A review of problems following insertion of biliary stents illustrated by an unusual complication

Endoscopic Treatment of Duodenocolic Fistula Caused by Migrating Biliary Stents

BACKGROUND Endoscopic biliary stent implantation is a recognized and effective method for the treatment of benign and malignant diseases of the bile duct and pancreas, ensuring smooth bile drainage. Currently, stent migration is considered a long-term and complex process, and in most cases, stents are removed through endoscopy or expelled from the body through the intestinal cavity. In rare cases, stents lead to formation of duodenocolic fistulas. CASE REPORT We report a case of duodenal colon fistula caused by a biliary stent penetrating the duodenum and entering the ascending colon. We removed the stent through endoscopy and clamped the fistulas of the colon and duodenum separately with titanium clips. Due to the presence of large common bile duct stones, nasobiliary drainage was performed again. Later, laparoscopic choledocholithotomy was performed, and the patient was discharged after rehabilitation. CONCLUSIONS ERCP endoscopy must consider the possibility of stent displacement in patients with biliary stents. In the case of CBD biliary stent dislocation in the patient, continuous abdominal plain films and physical examinations are required until spontaneous discharge is confirmed. In addition, for patients with benign bile duct stenosis undergoing biliary drainage, doctors should urge them to return to the hospital on time to remove the stent. For patients with postoperative abdominal pain or peritonitis symptoms, abdominal CT scan confirmation is required and early intervention should be considered.

Outcome of forgotten biliary stents for more than five years-A two-decade experience

BACKGROUND AND OBJECTIVES

Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years.

METHODS

The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients.

RESULTS

The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%).

CONCLUSIONS

Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.

CT imaging features of bile duct stent complications

Biliary stents have been widely used to treat both malignant and benign biliary obstruction. Biliary stenting serves as a temporary measure to maintain ductal patency and promote bile drainage. Biliary decompression can help relieve clinical symptoms of pain, obstructive jaundice, pruritis, fat malabsorption, and failure to thrive and prevent disease progression, such as secondary biliary cirrhosis and end-stage liver failure. Endoscopic placement of biliary endoprosthesis is a minimally invasive procedure well tolerated by most patients but is not without problems. Multiple early and late complications have been reported in the literature and Computed Tomography (CT) is the most used modality to assess normal positions and evaluate patients suspected of stent complications. The aim of this article is to provide a review various of biliary stent related complications, as seen on CT. Current literature on risk factors, diagnosis and management is also discussed.

A 21-Year-Old Man with Previous History of Gastrectomy, Cholecystectomy, and Biliary Stenting with Failed Non-Operative Management of Blunt Trauma to the Liver Due to Traumatic Stent Perforation

BACKGROUND Conservative management of blunt trauma to the liver is commonly used when there are no immediate signs of rupture or hemorrhage, but requires patient monitoring. The rate of failure for non-operative management ranges is 3-15%. This report is of a 21-year-old man with a previous history of gastrectomy, cholecystectomy, and biliary stenting with failed non-operative management of blunt trauma to the liver following a motor vehicle crash, due to traumatic stent perforation. CASE REPORT The patient reported abdominal pain and had positive FAST for fluid in the hepatorenal space. CT abdomen showed grade 3 hepatic injury and a common bile duct stent. He was resuscitated and admitted to the ICU. He developed escalating abdominal pain and tachycardia without hypotension. Repeat CT demonstrated a paraduodenal gas bubble. He underwent exploratory laparotomy, during which the following were found: hemoperitoneum, no active bleeding, a 3-cm blue stent exiting the left hepatic duct surrounded by a fibrous tract, and bile spilling from around the stent. The protruding portion of the stent was resected, the was tract oversewn, and the abdomen was closed. Once stabilized, the patient underwent ERCP with removal of the remaining stent segment. The postoperative course was complicated by surgical wound infection and fascial dehiscence managed operatively and with local wound care, and deep-space infections managed by interventional radiology drainage. CONCLUSIONS Blunt trauma injury of the liver can be successfully managed conservatively. However, this case highlights the importance of knowledge of the patient's medical history and the presence of biliary stents, which can result in traumatic biliary perforation with an intact liver.

A Novel Case of Biliary Stent Migration Causing Sigmoid Diverticula Entrapment

Pancreaticobiliary obstruction is a rare but life-threatening complication. Plastic biliary stents are a temporary utility to maintain the patency of the common bile ducts, typically lasting about four months. Biliary stents can rarely have complications, with the most common being migration through the gastrointestinal tract. We present a case of a patient with a plastic stent placed over five years, which was complicated by severe hematochezia due to the retention of the stent in a diverticulum. Given the increased risk of life-threatening complications post-stent life expectancy, there should be systems in place to prevent patients from being lost to follow-up.

Emerging Systemic Therapies in Advanced Unresectable Biliary Tract Cancer: Review and Canadian Perspective

Biliary tract cancer (BTC) is a group of rare and aggressive malignancies with a dismal prognosis. There is currently a significant lack in effective treatment options for BTC, with gemcitabine-cisplatin remaining the first-line standard of care treatment for over a decade. A wave of investigational therapies, including new chemotherapy combinations, immunotherapy, and biomarker-driven targeted therapy have demonstrated promising results in BTC, and there is hope for many of these therapies to be incorporated into the Canadian treatment landscape in the near future. This review discusses the emerging therapies under investigation for BTC and provides a perspective on how they may fit into Canadian practice, with a focus on the barriers to treatment access.

Intraductal fully covered self-expanding metal stents in the management of post-liver transplant anastomotic strictures: a UK wide experience

BACKGROUND

Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis.

OBJECTIVES

We conducted a multicentre study to analyse their use and efficacy in the management of AS.

DESIGN

This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom.

METHODS

Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data.

RESULTS

In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma (n = 35, 22%), followed by alcohol-related liver disease (n = 29, 18%), non-alcoholic steatohepatitis (n = 20, 12%), primary biliary cholangitis (n = 15, 9%), acute liver failure (n = 13, 8%), viral hepatitis (n = 13, 8%) and autoimmune hepatitis (n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12-74), and stent duration was 15 weeks (range, 3 days-78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4-88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically.

CONCLUSION

IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.

Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents

BACKGROUND

Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known complication, although data beyond the recommended interval of temporary stenting (3-6 months) are lacking. We compared the long-term incidence of DSM between straight and double-pigtail stents in patients with IBDS.

METHODS

Consecutive patients with IBDS undergoing plastic biliary stenting (1/2009-12/2019) were retrospectively reviewed. DSM was confirmed on follow-up examination when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Kaplan-Meier and Cox regression analyses were used to determine estimates and predictors of DSM.

RESULTS

Overall, 618 biliary stenting procedures (410 patients) were included: 289 with a straight stent (group A) and 329 with a double-pigtail (group B). By Kaplan-Meier analysis, the DSM rates were 8.4 and 14.6% at 6 months, 21.4 and 27.7% at 12 months, 27 and 43.5% at 18 months, and 37.2 and 60.4% at 24 months, for groups A and B, respectively (p = 0.004). Double-pigtail stents were at higher risk for DSM (HR = 7.38, p = 0.04), whereas an inverse correlation was noted with age (HR = 0.97, p = 0.0001). Considering only temporary stenting procedures (≤ 6 months; n = 297), the probability of DSM was not significantly different between the two groups (p = 0.07).

CONCLUSIONS

In a setting of prolonged stenting for IBDS, the probability of DSM appears to be higher when a double-pigtail stent is used and in younger patients. A relative anti-migratory advantage of double-pigtail over straight stents appears negligible in this study.

Minimally invasive management of an ascending colonic perforation secondary to distal biliary stent migration: a multidisciplinary, novel laparoendoscopic approach

Endobiliary stents placed for benign and malignant indications can spontaneously dislocate from the biliary system and migrate to the distal gastrointestinal tract. Stent migration can result in gastrointestinal perforation, with the most common locations in the sigmoid and distal colon, and may require surgical intervention. We describe the case of a 60-year-old female presenting with an ascending colonic perforation secondary to a dislodged plastic biliary stent placed for palliation of her gallbladder carcinoma. The patient was managed with a combined laparoendoscopic approach by a multidisciplinary team—gastroenterology performed an endoscopic stent retrieval and colorectal surgery identified the location of the perforation laparoscopically and performed colonic serosal repairs. The patient had an uneventful postoperative course and was discharged on postoperative day 4. This case demonstrates a novel minimally invasive laparoendoscopic approach at a high-volume academic center for the treatment of ascending colonic perforation secondary to biliary stent migration.

Implants with Sensing Capabilities

Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.

Colonic diverticular perforation by a migrated biliary stent: A case report with literature review

RATIONALE

Plastic endobiliary stents, after endoscopic retrograde cholangiopancreatography, can get spontaneously dislocated from the common bile duct and migrate intothe distal bowel. Most migrated biliary stents are removed with the passing of stool. However, migrated biliary stents can cause bowel perforation, albeit rarely, and surgical intervention may be required. Recently, we observed a colonic diverticular perforation caused by a migrated biliary stent, and we have reported this case with a review of the literature.

PATIENTS CONCERNS

A 74-year-old man presented with severe right lower quadrant pain after biliary stent insertion 1month ago.

DIAGNOSES

Abdominal computed tomography revealed perforation of the proximal ascending colon by the migrated biliary stent, combined with localized peritonitis.

INTERVENTIONS

Emergency diagnostic laparoscopic examination revealed penetration of the proximal ascending colon by the plastic biliary stent, and right hemicolectomy was performed.

OUTCOMES

On pathological examination, colonic diverticular perforation by the biliary stent was confirmed. The patient was discharged without any additional complications.

LESSONS

Endoscopic retrograde cholangiopancreatography endoscopists must always be cautious of the possibility of stent migration in patients with biliary stents in situ. In cases of biliary stent dislocation from the common bile duct in asymptomatic patients, follow-up with serial, plain abdominal radiographs, and physical examination is needed until confirmation of spontaneous passage through stool. In symptomatic cases suggesting peritonitis, abdominal computed tomography scan confirmation is needed, and early intervention should be considered.

Successful Removal of a Biliary Stent in the Jejunum Using Double-Balloon Enteroscopy

Background:

Plastic biliary stent placement has been widely used as a safe approach for the management of hilar neoplasms or the dilation of benign biliary obstruction. Despite the complexity of this procedure, this approach is followed by a few complications. The incidence rate of stent migration is about 10%. In a majority of cases, the migrated stents are retained within the gastrointestinal tract and pass through the intestine with no complication or need for medical intervention.

Case Report:

In this paper, we described the case of the migrated biliary stent with prolonged abdominal pain, which was removed successfully by using double-balloon.

Conclusion:

In the case of patient with prolonged abdominal pain and previous history of biliary stent placement, migration of stent should be considered as differential diagnosis and Double-Balloon Enteroscopy can be a safe approach in those cases.

Biliary stent migration: why, how, and what?

BACKGROUND AND PURPOSE

The frequency, risk factors as well as the sites of biliary stent migration are variable in the literature. This retrospective study investigated the frequency of biliary stent migration, why biliary stents migrated, how the migrated stents affected the patients, and what are the different techniques retrieved the migrated stents.

PATIENTS AND METHODS

Out of 876 stented patients, 74 patients (8.4%) had their stents migrated. Patients with and without migrated stents were compared regarding endoscopy and stent-related parameters. The sequels of stent migrations were reported. Furthermore, the methods used for stent retrieval were reviewed.

RESULTS

Proximal and distal stent migration occurred at a rate of 3 and 5.5%, respectively. The independent predictors for stent migration were moderate to marked common bile duct (CBD) dilation, complete sphincterotomy, the use of balloon dilation, and stent insertion for more than 1 month. Cholangitis and stent obstruction was the most commonly reported adverse event (n = 18, 24.3%). Distal stent migration associated with two cases of bleeding due to duodenal wall injury, and two cases of duodenal perforation. All the retained migrated stents in the current study were retrieved by endoscopy using extraction balloon, Dormia basket, snares, and foreign body forceps.

CONCLUSION

Biliary stent migration occurs at a rate of 8.4%. Stents do migrate because of dilated CBD, wide sphincterotomy, and biliary balloon dilation. Furthermore, wide, straight stents inserted for more than 1 month easily migrate. The migrated stents migrated intraluminal in the CBD, duodenum or the colon. All the retained migrated stents were retrieved endoscopically.

Duodenal diverticulum at the site of the major papilla may be a risk factor for biliary stent migration

Stent migration is a well-documented complication following biliary stent insertion. The majority of cases demonstrate passage through the bowel without incident; however, migration may also result in complications, including bowel obstruction or perforation requiring urgent intervention. Risk factors for stent migration comprise of disease pathology as well as stent characteristics including dimension, material and number. Although duodenal diverticulae has been noted as a risk factor for duodenal perforation or obstruction post stent migration, it has yet to be implicated as a contributor to migration itself. Here, we present an unusual case of ileal obstruction secondary to biliary stent impaction, in which the presence of a duodenal diverticulum may be considered a viable risk factor for stent migration.

Sigmoid colon perforation caused by migrated plastic biliary stents: a case report

INTRODUCTION

Endoscopic migration of plastic biliary stents is performed by endoscopic retrograde cholangiopancreatography (ERCP) for biliary and pancreatic diseases. This plays an increasingly important role. Intestinal perforation caused by stent migration is one of the complications. Although sigmoid colon perforation caused by stent migration is rare, it can be life-threatening. This case shows us that we should increase awareness of sudden abdominal pain after ERCP.

METHOD

We provide a review of the clinical manifestations, imaging data of this case, and the literature related to the perforation caused by stent migration.

RESULTS

A male patient had a history of choledocholithiasis, cholecystolithiasis, and biliary pancreatitis treated with ERCP and a pancreatic stent. After the operation, the patient developed cholangitis and was treated with ERCP and a plastic biliary stent. This patient was admitted to the emergency department with sudden lower abdominal pain. A CT scan showed sigmoid colon perforation by a foreign body and infra-diaphragmatic free air. An emergency surgery confirmed that the stent had caused the perforation. The patient was then treated with sigmoid colectomy and sigmoidostomy.

DISCUSSION

Biliary stent migration after ERCP is rare, but intestinal perforation caused by migration should be considered in cases of abdominal pain of unknown cause.

Transhepatic intraperitoneally migrated biliary stent: A rare finding during laparoscopic cholecystectomy

Biliary endoprostheses are increasingly being utilised across both the developing and developed world, due to growing access to endoscopic biliary stenting. Stent migration, a well-documented complication of this minimally invasive procedure, occurs in up to 10% of cases post-insertion, sometimes leading to catastrophic complications. While distal migration frequently leads to spontaneous passage of the stent, proximal migration can result in a variety of problems. We here describe a rare case of transhepatic intraperitoneal migration of a double-pigtail, plastic stent and present a comprehensive review of literature.

Livovsky D, Nubani A, Mari A, Goldin E, Mahamid M. Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study

Background: Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction. Aim: We aimed to report the safety of retained biliary stone. Methods: a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis. Results: Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively). Conclusion: endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.

Retained biliary plastic stents - lest we forget

Prolonged indwelling of endoscopically placed biliary plastic stents may lead to complications. We conducted a retrospective analysis of patients who underwent endoscopic retrograde cholangio-pancreaticography (ERCP) at our centre in 2017 and were noted to have retained biliary plastic stents ( > 3 months after an index ERCP). A total of 127 patients had previously placed biliary plastic stents, out of which 45 (35.4%) were retained. The median age of the latter was 52 years (range = 22-79 years) with 27 (60%) patients being men. The median duration of the retained stents was 144 days (range = 94-3292 days). The majority of the patients were asymptomatic. However, 9 (20%) patients had cholangitis, 2 (4.4%) had choledocholithiasis, 2 (4.4%) had cholangitic abscess and 1 (2.2%) developed septicaemia. Fortunately, all these complications could be managed medically and endoscopically. Retention of biliary plastic stents is a problem often overlooked and underestimated in clinical practice. Various measures need to be instituted to create awareness of this entity to prevent undesirable outcomes.

Risk factors for distal migration of biliary plastic stents and related duodenal injury

BACKGROUND

The risk factors of duodenal injury from distal migrated biliary plastic stents remain uncertain. The aim of this study was to determine the risk factors of distal migration and its related duodenal injury in patients who underwent placement of a single biliary plastic stent for biliary strictures.

METHODS

We retrospectively reviewed all patients with biliary strictures who underwent endoscopic placement of a single biliary plastic stent from January 2006 to October 2017.

RESULTS

Two hundred forty-eight patients with 402 endoscopic retrograde cholangiopancreatography procedures were included. The incidence of distal migration was 6.2%. The frequency of duodenal injury was 2.2% in all cases and 36% in cases with distal migration. Benign biliary strictures (BBS), length of the stent above the proximal end of the stricture (> 2 cm), and duration of stent retention (< 3 months) were independently associated with distal migration (p = 0.018, p = 0.009, and p = 0.016, respectively). Duodenal injury occurred more commonly in cases with larger angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body (p = 0.018) or in cases with stent retention < 3 months (p = 0.031).

CONCLUSIONS

The risk factors of distal migration are BBS and the length of the stent above the proximal end of the stricture. The risk factor of duodenal injury due to distal migration is large angle (≥ 30°) between the distal end of the stent and the centerline of the patient's body. Distal migration and related duodenal injury are more likely to present during the early period after biliary stenting.

Removal of proximally migrated biliary stents by using single-operator cholangioscopy

Background and Aims

Migration is a late adverse event of biliary stent placement. It occurs in 1% to 20% of cases and is associated with a diverse array of adverse events. In this article, we report our take on endoscopic extraction of proximally migrated biliary stents by the use of single-operator cholangioscopy.

Methods

This report includes 3 patients who were found to have proximal stent migration while being treated for biliary stones. One patient had a migrated metal stent, and the other 2 had plastic stents. Single-operator cholangioscopy was used to retrieve the stents in all patients. The SpyBite biopsy forceps accessory was used to extract the metal stent, whereas the SpyBasket and the SpySnare were used to extract the plastic stents.

Results

All patients underwent successful stent removal by the techniques described in this report, with no immediate adverse events, and they completed more than 4 weeks of follow-up care with no further adverse events.

Conclusions

Digital single-operator cholangioscopy with SpyBasket, retrieval snare, and SpyBite biopsy forceps can be useful tools to remove migrated plastic and metallic stents, respectively.

Sigmoid Diverticulitis and Perforation Secondary to Biliary Stent Migration

Introduction

Biliary stent migration occurs in 5-10% of patients. Generally, this is a benign process and stents pass or are retrieved endoscopically. In rare instances, intestinal perforation has occurred.

Presentation of Case

A 79-year-old female presented with a one-day history of abdominal pain. She had undergone an ERCP four weeks previously for primary choledocholithiasis during which time a sphincterotomy and sphincteroplasty were performed, and stents were placed in the common bile duct. CT scan of the abdomen and pelvis demonstrated a biliary stent that had migrated into the sigmoid colon, appearing to perforate the colon with free air throughout the abdomen. Patient was taken for diagnostic laparoscopy and noted to have biliary stent perforating the sigmoid colon. Procedure was converted to open, and Hartmann's procedure was performed with end colostomy.

Conclusion

Generally, biliary stent migration is a benign process, but in rare instances, intestinal perforation has occurred. Sites of perforation include the duodenum, distal small bowel, and colon. Perforation is more common with an additional pathology present such as hernias or diverticular disease. Migration and perforation also appear more common with straight biliary stents. In patients with known diverticular disease and straight biliary stents, considerations should be made for early stent removal.

An Unusual Case of Biliary Stent Migration in Sacrum

The common bile duct stenting has been a common endoscopic procedure practiced worldwide for the treatment of benign or malignant bile duct obstruction. Although the procedure has shown a very low morbidity, it is not free from complications. Stent migration has been a common late complication seen in 10% of cases presenting with various manifestations depending on the site of impaction. Here, we present a rare case of distal stent migration with impaction in the sacral foramina due to perforation through sigmoid diverticula with review of literature.

Size does matter: when a large plastic biliary stent ends up in the root of the mesentery

Duodenal perforations due to biliary stenting migration, although rare, can occur. We report a unique case of duodenal perforation due to a large in length plastic stent with no (or marginal) migration, which ended up in the root of the mesentery, explaining the normal laboratory values and minimal imaging findings observed. Any clinical symptom during the postprocedural period should raise the suspicion of a major complication and prompt quick management decisions.

Complications and management of forgotten long-term biliary stents

AIM

To evaluate complications and management outcomes of retained long-term plastic biliary stents.

METHODS

Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of long-term plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ² tests. Statistical significance was defined as P < 0.05 (two-tailed).

RESULTS

Mean age of patients was 73.7 ± 12 years and male-to-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones (63.2%, 24/38) and benign bile duct stricture (52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases (26.3%), stents were retained for more than 24 mo. Common bile duct (CBD) stones or sludge were found in most cases (92.1%, 35/38). The most common complication was acute cholangitis (94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1% (35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7% (28/38) of the cases. When patients were divided into two groups by duration of stent placement (12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents.

CONCLUSION

The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

Risk factors for biliary stent migration in patients with benign biliary strictures

AIM: To investigate risk factors for stent migration in patients with benign biliary strictures.

METHODS: The clinical data for 244 patients who underwent endoscopic retrograde biliary drainage (ERBD) for benign biliary strictures (BBS) from January 2005 to December 2009 were retrospectively reviewed. Details noted included the cause and location of stricture, length and number of stents, direction of stent migration, manifestations of patients with migrated stent, and methods used for retrieval of migrated stents.

RESULTS: Four hundred and eight biliary plastic stent placement procedures were performed for benign biliary strictures in 244 patients. There were 56 migrated stents identified. Compared to other causes, stricture after biliary duct exploration was associated with a significantly lower migration rate (6.8% vs 21.18%, χ² = 42.585, P < 0.001). Migration direction was associated with the location of stricture (23.1% vs 76.9%; 73.3% vs 26.7%, both P < 0.001). The length of stent is associated with migration direction (23.1% vs 73.3%; 76.9% vs 26.7%, both P < 0.001). Short stent tends to migrate proximately, whilst long stent more often migrates distally. Both single and double stent placement was associated with higher migration rate than multiple stent placement (19.3%, 20.9% vs 2.7%, both P < 0.001). However, there is no significant difference in migration rate between single and double stent placement. The number of stents was not associated with migration direction. All migrated stents could be successfully retrieved endoscopically.

CONCLUSION: The risk factors for plastic stent migration in patients with benign biliary duct strictures include etiology of stricture, location of stricture, length and number of stents. Therefore, stent migration rate can be significantly reduced if the above conditions are carefully assessed in clinical practice.