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While the only available definitive treatment option was previously surgery, the advancement in the minimally invasive endoscopic field led to the development of over-the-scope clips (OTSCs), which allow complete closure of full-thickness defects endoscopically.
A 66-year-old man was referred to our institution to resume management of choledocholithiasis and indeterminate biliary stricture. Eighteen months prior, he had jaundice secondary to bile duct stones and mid-distal common bile duct stricture for which he underwent ERCP and plastic stent placement. The COVID-19 pandemic led to delay in the necessary follow-up.
Examination during EGD and upper EUS showed an incidental finding of a biliary stent emerging from the major papilla and penetrating the opposite duodenal wall (type 1 perforation) (Video 1, available online at www.giejournal.org). The fluoroscopic image confirmed the perforation and approximately 1 cm of the stent extended outside the duodenal lumen. The defect measured 4 mm in diameter (Fig. 1; Video 1). The stent was pulled with a rat-tooth grasper under fluoroscopy (Fig. 2; Video 1). Coagulation for de-epithelialization of the surrounding tissue using argon plasma coagulation (Erbe, Marietta, Ga, USA) was successful (Fig. 3; Video 1). Although this step is not required, it can assist with de-epithelization and help with locating the defect after stent removal. An OTSC (OTSC 11/6T Clip; OVESCO, Tuebingen, Germany) was used. The gastroscope (GIF-H190; Olympus, Center Valley, Pa, USA) was readvanced and the defect was visualized. The tissue was carefully suctioned into the cap to allow successful clip deployment and defect closure (Figs. 4 and 5; Video 1). A lack of contrast extravasation confirmed complete closure (Fig. 6; Video 1).
Figure 1The fluoroscopic image confirmed the perforation, and approximately 1 cm of the stent extended outside the duodenal lumen and defect measured 4 mm in diameter.
A postprocedural CT scan showed no evidence of drainable fluid collection or extraluminal gas (Fig. 7; Video 1). The patient had no immediate or delayed adverse events. At his 2-month follow-up, he denied any pain, nausea, emesis, weight loss, or jaundice.
Figure 7A postprocedural CT scan showed the clip in the proper place and no extraluminal fluid collection, air, or contrast extravasation.
A 71-year-old woman presented to an outside hospital with painless jaundice requiring ERCP and bilateral plastic biliary stent placement. Five days later, she was referred to our hospital for duodenal perforation from a migrated biliary stent with retroperitoneal fluid collection seen on a CT scan. She underwent a similar approach with removal of the stent via rat-tooth forceps and primary endoscopic closure of the duodenal defect with tissue ablation with argon plasma coagulation and OTSC closure (Fig. 8; Video 1). She received antibiotics and percutaneous drain placement into the fluid collection. Again, the closure remained intact.
Figure 8Over-the-scope-clip closure of duodenal defect.
A 71-year-old woman with metastatic pancreatic adenocarcinoma presented with septic shock and encephalopathy, and she was found to have a migrated biliary stent with duodenal perforation. Her course was complicated by multiple intra-abdominal abscesses, extensive pneumoperitoneum (Fig. 9; Video 1), and was deemed not a surgical candidate given disease severity.
Figure 9Perforation of a common bile duct stent (red arrow) through the second/third portion of the duodenum with intra-abdominal free fluid (blue outline) and air (green outline).
She underwent an ERCP that showed a migrated biliary stent causing opposing duodenal wall perforation. The defect site was ablated and an OTSC mended the perforation. Antibiotics were continued and she underwent percutaneous drain placement with radiology. There were no immediate adverse events and she had improvement in pain and mentation.
Conclusion
Duodenal perforations from migrating plastic biliary stents are rare; however, they can be significantly morbid when they occur. While the presentations and time intervals between original stent placement to identification of duodenal perforation differed among the 3 cases (Table 1; Video 1), we found that endoscopic closure with OTSCs is an excellent option for intestinal perforation as a definitive treatment or bridge to further management.
Table 1Case comparison
Case 1
Case 2
Case 3
Age, sex
66, male
71, female
71, female
Clinical presentation
No significant history, presented with mild generalized abdominal pain
History of cholangiocarcinoma with biliary obstruction status after drainage with stents and colon cancer status post–partial colectomy, presented with obstructive painless jaundice with nausea, anorexia, and weight loss
History of metastatic pancreatic adenocarcinoma on palliative chemotherapy, presented with septic shock and encephalopathy
Abnormal cross-sectional imaging on presentation
Incidental finding of a biliary stent emerging from the major papilla and penetrating the opposite duodenal wall (type 1 perforation)
Duodenal perforation from a migrated biliary stent with concomitant retroperitoneal fluid collection seen on a CT scan
Migrated biliary stent with duodenal perforation and multiple intra-abdominal abscesses, and extensive pneumoperitoneum
Indication for biliary stent
Obstructive jaundice, choledocholithiasis, and indeterminate bile duct stricture
Malignant extrahepatic bile duct obstruction
Malignant extrahepatic bile duct obstruction
Interval time between biliary stent placement and diagnosis of perforation
18 months
5 days
10 weeks
Closure technique
Argon plasma coagulation used to demarcate perforation, rat-tooth grasper to remove stent, OVESCO 11/6T over-the-scope clip
Clinical outcome
Successful closure without drainable fluid collection or extraluminal gas after the procedure. At 2-month follow-up he denied any pain, nausea, emesis, weight loss, or jaundice.
Successful closure, resolving jaundice, and down-trending bilirubin. A few days later she underwent uncomplicated surgical resection of the tumor along with partial hepatectomy.
Successful closure and remained on low-dose norepinephrine, stress-dose steroids, and meropenem and was deemed stable for transfer. She was not in our network and was not seen in a follow-up.
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