Balaj Rai, MD1, William R. Geisen, DO1, Joshua R. Peck, MD2 1Christ Hospital, Cincinnati, OH; 2Ohio Gastroenterology and Liver Institute, Cincinnati, OH
Introduction: Endoscopic stents can establish patency in hepatobiliary obstruction. While endoscopy can show occlusion, computed tomography (CT) scans reveal extraluminal complication such as perforation.
Case Description/Methods: A 52-year-old female with biliary strictures requiring prior stent revisions, presented with abdominal pain. On prior admission, a 10 mm x 6 cm metal stent was placed for a distal biliary stricture with adequate fluoroscopic drainage (Image 1A). A CT scan of the abdomen and pelvis showed an irregular CBD stent with suspected stent fragmentation in the pancreatic head (Image 1B). Endoscopic retrograde cholangiopancreatography revealed a fragmented stent within the CBD with shrapnel perforating the duodenum. The distal portion of the stent was able to be removed with rat tooth forceps (Image 1C). Multiple attempts to remove the proximal fragmented portion using a 15 mm balloon were unsuccessful. A 8.5 Fr x 7 cm plastic biliary stent was introduced through the existing stent to ensure adequate drainage. Upon reexamination, a coiled piece of metal was visualized in the gastric antrum, likely attached to the proximal CBD stent fragment. The piece was unable to be removed/cut with endoscopic scissors. Two months later, the patient was readmitted for an elective biliary reconstruction and underwent an exploratory laparotomy with a Roux-en-Y hepaticojejunostomy and pancreatojejunostomy. Her hospital course was complicated by acute respiratory distress syndrome and splenic artery pseudoaneurysm. The patient was not able to be resuscitated despite surgical intervention.
Discussion: Reported cases are associated with nitrol-based stents, which are less malleable and prone to fatigue from peristaltic stress. Though bare metal stents are preferentially deployed with longer patency duration, patients may benefit from plastic stents if repeat stenting is anticipated. Manufacturing errors and bile-induced corrosion may also be factors in fracture.
We postulate that this patient’s friable mucosa secondary to recurrent stenting allowed distal migration, exposing the stent to increased shearing force. Stent fracture reporting is imperative for proper management and shrapnel must be carefully removed to prevent rupture/fistulization. Endoscopists need to be aware of complication so we can improve detection, mitigate risks, and select products with commendable structural integrity for complicated restenting.
Figure: Image 1A. A 10 mm x 6 cm fully covered metal stent was placed for a distal biliary stricture with excellent drainage on fluoroscopy. Image 1B. A follow-up CT scan of the abdomen and pelvis at five months showed showed an irregular CBD stent with suspected fragmentation in the pancreatic head. Image 1C. The distal portion of the stent was able to be removed with rat tooth forceps and dragged out of the mouth via ERCP.
Disclosures: Balaj Rai indicated no relevant financial relationships. William Geisen indicated no relevant financial relationships. Joshua Peck indicated no relevant financial relationships.
Balaj Rai, MD1, William R. Geisen, DO1, Joshua R. Peck, MD2. P2193 - Biliary Stent Fragmentation With Perforation into the Gastric Antrum Resulting in Mortality, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.