perforating through the bowel wall into the mesentery (Figure 1A) and a second stent within a mid-jejunal loop (Figure 1B, C). The CT scan showed significant surrounding inflammatory phlegmon, but no free air or focal abscess was noted. After discussion with the patient, it was decided to proceed with surgical treatment of the bowel perforation and removal of both biliary stents.

Figure 1 Computed tomography scan. A: Small bowel perforation by migrated biliary stent (Axial view); B: Second migrated biliary stent (Axial view); C: Second migrated biliary stent (Coronal view).

MULTIDISCIPLINARY EXPERT CONSULTATION

The gastroenterology team was consulted, and they agreed with surgical exploration.

FINAL DIAGNOSIS

Small bowel perforation from a migrated biliary stent.

TREATMENT

The patient underwent a laparotomy at which time extensive adhesions were noted. The bowel was cocooned in most of the abdomen, with multiple interloop adhesions, as well as adhesions to the abdominal wall. The segment of bowel with the perforation was planned for resection due to the extensive inflammation. The second stent was milked within the bowel lumen to the area of the first stent, and both stents were removed in a single resection, after which a primary anastomosis was done. As a result of the extensive adhesions, and the urgent nature of the surgery, the right upper quadrant was not explored at this time. On detailed examination of the specimen, the resected small bowel had hypertrophic changes of the luminal mucosa at the internal opening of the perforation track (Figures 2, 3).

Figure 2 Small bowel segment with stent perforating through it, together with second migrated stent.

Figure 3 Internal opening of perforation.

OUTCOME AND FOLLOW-UP

The patient had an uneventful recovery and she was discharged eight days later to a rehab facility.

DISCUSSION

Endoscopic placement of stents in common bile duct of pancreatic duct has been an important scientific achievement of modern medicine and is a frequently employed method to relieve either benign or malignant stenosis/obstruction of biliary or pancreatic tract. It was first described in 1980 by Soehandra et al[5] as an alternative method of decompressing the biliary system for high risk or inoperable cases instead of surgical choledochoduodenostomy. After the first description of endoscopic biliary stent placement, the whole procedure and the available stents have been significantly improved and the popularity of this technique is gradually increasing as it constitutes a less morbid intervention comparing to a surgical operation[6]. Despite its clear benefit and the significant improvements in this field, there is always the risk of significant complications during or after endoscopic procedures like upper endoscopy and biliary tract cannulation.

Well described complications of biliary stent placement include stent occlusion by clogging with possible subsequent cholecystitis or cholangitis, pancreatitis from duct manipulation, hemorrhage, stent fracture and stent migration[1,2,6,7]. The total rate of biliary stent complications varies among different institutes because of different level of experience, different available equipment and different etiologic reasons for the intervention. According to Arhan et al[2] the complication rete for biliary stents is between 8% and 10%. Stent migration rate ranges from 5% to 10%, with the migration rates in plastic stents higher compared to others[2,7,8]. Biliary stent migration can be further categorized into proximal and distal migration. Distally migrated stents usually pass through the bowel without any complication[1,9]. In our case the patient had multiple previous laparotomies which led to adhesions, thereby making the bowel less mobile. This led to an increased likelihood that the stent would get impacted and not pass. In general, most institutions have policies in place to make sure all stent patients are called back for stent removal, including our own. At the last ERCP there was a normal cholangiogram and the stent was no longer in place. It was felt to have migrated, but without symptoms the impression was that it had completely passed through and eliminated from the GI tract safely. In retrospect an X-ray or further imaging at that time would have been helpful.

Bowel perforation from a migrated stent is a serious complication, which can occur in any part of the small or large bowel. The vast majority of reported cases with bowel perforation from migrated biliary stent describe either duodenal perforation or large bowel perforation, with very few cases of small bowel perforation. Most patients with perforation will present with diffuse peritonitis and signs of sepsis. In our patient, we believe the amount of infection was limited by the perforation happening slowly over time, and her septic response was also blunted by her HIV with a low CD4 count.A growing body of literature exists on this topic and different treatment approaches have been proposed. Diller et al[10] reported a case series of stent migration necessitating surgical intervention in 2003. The size of the stents varied between 7 and 14 Fr and the lengths ranged from 7 to 12 cm. Two patients had Polyurethane stents, one patient had Teflon stent placement and the other two patients had metallic stents. The diagnosis was biliary obstruction from acute pancreatitis in 4 patients and the fifth patient received a prophylactic stent after liver transplantation. One of those five patients died from postoperative respiratory failure. In this study they reported a stent migration rate of 3.7% among 987 patients. Namdar et al[1] reported a case of rectal perforation from migrated biliary stent and review of literature with 12 cases in total and 7 cases from 2000. Several studies have shown that downstream migration is more frequent in benign than in malignant biliary disease, with the possible explanation being the resolution of the stenosis after regression of inflammation[1]. In addition, they state that any migrated biliary stent should be removed immediately regardless of the patient’s clinical status[1]. An early growing body of literature describes endoscopic techniques for treatment of bowel perforation from migrated stent, but the majority focus on duodenal perforation or distal large bowel perforation. Bureau et al[11] recently described a case series of six patients with lateral duodenal wall perforation from displaced plastic biliary stent that were treated with over-the-scope clip. Given that in our case the bowel perforation was in a mid-jejunal loop, the endoscopic approach was less feasible. In addition, there was already significant inflammation seen around the bowel on CT scan, and we were concerned that an endoscopic mucosal repair would not hold. As such, we proceeded directly to surgery.

We performed a systematic review of literature from 2000 until 2020 for bowel perforation from migrated biliary stents and we found 81 cases (Table 1). Eligible articles were identified by a search of MEDLINE bibliographical database (last search: July 4th, 2021) using the following search algorithm: (("intestinal perforation"[MeSH Terms] OR ("intestinal"[All Fields] AND "perforation"[All Fields]) OR "intestinal perforation"[All Fields] OR ("bowel"[All Fields] AND "perforation"[All Fields]) OR "bowel perforation"[All Fields]) AND ("migrate"[All Fields] OR "migrated"[All Fields] OR "migrates"[All Fields] OR "migrating"[All Fields] OR "migration"[All Fields] OR "migrational"[All Fields] OR "migrations"[All Fields] OR "migrator"[All Fields] OR "migrators"[All Fields]) AND "biliary"[All Fields] AND ("stent s"[All Fields] OR "stentings"[All Fields] OR "stents"[MeSH Terms] OR "stents"[All Fields] OR "stent"[All Fields] OR "stented"[All Fields] OR "stenting"[All Fields])) AND (2000:2020[pdat]). Further search was performed in the references of related articles and relative articles with our topic were included. Manuscripts with full text available online were used and E-Videos, E-pictures and not English manuscripts were excluded. Cases were also excluded if there was not full text available online. Wang et al[3] in 2020 reported three cases of duodenal perforation due to biliary stent migration and performed a review of literature of duodenal perforation from migrated stents. In this study they reported that duodenal perforation from migrated biliary stents are mainly caused by distal stent migration[3]. Kawaguchi et al[12] studied 396 patients with bile duct stenosis between June 2003 and March 2009, retrospectively examined the frequency of stent migration and analyzed the patient factors and stent characteristics. They found that potential risk factors for stent migration are stent with large diameter, straight-type stents, stent duration > 1 mo, and common bile duct diameter > 10 mm[12].

Table 1 Systematic review of literature from 2000 until 2020 for bowel perforation from migrated biliary stents.

No	Year	Age, yr	Gender	Type of stent1	Site of perforation	Treatment	Country	Mortality	Stent length	Stent size	Ref.
1	2000	81	M	P	SB	ST	Norway	Y	6.5	10 Fr	[13]
2	2000	86	M	P	LB	ST	Norway	N	5	7 Fr	[13]
3	2000	74	M	P	DU	ET	Spain	N	15	10 Fr	[14]
4	2001	58	M	P	DU	ET	Italy	N	12	10 Fr	[15]
5	2001	43	F	P	DU	ET	India	N	NA	10 Fr	[16]
6	2001	NA	NA	P	SB	ST	United States	N	12	11.5 Fr	[17]
7	2001	88	F	P	DU	ST	Germany	N	10	7 Fr	[18]
9	2001	31	F	NA	BD	ST	Denmark	N	NA	NA	[19]
10	2001	47	M	P	LB	ST	Spain	N	10	10 Fr	[20]
11	2002	72	F	P	SB	ST	Italy	N	NA	12 Fr	[21]
12	2002	NA	NA	P	SB	ST	United States	N	7	8.5 Fr	[22]
13	2003	85	F	P	LB	ST	Germany	N	NA	NA	[23]
14	2003	86	M	P	DU	ET	Italy	Y	15	10 Fr	[24]
15	2003	27	F	P	SB	ST	Germany	N	12	12 Fr	[10]
16	2003	58	M	P	LB	ET-ST	Germany	N	10	7 Fr	[10]
17	2003	60	F	P	SB	ST	Germany	N	12	14 Fr	[10]
18	2003	64	M	M	LB	ST	Germany	Y	7	10 Fr	[10]
19	2003	65	M	M	NA	ST	Germany	N	7	10 Fr	[10]
20	2003	62	F	P	LB	ST	Argentina	N	NA	8 Fr	[25]
21	2003	62	F	P	SB	ST	Argentina	N	NA	5.5/10 Fr	[25]
22	2003	80	F	P	LB	ST	Australia	N	10	10 Fr	[26]
23	2004	65	F	P	LB	ST	United States	N	NA	NA	[27]
24	2005	69	M	M	DU	ST	United States	N	NA	NA	[28]
25	2006	55	M	P	DU	ET	Greece	Y	NA	NA	[29]
26	2006	74	M	P	DU	ST	India	NA	10	7 Fr	[30]
27	2006	54	F	P	SB	ST	United Kingdom	N	7	10 Fr	[31]
28	2006	85	M	P	DU	ST	Italy	N	10	9 Fr	[32]
29	2007	65	F	P	LB	ST	Germany	N	10	12 Fr	[1]
30	2008	75	M	P	DU	ST	Taiwan	N	NA	NA	[33]
31	2008	52	F	P	DU	ST	Turkey	N	10	8.5 Fr	[34]
32	2008	67	M	P	DU	ST	Australia	Y	NA	5/10 Fr	[35]
33	2008	43	M	P	DU	ET	Belgium	N	NA	NA	[36]
34	2008	71	F	P	SB	ST	Belgium	N	NA	NA	[36]
35	2009	77	M	P	LB	PI	United States	N	12	10 Fr	[37]
36	2009	76	F	P	SB	PI	United States	N	NA	10 Fr	[38]
37	2009	59	F	P	SB	ST	Turkey	N	7	11 Fr	[39]
38	2011	58	M	P	DU	PI	United Kingdom	N	10	8.5 Fr	[40]
39	2011	65	F	P	LB	ST	Germany	N	10	10 F Fr	[41]
40	2011	73	NA	P	LB	ST	France	N	5	10 Fr	[42]
41	2011	75	M	P	SB	ST	United Kingdom	N	NA	NA	[43]
42	2011	70	M	P	DU	ET	China	N	NA	8.5 Fr	[44]
43	2011	82	F	P	LB	ET	United Kingdom	N	7	7 Fr	[45]
44	2012	55	M	P	DU	ET	South Korea	N	7/5	5 Fr	[46]
45	2012	27	F	P	DU	ST	United Kingdom	N	12	7 Fr	[47]
46	2012	87	F	P	DU	ET	United States	N	15	8.5 Fr	[48]
47	2012	73	M	P	LB	ET	Spain	N	12	10 Fr	[49]
48	2012	50	NA	P	LB	ET	Belgium	N	NA	NA	[50]
49	2013	51	M	P	DU	ST	S. Arabia	N	10	10 Fr	[51]
50	2013	66	M	P	LB	ET	United Kingdom	N	NA	NA	[52]
51	2013	50	M	M	SB	ST	India	N	NA	NA	[53]
52	2014	67	M	P	DU	ST	United States	Y	12	10 Fr	[54]
53	2014	73	M	P	LB	ST	Australia	N	5	10 Fr	[55]
54	2014	66	F	P	DU	ET	The Netherlands	N	15	NA	[56]
55	2015	48	M	P	DU	ET	United States	N	NA	NA	[57]
56	2015	NA	F	P	LB	ST	Italy	N	12	12 Fr	[58]
57	2015	NA	F	P	LB	ET	Italy	N	12	12 Fr	[58]
58	2015	52	F	P	SB	ST	Turkey	N	NA	NA	[7]
59	2015	NA	M	P	LB	ST	United Kingdom	Y	NA	NA	[59]
60	2016	85	F	P	SB	NA	Turkey	Y	NA	NA	[6]
61	2017	75	F	P	LB	ST	Greece	N	NA	NA	[60]
62	2018	57	M	P	DU	ET	United States	N	15	8.5 Fr	[61]
63	2018	79	F	P	DU	ET	United States	N	12+15	7+10 Fr	[62]
64	2018	87	M	P	DU	ST	Greece	N	15	10F	[63]
65	2018	20	M	P	SB	ST	Turkey	N	NA	NA	[64]
66	2019	71	M	P	DU	ET	France	N	12	8.5 Fr	[65]
67	2019	50	M	P	DU	ET	South Korea	N	10	10F	[66]
68	2019	78	M	P	DU	ET	South Korea	N	10	7 Fr	[66]
69	2019	72	M	P	DU	ET	South Korea	N	12	10 Fr	[66]
70	2019	84	F	P	DU	ET	South Korea	N	12	10 Fr	[66]
71	2019	73	F	P	DU	ET	South Korea	N	15	10 Fr	[66]
72	2019	63	F	P	DU	ST	Jordan	N	10	10 Fr	[67]
73	2019	65	F	P	LB	ST	Portugal	N	5	10 Fr	[68]
74	2019	79	F	P	LB	ST	United States	N	10	7+10 Fr	[69]
75	2020	90	F	P	SB	ST	Australia	N	9	10 Fr	[70]
76	2020	84	F	P	SB	ST	Australia	N	7	10 Fr	[71]
77	2020	72	M	P	DU	ET	China	N	9	8.5 Fr	[3]
78	2020	84	M	P	DU	ET	China	N	12	7 Fr	[3]
79	2020	52	M	P	DU	ET	China	N	9	8.5 Fr	[3]

¹Time interval from stent placement to complication in days.

P: Plastic; M: Metallic; BD: Bile duct; DU: Duodenum; SB: Small bowel; LB: Large bowel; ST: Surgical treatment; ET: Endoscopic treatment; PI: Percutaneous intervention; NA: Not available.

In our review of literature (Table 1) there were 39 (50%) of male gender, 35 (44.9%) of female gender and 4 (5.1%) patients with missing data. The mean age of the total population was 66 (± 15.5) and the median 67 (IQR-56-77.5). The majority of patients had a plastic stent (93.6%). The stent length ranged from 5 to 15 cm and the stent size from 5 to 14 Fr. However, the majority of patients (50%) had a stent of 10 Fr or 12 Fr size. From the total population 35 patients (44.9%) had duodenal perforation, 23 patients (29.5%) had large bowel perforation, 18 patients (23.1%) had small bowel perforation, one patient had bile duct perforation and the last patient had no available information regarding the site of perforation. From the whole cohort, 47 patients (60.3%) had surgical intervention, 27 patients (34.6%) had endoscopic removal of the stent and 3 patients (3.8) had percutaneous removal of the stent. The overall mortality among the 54 patients was 8 patients (10.1%). Finally, the distribution of case reports was 38 (48.7%) from Europe, 21 (26.9%) from Asia-Middle East, 12 (15.4%) from the United States, 5 (6.4%) from Australia and 2 (2.6%) from South America.

CONCLUSION

From this review of literature, we can see that most common types of migrated stents entailing bowel perforation are the plastic stents and the most common site of perforation is duodenum. A significant finding is the mortality after bowel perforation from biliary stent which is as high as 10.3%. The main treatment is surgical stent removal, but a growing body of literature shows that endoscopic removal and mucosal repair is feasible in select cases. This has still not been accomplished in the mid portion of the bowel, however this might be an area for future innovation and research.