Colonic perforation secondary to migrated biliary stent. Case report of an unusual complication, and literature review.

K Hunter, T Siddiqui, OO Komolafe, DCS Chong.

Corresponding author: Mr Segun Komolafe – skomolafe@yahoo.co.uk
Department of Surgery
Stobhill Hospital
Balornock Road
Glasgow G21 3UW

Abstract
Endoscopic stents are widely used to facilitate biliary drainage in hepatic, biliary and pancreatic conditions. Migration of the stent is a potentially serious complication. We report a case of migration of a biliary stent to the sigmoid colon at which point the stent perforated the colon and become lodged subcutaneously. The patient was managed successfully by local exploration to retrieve the stent without bowel resection. We also review the literature on complications caused by migrated biliary stents.

Keywords: biliary stent, stent migration, colonic perforation, colocutaneous fistula

Case Report
A 72 year old lady presented with a week-long history of left iliac fossa pain. She had a history of laparoscopic cholecystectomy six years previously, complicated by bile duct injury, and subsequent endoscopic biliary stent insertion. She also had ischaemic heart disease and chronic obstructive pulmonary disease with extensive pharmacopoeia. On examination there was a tender mass in the left iliac fossa, with no peritonitis. Plain abdominal x-ray showed a tubular structure in the left iliac fossa (figure 1). Initial blood tests revealed elevated inflammatory markers.

 

Figure 1
Plain abdominal radiograph showing biliary stent (white arrow) in left iliac fossa.

Subsequent CT scan showed that this tubular structure was most likely the biliary stent which was no longer in the common bile duct. The stent appeared to have travelled into the sigmoid colon at which point it had perforated through a diverticulum and started to migrate subcutaneously (figure 2). The palpable mass was due to local inflammatory reaction.

Figure 2
CT scan showing biliary stent (white arrow) migrating into subcutaneous tissues in left iliac fossa.

In view of the patient’s significant co-morbidity, the consensus was that laparotomy and colonic resection should be avoided. Following extensive discussion the patient consented to removal of the stent via a small incision over the palpable mass, with the intention of forming a controlled colo-cutaneous fistula in the short term. In the event of subsequent signs of peritonitis, or systemic sepsis, laparotomy would be performed.

The stent was easily located in the subcutaneous tissues (figure 3a) and removed, with faecal material on the colonic aspect of the stent (figure 3b). A stoma bag was placed over the wound and the patient was closely observed post operatively. She made an excellent recovery with no evidence of peritonitis or fistula and was discharged one week following surgery. She has been well to date (18 months) with no intra-abdominal sepsis or delayed fistulation. To our knowledge, this is the first reported case of a migrated biliary stent fistulating cutaenously in the UK 1 – 6.

Figure 3
A. Stent identified in subcutaneous tissues

B. Stent after retrieval

Discussion
Endoscopic biliary stent insertion was first described in 1980 by Soehendra and Reynders7. It has since become well established for use in hepatic, biliary and pancreatic disease in cases of biliary outflow obstruction, such as choledocholithiasis, cholangiocarcinoma and chronic pancreatitis. Early complications of stent insertion are relatively common and well recognised, occurring in 17% of cases8. These include pancreatitis, haemorrhage, local perforation and cholangitis. Late complications, classified as occurring after 30 days, occur in 31% of cases8. These include stent occlusion, cholangitis secondary to obstructed drainage9, and very rarely migration.

Displacement of a biliary stent may be proximal or distal. Proximal displacement occurs in 4.9% of cases10 and is more likely to occur in malignant strictures, stents of a larger diameter (greater than 10 French) and shorter length (less than 7cm)10. Over 90% of these stents can be extracted endoscopically11, 12. Distal displacement occurs in 5.9% of cases10 and has an increased incidence post-sphincterotomy or in the presence of Sphincter of Oddi dysfunction, with longer stents (greater than 7cm), and in benign disease, especially papillary stenosis13. This is thought to be due to regression of benign strictures following stent insertion as inflammatory markers resolve10.

The majority of cases of migration pass unnoticed as the stent is passed in the faeces or remains in the gastrointestinal tract asymptomatically10, 11. Risk factors for complications of migration include weak points in the bowel wall such as diverticulae; or areas where the bowel is fixed and therefore the stent becomes lodged. These include retroperitoneal segments, loops in abdominal herniae, or at intra-abdominal adhesions. The main complications are obstruction, perforation and fistulation.

Reports of obstruction have involved the appendiceal orifice, causing appendicitis 14 and the small bowel15. Perforation occurs most often in the duodenum12, 16 – 18 due to its anatomical retroperitoneal fixity1. Cases of perforation have also been reported in the liver19, jejunum20, sigmoid colon5, 6 and ileum21. A review of the literature up to January 2007 reported 11 cases of colonic perforation due to biliary stent migration22, with resulting necrotising fasciitis was reported in one case23. Cases of perforation have also been reported associated with parastomal24, incisional25 and other incarcerated herniae26. Localised chronic mucosal pressure may cause fistula formation. Reported cases include biliocolic27, colovaginal28, colovesicular29, enterocutaneous5 and colocutaneous30 fistulae.

Plastic stents are more likely to become displaced (5-8% incidence) in comparison to metallic stents (<1%) 25, 31, although these still tend to be the material of choice as they are cheaper and easier to remove or change. Patients with known biliary stents should be under regular follow up. If the stent has migrated, it should be removed endoscopically. If the stent is not accessible, the patient should have serial abdominal x-rays3, 4, 33 to check the stent location. The onset of suspected stent-related symptoms is an indication for more detailed imaging, and possible invasive intervention. The aim of this is to locate and retrieve the stent before development of fistulae34 or perforation of a viscus35, 36.

Given the ubiquity of biliary stents, we suggest that complications of a migrated stent ought to always be in the differential diagnoses of previously-stented patients with new abdominal signs or symptoms.

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