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CASE REPORT
Full Length Migration of Plastic Biliary Stent into the Left Lobe
of Liver and Its Endoscopic Retrieval
Ali Mothanna Al-Zubaidi1, Abdo Hasan Al-Zubaidi2, Laeeque Ahmed Qureshi1 and Esam Elldein Al-Haroon1
ABSTRACT
An elderly female was admitted with obstructive jaundice, secondary to an impacted 1.7 cm size stone in distal CBD.
Cholangiogram obtained during ERCP revealed dilated biliary system with large, immobile stone at the lower end of CBD.
A large size sphincterotomy was performed and stone extraction using biliary balloon / dormia basket attempted which
was unsuccessful as the stone was impacted in distal CBD. Therefore, a plastic biliary stent of 9 cm/8.5 french size was
inserted successfully to secure the biliary drainage. Patient improved clinically and discharged home on ursodeoxycholic
acid. Four weeks later, she presented to emergency department with signs of cholangitis. An emergency ERCP was
performed. The stent had migrated up completely into the left intra hepatic duct. In this session, the stone was extracted
and biliary drainage secured. Migrated stent was removed later on by another ERCP procedure.
Key Words: Cholangitis. Biliary stent migration. Endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis.
INTRODUCTION
Stent migration occurs in about 5 - 10% of patients
undergoing biliary stenting.1 Complications from biliary
stenting are rare. One of the late complications of longterm biliary stenting includes stent dislocation and
migration,2 which in turn can lead to visceral obstruction,
depending on the site of dislodgement.2
The risk of stent migration is greater in benign biliary
strictures than in malignant strictures. Multiple biliary
stent placements decrease the frequency of migration.
Increasing indications for stent insertion have
contributed to a growing number of reports relating to
unusual distal intestinal complications.3
The presently reported cases describes one such event
with preceding events and endoscopic retrieval.
CASE REPORT
A 75 years old female presented to emergency
department with jaundice. Obstructive pattern was noted
on initial LFTs and an abdominal sonography confirmed
the biliary obstruction by a large stone of 1.7 cms size in
distal end of CBD with dilated proximal biliary system. An
endoscopic attempt was planned to extract the stone,
therefore, an elective ERCP was performed during
which a large size sphincterotomy was performed and
1
2
Department of Gastroenterology and Endoscopy, King Khalid
Hospital, Najran, Saudi Arabia.
Department of General Surgery and Endoscopy, King Khalid
Hospital, Najran, Saudi Arabia.
Correspondence: Dr. Ali Mothanna Al-Zubaidi, Consultant
Gastroenterologist and Hepatology, King Khalid Hospital,
Najran, Kingdom of Saudi Arabia.
E-mail: [email protected]
Received: December 02, 2012; Accepted: October 08, 2013.
repeated attempts were made to remove the stone using
balloon and Dormia basket but proved unsuccessful as
the stone was impacted in the distal CBD. Therefore, a
plastic biliary stent of 9 cm/8.5 french size was placed
successfully to secure the biliary drainage. Patient's
condition improved clinically after placement of stent and
jaundice decreased, so she was discharged home on
ursodeoxycholic acid with the plan to repeat ERCP for
stone removal after 8 weeks.
Four weeks later, she was presented to the emergency
department with fever, rigors and worsening of jaundice
and appeared toxic due to cholangitis. ICU admission
was made with support of intravenous antibiotics and
fluids. An emergency ERCP was performed on the same
day. The previously placed stent was not seen in place
and scout fluoroscopy revealed its migration upto its full
length into the left intrahepatic duct. Endoscopic
attempts to remove the stent were not made this time as
the patient was appearing toxic. Stone appeared to be
mobile this time. Careful extension of the previous very
large sphincterotomy was made and stone was
extracted by a balloon and taken out from the gut using
basket to avoid the occurrence of possible stone
induced ileus. Pus was also drained. Patient showed a
dramatic clinical improvement after stone removal.
After one week duration, a plane X-ray of abdomen was
taken which was giving a false impression of stent
migration into the stomach as the proximal end of stent
was seen in the gastric air bubble (Figure 1). For this
reason, an upper GI endoscopy was performed to
remove the stent from stomach but nothing was found in
stomach.
A CT scan of abdomen was performed to localize the
stent. It was reported that the stent had migrated
completely in the left intrahepatic duct (Figure 2).
Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (11): 861-862
861
Ali Mothanna Al-Zubaidi, Abdo Hasan Al-Zubaidi, Laeeque Ahmed Qureshi and Esam Elldein Al-Haroon
Proximal migration of a biliary or pancreatic stent is an
infrequent event but its management can be technically
challenging.7 Incidence rates of 5.2% and 7.5% were
observed for proximal and distal pancreatic stent
migration, respectively.8 Stent migration can lead to
serious complications and produce significant morbidity
and mortality.9
In choledocholithiasis with dilated common bile duct,
short and large size stent are the main risk factors for
proximal migration of stent.10 Retrieval of a proximally
migrated stent requires experience with different
endoscopic devices. Moreover, distal migration needs
attention because it can cause severe complications.10
Figure 1-5: (1) X-Ray abdomen showing biliary stent across the vertebrae
with proximal end of stent is in gastric fundal air bubble.
(2) CT scan abdomen showing the presence of stent inside the left liver lobe.
(3) Cholangiogram showing the stent migrated up into left intra hepatic duct.
(4) Cholangiogram showing the stent in left intra-hepatic duct (thin arrow)
over the wire balloon (thick arrow) in an adjacent intra-hepatic duct.
(5) Cholangiogram after a successful retrieval of stent into the common bile
duct.
Once again, ERCP was performed, it was very difficult to
pass the guide wire in the same duct because it was
completely occupied by the stent, therefore, an adjacent
duct was cannulated using the balloon over the guide
wire and balloon pull through was performed many times
till the distal end of stent was moved a little bit into the
proximal common bile duct, from where it was
completely pulled down by further balloon pull through to
the common bile duct then to the duodenum and snared
out completely (Figures 3 - 5). Patient was kept under
close observation. She remained stable after stent removal
and had no complication, therefore, discharged home.
DISCUSSION
First introduced in 1979, endoscopy-guided plastic
biliary stent insertion has a well-established role in a
wide variety of obstructive biliary and pancreatic
disorders.3-5 Over the past decade, the use of this
modality has increased in prevalence and utility. Despite
the overall safety of this modality, on rare occasions,
these stents may migrate from the biliary tract.6 Over
80% of proximally migrated bile duct and pancreatic duct
stents may be extracted endoscopically. Few patients
may require surgery.7
862
In this case, the stent migration was proximal completely
into the left intrahepatic duct, and the possible risk of
migration was significantly dilated CBD 2.5 cm with large
round stone of approximate 1.7 cm size, which after the
release became mobile and pushed the stent upward in
the left intrahepatic duct. Such a case is rare, as the
literature was searched thoroughly but nothing was
found similar to this case. Removal of the stent by ERCP
was very challenging and use of new endoscopic
equipment such as use of cholangioscope and
Soehendra type stent retrieval device may be helpful for
such a migrated stents.
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Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (11): 861-862