Case Report Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 16, 2024; 16(7): 432-438
Published online Jul 16, 2024. doi: 10.4253/wjge.v16.i7.432
Recognition and management of stent malposition in the portal vein during endoscopic retrograde cholangiopancreatography: A case report
Rui Wu, Feng Zhang, Hao Zhu, Ming-Dong Liu, Yu-Zheng Zhuge, Lei Wang, Bin Zhang, Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
ORCID number: Rui Wu (0000-0002-0994-9699); Feng Zhang (0000-0002-3653-5977); Yu-Zheng Zhuge (0000-0002-3829-5831); Bin Zhang (0000-0003-3516-8105).
Author contributions: Zhang B, Wang L, and Zhuge YZ helped conceptualize and supervise the study; Zhang B, Zhang F, Zhu H, and Liu MD helped collect data; Wu R and Zhang B helped analyze the data; Wu R, Zhang B, Zhu H, and Liu MD helped review the literature; Wu R helped draft the manuscript; and all the authors helped revise the manuscript and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Bin Zhang, MD, PhD, Associate Professor, Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, China. billzhangnju@foxmail.com
Received: May 2, 2024
Revised: May 30, 2024
Accepted: June 27, 2024
Published online: July 16, 2024
Processing time: 66 Days and 23.2 Hours

Abstract
BACKGROUND

Portal vein injury is an uncommon complication of endoscopic retrograde cholangiopancreatography (ERCP), for which stent malpositioning in the portal vein is very rare and can lead to fatal events. We report a case of biliary stent migration to the portal vein and a novel method for its safe removal under the guidance of portal angiography. Moreover, we reviewed the literature and summarized reports on the identification and management of this condition.

CASE SUMMARY

A 59-year-old woman with pancreatic cancer presented with abdominal pain and a high fever 20 days after the placement of two plastic biliary stents under the guidance of ERCP. Blood cultures and laboratory tests revealed sepsis, which was treated with antibiotics. A contrast-enhanced computed tomography scan revealed that one of the biliary stents in the main portal vein was malpositioned. To safely remove the stent, portal angiography was performed to visualize the portal vein and to allow the management of any bleeding. The two stents were removed without obvious bleeding, and an uncovered self-expanding metal stent was placed in the common bile duct for drainage. The patient had an uneventful 6-month follow-up period, except for self-resolving portal vein thrombosis.

CONCLUSION

The combination of endoscopic and angiographic techniques allowed uneventful management of stent malposition in the portal vein.

Key Words: Endoscopic retrograde cholangiopancreatography; Stent malposition; Portal vein; Portal angiography; Case report

Core Tip: Stent malpositioning in the portal vein is a very rare complication of endoscopic retrograde cholangiopancreatography and can be fatal. We report a case of stent migration into the portal vein and a novel method for its safe removal under the surveillance of portal angiography. After reviewing the literature, we summarized the characteristics of reported cases, including predisposing factors and manifestations of stent malposition in the portal vein, and other treatments, such as immediate stent removal, metal stent placement in the bile duct, urgent surgery, and covered stent placement in the portal vein.



INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used in the diagnosis and management of pancreaticobiliary diseases. Portal vein injury is a rare complication of ERCP that can occur at any step during or after the procedure, including cannulation, sphincterotomy, stent placement, and nasobiliary drainage[1-5]. Stent malpositioning in the portal vein is extremely rare and may lead to fatal complications such as venous air embolism and fatal hemorrhage. This report describes a case of biliary stent migration into the portal vein and a novel method for its safe removal under the guidance of portal angiography. After searching PubMed for previously reported cases, we reviewed the literature on the identification and management of this complication[3,4,6-12].

CASE PRESENTATION
Chief complaints

A 59-year-old woman suffered from abdominal pain and a high fever for 10 days.

History of present illness

Ten days prior, the patient suffered a sudden onset of fever (41.0 °C) and abdominal pain. A 6-day course of antibiotics consisting of cefoperazone, sulbactam and metronidazole was undertaken at the local hospital, but the symptoms did not improve. Before admission, the patient presented with a fever fluctuating between 37.5 °C and 39.0 °C with chills. She had no history of hematemesis, melena, nausea, vomiting, diarrhea, or dark urine.

History of past illness

She was diagnosed with unresectable pancreatic cancer 6 months prior and had a history of duodenal ulceration. She underwent ERCP for biliary drainage at the time of cancer diagnosis 6 months prior and has since received 4 months of immunotherapy, 5 months of chemotherapy and 50 Gy/10 F local radiotherapy. One month prior, she underwent ERCP for replacement of plastic biliary stents (an 8.5 F, 7 cm single external flap stent and a 7 F, 7 cm single pigtail stent), as shown in Figure 1.

Figure 1
Figure 1 Two plastic biliary stents (an 8.5 F, 7 cm single external flap stent and a 7 F, 7 cm single pigtail stent) from previous endoscopic retrograde cholangiopancreatography. A: X-ray images; B: Endoscopic images.
Personal and family history

The patient’s personal and family history was not significant.

Physical examination

Body temperature, 37.5 °C; blood pressure, 108/69 mmHg; heart rate, 98 beats/min; respiratory rate, 20 breaths/min. Physical examination revealed moderate tenderness in the right upper quadrant without rebound tenderness and a negative Murphy’s sign.

Laboratory examinations

The relevant laboratory findings were as follows: White blood cell count, 11800/mm3; hemoglobin level, 9.00 g/dL; alanine aminotransferase level, 54.00 IU/L; total bilirubin level, 0.35 mg/dL; alkaline phosphatase level, 286.80 U/L; lactate dehydrogenase level, 327.00 U/L; and albumin level, 2.86 g/dL. The serum amylase level was normal. Blood culture revealed Eshcerichia hermannii and Enterococcus faecalis. Her C-reactive protein level was 212.90 mg/L, and her procalcitonin level was 2.90 ng/mL.

Imaging examinations

A contrast-enhanced computed tomography (CT) scan revealed a biliary stent in the main portal vein (Figure 2A and B).

Figure 2
Figure 2 Contrast-enhanced computed tomography. A: Contrast-enhanced computed tomography (CT) image showing that a biliary stent had entered the main portal vein; B: Contrast-enhanced CT images of the reconstructed portal vein; C: The single pigtail stent separated from the single flap stent and migrated straight up the spine into the portal vein; D: Repeated portal angiography showed no contrast leakage after placement of the fully covered metal stent in the common bile duct.
FINAL DIAGNOSIS

The diagnosis was portal vein injury caused by biliary stent malposition and consequent sepsis.

TREATMENT

The patient’s temperature returned to normal after imipenem treatment, according to the drug susceptibility test. After discussion with a multidisciplinary team, we decided to remove the stent endoscopically under the guidance of portal angiography. During the procedure, portal angiography was first performed to visualize the portal vein and its relationship to the stents. As shown in Figure 2C, the single pigtail stent separated from the single flap stent and migrated straight up the spine into the portal vein. The two stents were then carefully removed, and there was no obvious bleeding from the papilla. An uncovered self-expanding metal stent was then placed in the common bile duct for drainage. Finally, repeated portal angiography revealed no active bleeding (Figure 2D), and endoscopic nasobiliary drainage was performed.

OUTCOME AND FOLLOW-UP

After the procedure, the patient had a transient fever that did not recur. The patient did not complain of abdominal pain, melena, nausea or vomiting, and her amylase level after ERCP was normal. Four days after ERCP, a repeat contrast-enhanced CT scan revealed portal vein thrombosis (Figure 3A), and the nasobiliary drain was removed. The patient did not receive anticoagulant therapy due to duodenal ulcers and fecal occult blood. The thrombus was noticeably reduced in size at the first month follow-up (Figure 3B) and was no longer present at the third month follow-up (Figure 3C). The patient continued to receive chemotherapy and experienced an uneventful 6-month follow-up period.

Figure 3
Figure 3 Repeat contrast-enhanced computed tomography scan showing portal vein thrombosis. A: Portal vein thrombosis occurred after endoscopic retrograde cholangiopancreatography; B: The portal vein thrombus appeared significantly smaller at the one-month follow-up exam; C: The portal vein thrombus was no longer present at the three-month follow-up exam.
DISCUSSION

Portal vein injury is a rare complication of ERCP and can result in bleeding, sepsis, portal vein thrombosis and air embolism[13-18]. Among all types of portal vein injury, stent malpositioning into the portal vein is very rare and comparatively severe, with only a few cases reported in the literature (Table 1). Stent malpositioning tended to occur in patients with cholangitis or tumors, probably due to tissue fragility caused by inflammation or tumor invasion. In the case of malignancy, combining chemotherapy or adding radiotherapy may also increase the fragility of the tissue. In these cases, difficult cannulation and sphincterotomy often accompany the procedure and therefore increase the risk of stent malpositioning into the portal system. Stents may enter the portal vein during the procedure or migrate into the portal vein days or months after the procedure. During ERCP, there are several signs that a stent may have been placed in the portal vein. First, the endoscopist may feel resistance when placing the catheter or stent. Second, the injected contrast material may rapidly flow toward the liver and disappear within seconds. Third, the stent appears “straight up” along the portal vein and parallel to the spine on X-ray. Figure 2A clearly shows the position of the migrated stent in relation to the other well-positioned stent in the CBD. Finally, the aspiration of blood helps to confirm whether the cannula entered the portal vein. After ERCP, if stent malpositioning is not immediately detected during the procedure, patients may present with abdominal pain, fever, melena and unimproved jaundice. Abdominal ultrasound and CT usually help clinicians confirm the diagnosis. In this particularly rare case, the stent was correctly placed during the procedure and functioned normally for one month until it migrated to the portal vein. The patient presented with fever and abdominal pain, and the CT scan clearly showed the migration of the stent. It was reasonable to assume that the stent migrated after penetrating the fragile bile duct wall because of tumor growth, chemotherapy and radiotherapy. In addition, tension from the pigtail can easily cause perforation and induce stent migration.

Table 1 Published case reports of endoscopic retrograde cholangiopancreatography-related stent malpositioning in the portal vein.
Ref.
Gender, age
Indication for ERCP
Procedure
Stent
Clinical manifestation
Treatment
Follow-up
Outcome
Stableforth et al[6], 2011Male, 73Pancreatic cancerPBS replacement7-Fr, 10-cm straightConsistent jaundice; Brisk bleeding after removal of the stent; Filling of the portal vein and rapid washout of contrast material; confirmed by CTPBS left in situ; metal stent placement via PTC2 monthsNo complications
Miloudi et al[7], 2011Female, 60Benign narrowing of the CBD after transplantationPBS replacement10-Fr, 10-cmDifficult insertion of the new PBS; Fever and abdominal pain shortly after ERCP; Confirmed by abdominal ultrasound and CTSurgery to remove the prosthesis, close the fistula, repair the portal vein, and develop hepatico-jejunal anastomosisSeveral daysUneventful
Leung et al[8], 2012Female, 10Recurrent pancreatitisPancreatic sphincterotomy, pancreatic stent placement3-Fr, 6 cm, pigtailFever, abdominal pain, and elevated amylase; Confirmed by ultrasound and CTRemove the stent by ERCP on the 3rd postoperative day3 monthsPortal vein thrombosis gradually resolved
Dawwas et al[9], 2013Male, 69CBD stonesDifficult cannulation, biliary sphincterotomy, PBS placement7-Fr, 4-cm, double pigtailBleeding after removal of previous stent, and faint, rapidly dissipating, biliary-like opacification on contrast injectionsAbandon the procedure immediately2 monthsGas and thrombosis in the portal vein gradually resolved
So et al[10], 2015Male, 55Hilar invasion of hepatocellular carcinomaPBS replacementNARecurrent melena and bacteremia; Exacerbated bleeding after removing the stent; Cholangiography revealed leakage of contrast dye into the portal veinPlacing fully covered self-expandable metal stent in the bile ductSeveral daysRecovering from recurrent bacteremia and bleeding
Russo et al[11], 2017Female, 39Acute cholangitisBiliary sphincterotomy, failed sweeping of stones by a ballon, and PBS placement7-Fr, 7-cmResistance on stent placement, bleeding upon stent deploymentPBS left in situ, emergent laparotomy to repair the injury and T-tube placementSeveral daysResolve from the surgery
João et al[12], 2022Female, 60Biliary anastomotic stenosis after liver transplantationDifficult cannulation, biliary sphincterotomy, balloon dilation, PBS placementTwo 8.5-Fr, 9.0-cmSpurting hemorrhage when removing the stentEndoscopic removal of stent, percutaneous transhepatic fully covered self-expanded metal stent in the portal vein1 monthClinically stable, no bleeding relapse
Lin et al[3], 2023Male, 34CBD stones, cholangitisDifficult cannulation, sphincterotomy, balloon dilation, PBS placement7-FrHemobilia upon inserting the stent; Confirmed by CT scanSurgery: Cholecystectomy and CBD stones
removement, endoscopic removal of stent
9 monthsUneventful
Taşar et al[4], 2023Female, 54CBD stones, cholangitisDifficult cannulation, sphincterotomy, stone extraction, PBS placement10-Fr, 7-cmHemorrhage, fever and persistent jaundice; Confirmed by CT scanLaparoscopic exploration with ERCPSeveral monthsChronic portal thrombus

The table shows several treatment options, including immediate stent removal, metal stent placement in the bile duct, emergency laparotomy and surgical repair, and the placement of a fully covered metal stent in the portal vein via a percutaneous or transjugular approach. In this case, the stents were removed endoscopically under the guidance of portal angiography. In the event of portal bleeding, covered, self-expanding metal stents could be delivered into the portal vein and expanded to close the fistula and stop the bleeding. This method was safer than direct endoscopic removal of the stent for timely management of bleeding and less invasive than surgery.

Of the cases that have been reported, few rare cases of fatal bleeding after stent migration to the portal vein or stent removal from the portal vein have been reported, and in most cases, this can be managed uneventfully. There are several explanations. First, the pressure in the portal vein (5-10 mmHg) is lower than that in the bile duct (10-15 mmHg), so blood cannot flow strongly against the pressure gradient[16]. Second, the formation of portal vein thrombosis can occlude the vessel and control bleeding. Third, the portal vein and common bile duct pass together within the hepatoduodenal ligament, and after stent removal, these tissues may shrink to seal the site of injury. However, portal hypertension, large French stents and coagulation disorders can increase the risk of fatal bleeding.

To avoid stent migration to the portal vein, endoscopists must proceed with caution in patients with cancer or cholangitis, especially if cannulation and sphincterotomy are difficult. The sensation of resistance when passing the catheter or stent, the rapid washing out of contrast agent, and the aspiration of blood will reveal portal vein injury, thus stopping the procedure without force is critical. If stent migration to the portal vein occurs, portal vein angiography or surgery can be considered, and the stent can be removed endoscopically to manage potentially fatal bleeding.

CONCLUSION

In conclusion, we report a case of stent migration into the portal vein after ERCP in a patient who presented with fever and abdominal pain after pancreatic cancer diagnosis. The combination of endoscopic and angiographic techniques allowed uneventful management. Literature was reviewed for reported cases in which this rare complication was identified and managed.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single-blind

Specialty type: Gastroenterology and hepatology

Country of origin: China

Peer-review report’s classification

Scientific Quality: Grade B

Novelty: Grade B

Creativity or Innovation: Grade B

Scientific Significance: Grade B

P-Reviewer: Chow WK S-Editor: Chen YL L-Editor: A P-Editor: Cai YX

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