Clinical Picture
Migrated biliary stent Marta Cano-Hoz, Miguel F Carrascosa, Ainhoa Díaz Pérez, Rocío Ramos-Martín Lancet Gastroenterol Hepatol 2018; 3: 288 Internal Medicine Department (M Cano-Hoz MD, M F Carrascosa MD), Department of Gastroenterology (A Díaz Pérez MD), and Radiology Department (R Ramos-Martín MD), Hospital of Laredo, Laredo, Spain Correspondence to: Dr Miguel F Carrascosa, Internal Medicine Department, Hospital of Laredo, Avenida de los Derechos Humanos s/n, 39770 Laredo, Cantabria, Spain
[email protected]
A 92-year-old woman presented to our hospital’s emergency department with a 4-day history of dysuria and fever. She had undergone radical right nephrectomy 30 years earlier due to Wilms’ tumour. 17 months before admission in July, 2017, a plastic biliary stent had been endoscopically inserted because of benign stricture related to distal choledocholithiasis. On admission, plain abdominal radiography showed a tube-like image located in the pelvic region (figure, A). Abdominal CT revealed that this tubular structure penetrated the rectosigmoid colon and appeared to be in close contact with the left ureter (figure, B). As secondary obstructive hydronephrosis was also evident, percutaneous nephrostomy was done. Afterwards, the patient was started on antibiotic therapy because blood cultures were positive for Enterococcus faecium, Escherichia coli, and Pseudomonas fluorescens. Considering the patient’s frailty and the absence of peritonitis or pneumoperitoneum, a colonoscopy was performed. This procedure showed a biliary stent partially embedded in the rectosigmoid junction wall (figure, C), which was carefully removed and the defects closed A
B
endoscopically using metallic clips. She had an uneventful recovery after the procedure and was discharged home. At a 3 month follow-up visit, the patient remained asymptomatic but a nephrostomy catheter was inserted. Endoscopic biliary tree stenting is a well established treatment for obstructive jaundice secondary to benign or malignant strictures. However, proximal or distal stent migration occurs in up to 6–10% of cases, particularly in patients with benign diseases in whom plastic stents have been inserted. Although distal migration into the intestinal tract is followed by spontaneous passage of the stent in most cases, it can lead to life-threatening complications (penetration, perforation, peritonitis, intestinal obstruction, sepsis, fistula formation, and others). Contributors MC-H cared for the patient. All authors wrote and edited the report, MFC did the literature search, RR-M provided figure parts A and B, and ADP provided figure part C. Written consent to publish was obtained from the patient’s daughter. Declaration of interests We declare no competing interests.
C
Figure: Migrated biliary stent in a 92-year-old woman (A) Abdominal radiograph showing an abnormal position of the biliary stent (arrows). (B) CT of the abdomen showing the misplaced stent causing perforation of the colonic wall and protrusion towards the left ureter (arrows). (C) Colonoscopic appearance of the biliary stent penetrating into the rectosigmoid wall.
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www.thelancet.com/gastrohep Vol 3 April 2018
