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UNUSUAL CASE |
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| Year : 2021 | Volume
: 17
| Issue : 1 | Page : 85-87 |
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Transhepatic intraperitoneally migrated biliary stent: A rare finding during laparoscopic cholecystectomy
Ahmad Ozair, Faraz Ahmad, Surender Kumar, Sumit Rungta
Department of General Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| Date of Submission | 06-Feb-2020 |
| Date of Acceptance | 07-Feb-2020 |
| Date of Web Publication | 28-Mar-2020 |
Correspondence Address:
Mr. Ahmad Ozair
Department of General Surgery, King George's Medical University, Chowk, Lucknow - 226 003, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmas.JMAS_32_20
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.
Keywords: Bile duct, biliary stent, endoscopic retrograde cholangiopancreatography, endoscopy, laparoscopic cholecystectomy, minimal access surgery
How to cite this article:
Ozair A, Ahmad F, Kumar S, Rungta S. Transhepatic intraperitoneally migrated biliary stent: A rare finding during laparoscopic cholecystectomy. J Min Access Surg 2021;17:85-7 |
How to cite this URL:
Ozair A, Ahmad F, Kumar S, Rungta S. Transhepatic intraperitoneally migrated biliary stent: A rare finding during laparoscopic cholecystectomy. J Min Access Surg [serial online] 2021 [cited 2021 Jan 21];17:85-7. Available from: https://www.journalofmas.com/text.asp?2021/17/1/85/281502 |
| ¤ Introduction | |  |
Biliary stenting is now a widely accessible, minimally invasive procedure being performed across both the developing and the developed world. Stenting is useful in the narrowing of the biliary tree for both benign and malignant diseases, along with its utilisation in the treatment of post-operative bile leaks.[1] However, due to increase in the number of these procedures performed over the last 10 years, a greater understanding of the morbidity involved has emerged, of which a practising surgeon needs to be aware. While the most common complication of stenting continues to remain as stent occlusion, stent migration is not an infrequent problem either, occurring in up to 10% of cases. Proximal migration is less commonly reported than distal migration, with migration into intrahepatic structures rarer. However, <15 cases in the world have been documented where a migrated biliary stent pierced hepatic/intrahepatic structures.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] We here present this rare case of a transhepatic intraperitoneally migrated stent, which was incidentally detected on laparoscopic cholecystectomy, and a comprehensive review of literature [Table 1]. | Table 1: Prior reported cases of proximally migrated biliary stent with penetration or perforation of intrahepatic structures
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| ¤ Case Report | | |
A 35-year-old woman presented to the department of surgery outpatient clinic of the apex public referral centre of the province with severe right upper abdominal pain and high-grade fever. Ultrasonography revealed multiple, highly reflective, echogenic foci in the gallbladder lumen with posterior acoustic shadowing and peri-cholecystic oedema, accompanied by a dilated common bile duct (CBD) with thickened walls. She was diagnosed to be a case of acute cholecystitis with biliary sepsis and admitted and started on intravenous fluids, antibiotics and analgesics. After a week, she had improved enough to be sent to the department of medical gastroenterology for reference. Endoscopic retrograde cholangiopancreatography was performed with sphincterotomy and CBD stone removal, following which a double-pigtail, plastic biliary stent was inserted.
After cholecystitis had resolved, a decision of laparoscopic cholecystectomy was made. Due to the patient's inadequate financial condition, a pre-operative magnetic resonance cholangiopancreatography or computed tomography imaging could not be performed. However, intra-operatively present was an unexpected finding. After the dissection of the Calot's triangle, the protruding tip of the biliary stent was abruptly visualized [Figure 1]. Apparently, the stent had undergone transhepatic migration, with its tip rupturing the right hepatic duct (RHD), and had come to lie in the peritoneal cavity, without itself causing any apparent symptoms. | Figure 1: (a and b) After dissection of Calot's triangle during laparoscopic cholecystectomy, tip of pigtail stent seen protruding out of right hepatic duct and lying in the peritoneal cavity
Click here to view |
The stent was pulled out through the rupture in RHD and endo-suturing was done. Cholecystectomy was performed as usual and the port sites closed with a drain inserted. The patient had a full recovery within a week, following which the drain was removed. She was followed up for 6 months with no further significant event.
| ¤ Discussion | | |
Stent migration has been reported to cause a host of problems from the benign to the catastrophic, commonly including small bowel obstruction, penetration, perforation, sepsis, fistulae, abscesses or appendicitis.[1] Up to 10% of cases of stenting have been found to have migration, usually being into the duodenum from where they can be retrieved endoscopically.[1] Much rarer is the penetration and/or perforation of hepatic/intrahepatic structures by a migrated stent.
After a comprehensive review of literature on the MEDLINE database along with searching of reference lists of review papers, we identified 13 prior reported cases of stent penetrating an intrahepatic structure across the world [Table 1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] with the earliest case report dating back to 1988, describing stent-induced formation of broncho-pleuro-biliary fistula, leading to biliptysis and pleural effusion.[2] All 13 of these cases, along with ours, had used plastic stents (unreported in two cases), which have been found to be more commonly associated with migration compared to metallic stent which, however, suffer from greater risk of occlusion.[1] Interestingly, some of these cases also included stents widely advertised as having additional specifications by their manufacturers to prevent migration, including the Miller-double-mushroom type, the Cotton–Huibregtse type and the Amsterdam type.[4],[7],[9] It is also critical to recognise that migration can produce lethal sequelae such as pericardio-biliary fistula causing hemopericardium in two cases[11],[13] and bilio-pulmonary fistula leading to respiratory failure in another.[10] Surprisingly, even double-pigtail stents which have a lower incidence of stent displacement[1] found representation, as used in this case and in Choi and Paik.[14] Here, we had a proximally migrating causing rupture of RHD which was repaired primarily. Because of this and the pre-operative sphincterotomy, post-operative biliary leak did not occur.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| ¤ References | | |
| 1. | Bagul A, Pollard C, Dennison AR. A review of problems following insertion of biliary stents illustrated by an unusual complication. Ann R Coll Surg Engl 2010;92:w27-31.  |
| 2. | Dasmahapatra HK, Pepper JR. Bronchopleurobiliary fistula. A complication of intrahepatic biliary stent migration. Chest 1988;94:874-5. |
| 3. | Richenberg JI, Amin Z, Hatfield AR, Lees WR. Pleurobiliary fistula following Tannenbaum biliary stent insertion. Eur Radiol 1996;6:697-9. |
| 4. | Tan CC, Hall RI, Pallan JP, Irons RP, Freeman JG. Trans-hepatic proximal migration of percutaneous-endoscopic biliary stent presenting as an abdominal wall abscess. Gastrointest Endosc 1996;43:152-4. |
| 5. | Jendresen MB, Svendsen LB. Proximal displacement of biliary stent with distal perforation and impaction in the pancreas. Endoscopy 2001;33:195. |
| 6. | Liebich-Bartholain L, Kleinau U, Elsbernd H, Büchsel R. Biliary pneumonitis after proximal stent migration. Gastrointest Endosc 2001;54:382-4. |
| 7. | Mahadeva S, Ranjeev P, Goh KL. Hepaticogastric fistulation from a proximally migrated biliary stent. Gastrointest Endosc 2003;58:295-7. |
| 8. | Shah OJ, Khan FA, Robanni I, Wani NA. Hepatic perforation: A complication of proximal biliary stent migration. Endoscopy 2004;36:1040. |
| 9. | Hutchins GF, Stephanie L, Gravning SL. An uncommon complication of ERCP. Gastrointest Endosc 2012;75:699-701. |
| 10. | Antonsen J, Preisler L, Skram U, Klein M. Fatal biliary-pulmonary fistula due to a proximally migrating biliary stent. Endoscopy 2013;45 Suppl 2 UCTN:E265-6. |
| 11. | Lee V, Woldman S, Meier P. Biliary stent migration as a cause of cardiac tamponade. J Cardiovasc Med (Hagerstown) 2013;14:750-2. |
| 12. | Odemis B, Beyazit Y, Tanoglu A, Kayacetin E. Endoscopic extraction of proximally migrated biliary stent by intrastent balloon inflation. BMJ Case Rep 2014;2014. pii: Bcr2014207377. |
| 13. | Paranandi B, Joshi D, Johnson GJ, Webster GJ. Pericardiobiliary fistulation: A rare complication of therapeutic ERCP in a patient with IgG4-related sclerosing cholangitis. ACG Case Rep J 2015;2:242-4. |
| 14. | Choi YH, Paik WH. Proximal migration of a biliary stent through the liver capsule. Korean J Gastroenterol 2018;71:54-7. |
[Figure 1]
[Table 1]
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