The development of biliary drainage and stenting

Bacterial Pericarditis Caused by Penetration of a Migrated Biliary Stent from the Lateral Segment of the Liver: A Case Report

Endoscopic biliary stent insertion is a well-established procedure that is indispensable in the management of various benign and malignant biliary disorders, and one that helps prevent mortality related to invasive surgical procedures. We report a rare case of the distal migration of a biliary stent outside the abdomen to the pericardium, inducing constrictive pericarditis and septic shock. This case alerts clinicians to be aware of potential adverse events that can lead to unfavorable patient outcomes. Such adverse events can be effectively avoided through early detection and intervention.

Risk factors for proximal migration of biliary tube stents

AIM: To analyze the risk factors for biliary stent migration in patients with benign and malignant strictures.

METHODS: Endoscopic stent placement was performed in 396 patients with bile duct stenosis, at our institution, between June 2003 and March 2009. The indications for bile duct stent implantation included common bile duct stone in 190 patients, malignant lesions in 112, chronic pancreatitis in 62, autoimmune pancreatitis in 14, trauma in eight, surgical complications in six, and primary sclerosing cholangitis (PSC) in four. We retrospectively examined the frequency of stent migration, and analyzed the patient factors (disease, whether endoscopic sphincterotomy was performed, location of bile duct stenosis and diameter of the bile duct) and stent characteristics (duration of stent placement, stent type, diameter and length). Moreover, we investigated retrieval methods for migrated stents and their associated success rates.

RESULTS: The frequency of tube stent migration in the total patient population was 3.5%. The cases in which tube stent migration occurred included those with common bile duct stones (3/190; 1.6%), malignant lesions (2/112; 1.8%), chronic pancreatitis (4/62; 6.5%), autoimmune pancreatitis (2/14; 14.3%), trauma (1/8; 12.5%), surgical complications (2/6; 33.3%), and PSC (0/4; 0%). The potential risk factors for migration included bile duct stenosis secondary to benign disease such as chronic pancreatitis and autoimmune pancreatitis (P = 0.030); stenosis of the lower bile duct (P = 0.031); bile duct diameter > 10 mm (P = 0.023); duration of stent placement > 1 mo (P = 0.007); use of straight-type stents (P < 0.001); and 10-Fr sized stents (P < 0.001). Retrieval of the migrated stents was successful in all cases. The grasping technique, using a basket or snare, was effective for pig-tailed or thin and straight stents, whereas the guidewire cannulation technique was effective for thick and straight stents.

CONCLUSION: Migration of tube stents within the bile duct is rare but possible, and it is important to determine the risk factors involved in stent migration.

Migration of biliary plastic stents: experience of a tertiary center

BACKGROUND AND STUDY AIMS

Stent migration occurs in about 5-10% of patients undergoing biliary stenting. The aim of this study was to analyze the risk factors for stent migration in patients with benign and malignant strictures.

PATIENTS AND METHODS

We retrospectively analyzed records of 524 biliary plastic stent placement procedures. Details noted included the cause and localization of stricture, characteristics and number of stents, direction of stent migration, presentation of patient with migrated stent, and the methods used for retrieval of migrated stents.

RESULTS

Two hundred and four (38.9%) of the procedures were performed for benign biliary strictures (BBS) and 320 (61.1%) for malignant biliary strictures (MBS). Thirty-four patients had 45 migrated biliary stents. The rate of migration was 8.58% (proximal 4.58% and distal 4.00%). Migration frequency was higher in BBS compared with MBS (13.7% versus 5.3%, p=0.001). In BBS, the rate of stent migration was higher in cases with one (19.3%) and two stents (20.9%) when compared with cases with multiple stents (2.7%) (p=0.001; p=0.001, respectively). Migration occurred more frequently (10.9%) in cases with two stents when compared both to cases with one stent (3.0%) and those with multiple stents (0%) in MBS (p=0.008; p=0.020, respectively). In BBS, short stents migrated more frequently proximally (77%) and long stents more frequently distally (73%) (p=0.008). In BBS, migration in cases with proximal stricture occurred more frequently distally (76.9%), while in those with distal stricture, migration was more frequently proximal (73.3%) (p=0.008). All of the proximally migrated stents could be successfully retrieved endoscopically.

CONCLUSIONS

The risk of stent migration is higher in BBS compared with in MBS. The cases with multiple stents had significantly lower stent migration. In BBS, long stent, proximal and postcholecystectomy strictures were associated with distal migration, while short stent, distal and non-postcholecystectomy strictures were associated with proximal migration.

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma

BACKGROUND

Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed.

METHODS

Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed.

RESULTS

Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days.

CONCLUSION

At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.