Cut and Paste: Endoscopic Management of a Perforating Biliary Stent Utilizing Scissors and Clips

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

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.

Development of novel biliary metal stent with coil-spring structure and its application in vivo swine biliary stricture model

Background

As of date, endoscopic biliary stenting with plastic stent (PS) and self-expandable metal stent (SEMS) have been widely used for the palliation of biliary tract strictures. However, these two stents have several limitations regarding the management of biliary strictures caused by intrahepatic and hilar cholangiocarcinoma. PS has short patency and also risks bile duct injury and bowel perforation. SEMS is difficult to revise when occluded by tumor overgrowth. To compensate for such shortcomings, we developed a novel biliary metal stent with coil-spring structure. The aim of this study was to investigate the feasibility and efficacy of the novel stent in a swine model.

Methods

The biliary stricture model was prepared in six mini-pigs using endobiliary radiofrequency ablation. Conventional PS (n=2) and novel stents (n=4) were deployed endoscopically. Technical success was defined as successful stent placement and clinical success was defined as >50% reduction of serum bilirubin level. Adverse events, stent migration, and endoscopic removability for one month after stenting were also assessed.

Results

The biliary stricture was successfully created in all animals. The technical success rate was 100 %, and the clinical success rate was 50% in the PS group and 75% in the novel stent group. In the novel stent group, the median pre- and post-treatment serum bilirubin levels were 3.94 and 0.3 mg/dL. Stent migration occurred in two pigs and two stents were removed by endoscopy. There was no stent-related mortality.

Conclusions

The newly designed biliary metal stent was feasible and effective in a swine biliary stricture model. Further studies are needed to verify the usefulness of the novel stent in the management of biliary strictures.

Endoscopic treatment for duodenal perforation due to biliary stent dislocation: A case report and brief review of the literature

RATIONALE

Duodenal wall perforation by a dislocated biliary stent placed for biliary structure is rare but can be life-threatening. There are few reports on the management of stent-related duodenal perforation.

PATIENT CONCERNS

Three cases included in this study had undergone endoscopic retrograde cholangiopancreatography with placement of a plastic stent for biliary stricture. Two cases had symptoms (fever or abdominal pain), while other case showed no symptom after biliary stent placement.

DIAGNOSES

Dislocation of plastic stents was revealed on computed tomography or endoscopic images. Two patients were diagnosed with duodenal perforation due to distal migration of long stents with a straight shape on the distal side. One patient was diagnosed with fistula formation between the intrahepatic bile duct and duodenum due to perforation of a pigtail stent.

INTERVENTIONS

All cases could successfully be managed endoscopically with closure by hemoclips or stent replacement.

OUTCOMES

All 3 cases were improved after endoscopic treatment without any subsequent intervention.

LESSONS

Longer stents with a straight distal side are associated with a higher risk of duodenal perforation. Endoscopic management is appropriate as a first-line approach for a clinically stable patient. At the time of stent placement, we should pay attention to the length and type of stent.

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

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.

Novel Approach to Endoscopic Foreign Body Retrieval From the Gastric Body

Foreign body (FB) ingestion is a common occurrence in the United States with a reported incidence of 120 per 1 million people, accounting for up to 1500 fatalities annually. The majority of FB ingestions will pass through the gastrointestinal tract spontaneously, while in 10% to 20% of patients, intervention will be necessary. A variety of endoscopic devices can be utilized to facilitate FB removal from the gastrointestinal tract, including snares, retrieval nets, and grasping forceps. We report the case of a 58-year-old female who required utilization of endoscopic scissors for FB removal in the setting of multiple failed attempts with traditional methods. This case highlights a novel approach to gastric FB removal utilizing endoscopic scissor forceps, which should be considered in select cases to further improve the efficacy of endoscopic FB removal and reduce the need for surgical intervention.

Prevalence of and risk factors for stent migration-induced duodenal perforation

Background and study aims  The safety of transpapillary biliary drainage by stent placement through endoscopic retrograde cholangiography (ERC) may be compromised by the occurrence of stent migration-induced perforation of the duodenal wall (SMDP). We aimed to assess the prevalence rate, risk factors and clinical course of SMDP. Patients and methods  This retrospective cohort study included all patients who underwent an ERC with biliary plastic stent placement, between January 2014 and December 2018. Patients with an SMDP were identified from our endoscopy complication registry. Results  1227 patients underwent an ERC, of whom 629 patients (51 %) with biliary plastic stent placement; in 304 patients (25 %) stents were placed for perihilar strictures. Thirteen patients with SMDP were identified. The prevalence was 2.1 % for patients with biliary plastic stent placement and 4.3 % for patients stented for a perihilar stricture. All SMDPs occurred in patients with a perihilar stricture and with stents ≥ 12 cm (range 12-20 cm). Another potential risk factor was stent insertion into the left liver lobe, which was present in 10 of 13 patients. In 10 of 13 patients, SMDP was clinically suspected. Three of 13 patients were asymptomatic and diagnosed at elective stent retrieval. Eight patients could be endoscopically treated with an over-the-scope clip. Four patients died due to abdominal sepsis despite repeated interventions. Conclusion  SMDP is a rare but potentially life-threatening complication of ERC after transpapillary drainage for perihilar biliary strictures. Stents ≥ 12 cm and stent insertion into the left liver lobe may be associated risk factors.