2022, Number 1
Sigmoid colon perforation secondary to migration of a biliary endoprostheses. A case report
Full text
10.35366/109320
Language: English/Spanish [Versi?n en espa?ol]
References: 14
Page: 50-54
PDF size: 201.33 Kb.
ABSTRACT
Endoprostheses are an accepted therapy for several diseases of the biliary tract. Distal migration is a rare complication that can lead to serious complications. In 1996, the first case of a left colon perforation due to a plastic biliary stent was reported, and since then, 40 more cases were reported. We present one case of a patient with acute abdominal pain thirteen months after a placement of a plastic stent. At surgery we found the stent through a diverticulum in the sigmoid colon. A primary repair was performed, with an adequate clinical outcome.INTRODUCTION
The use of stents for managing bile duct pathology was described in 1980. Since then, their use has become an accepted therapy for benign and malignant biliary tract diseases.1 One of the complications described concerning the placement of stents, especially plastic ones, is migration, which can be either proximal or distal and occurs in 3 to 8% of patients.2,3 Although distal migration in the gastrointestinal tract is followed by spontaneous expulsion of the stent and stool in most cases, it can lead to severe complications such as perforation, abscesses, sepsis, and the development of fistulas.4
The first report of a biliary stent that migrated to the left colon and caused a perforation appeared in 1996. The first review about migrated stents with perforation to the left colon was published in 2007, describing one case and reporting 11 more.5 By 2014, there were only 25 reported cases in the English literature of biliary stents migrating to the colon.6 In most cases, the perforation occurred most often in a diverticulum of the sigmoid colon.
This paper reports a patient with an Amsterdam-type plastic biliary stent that accidentally migrated into the sigmoid colon, causing a free perforation managed with surgery without colostomy.
CASE PRESENTATION
A 72-year-old woman was admitted to our hospital with a diagnosis of Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography (ERCP) and placement of a 10 Fr 10 cm long Amsterdam-type biliary stent were performed in another hospital. Laparoscopic cholecystectomy was attempted on a scheduled basis, but due to the severe inflammatory process, it was decided to convert to open cholecystectomy. We performed trans cystic cholangiography, identifying a common bile duct filling defect (Figure 1). We performed a choledochotomy, the common bile duct stone was removed without the need to mobilize the stent, and a fenestrated subtotal cholecystectomy was performed. A closed suction drain was placed in the subhepatic space. The patient developed a low-output biliary fistula, which was resolved satisfactorily on an outpatient basis without needing specific management. After 15 days, the drainage was removed, management with ursodeoxycholic acid at 15 mg/kg orally was started, and an abdominal ultrasound was requested, which was performed six months later. It showed the intra- and extra-hepatic biliary tract of standard caliber without other alterations; the prosthesis was not visualized at the level of the biliary tract. Liver function tests (LFTs) showed a decrease in transaminase levels concerning preoperative, with aspartate aminotransferase (AST) 24 U/L versus 35 U/L, alanine aminotransferase (ALT) 28 U/L versus 23 U/L, and alkaline phosphatase (ALP) 111 U/L versus 275 U/L without reaching normal levels, and γ-glutamyl transferase at 108 U/L. No further action was taken.
The patient presented three months later for consultation with clinical data of mild diverticulitis. Laboratory tests were normal, including improved FFP. A physician outside the hospital had initiated management with oral trimethoprim-sulfamethoxazole at an unspecified dose. The antibiotic was continued to complete seven days.
Two months later, the patient presented again with acute abdominal pain. She had signs of peritonitis in the left lower quadrant of the abdomen. Laboratory tests showed leukocytes 16.8 × 103/µL, serum lactate 2.5 mmol/L, and lactate dehydrogenase 611 U/L. An abdominopelvic CT scan was performed, which showed findings suggestive of diverticulitis complicated with perforation and a hyperdense tubular image measuring approximately 90 × 5 mm at this level (Figure 2).
The patient underwent exploratory laparotomy, where a one-centimeter diameter perforation was found through a sigmoid colon diverticulum secondary to the stent (Figure 3) and multiple uncomplicated sigmoid diverticula. The stent was removed, the intestinal edges were debrided of healthy tissue, and primary closure was performed in two planes, the internal by continuous suture with 3-0 caliber polyglactin 910 and the external through Lembert type stitches with 3-0 caliber silk. There was no evidence of localized or generalized peritonitis, but in any case, a 12 Fr caliber closed suction drain was placed, directed to the parietocolic slide and pelvis. Postoperative evolution was uneventful; ceftriaxone 2 mg every 24 hours intravenously and metronidazole 500 mg every eight hours were administered; the patient was discharged on the fourth postoperative day, with an indication to complete five more days of metronidazole 500 mg every eight hours orally.
DISCUSSION
In our environment, endoscopists most frequently use plastic biliary stents. Patients with these stents require close follow-up for early removal or periodic replacement to avoid obstruction, rupture, infection, or migration. Performing the change every three months is recommended, although this period can be extended up to six months.
It has been observed that migration occurs more frequently with plastic prostheses than with metallic ones. Distal migration of stents has a variable incidence ranging from 4 to 8%.2,3,7 Distal migration is more frequent in cases of benign stenosis of the biliary tract, possibly because migration is favored when the inflammatory process and edema of the biliary tract mucosa disappear.4
The most frequent location of distal migration is the duodenum; most distally migrating prostheses pass through the intestinal lumen without complications and are evacuated with feces. On rare occasions, the prostheses do not have a typical passage through the digestive tract and become lodged in the intestinal wall, resulting in a series of complications; the most frequent causes of impaction are considered to be the presence of irregularities of the intestinal wall or the presence of fixation mechanisms of the intestine itself, such as the ligament of Treitz, parastomal hernias, ventral hernias, post-surgical adhesions, and colonic diverticula. Most of the complications associated with stent migration have occurred with straight stents. This type of migration is attributed to the external retention flaps, which cause easier adhesion to the bowel wall, with subsequent pressure necrosis and bowel perforation.4
One of the first retrospective studies that looked at the occurrence of prosthesis migration and risk factors was done by Johanson and colleagues, a single-institution retrospective study over four years. In 322 prostheses, they found 16 cases of proximal migration with a rate of 4.9% (95% confidence interval [CI], 3.1 to 8.5%) and 19 distal migrations with a rate of 5.9% (95% CI, 3.9 to 9.2%).2
In another study by Katsinelos and colleagues, the experience of three referral centers in Greece regarding stent migration was revised. In the study period, 378 biliary stents were placed, 57.4% for malignant causes and 42.6% for benign causes. Only 51 (13.5%) stents migrated, and 30 (58.8%) migrated distally, for an overall migration rate of 7.9%. Patients with migration had symptomatology of cholangitis or jaundice, while 13 (43%) patients with distal migration remained asymptomatic. No colonic perforations were described in this series and only three patients with impaction of the prosthesis at the ileocecal valve.7
In another study from a referral center, 524 plastic prostheses were placed in 353 patients over 15 months. The overall migration rate was 8.58%; 21 patients had distal migration, for a distal migration rate of 4.0%. The migration frequency was significantly higher in benign than malignant stenosis (13.7 versus 5.3%, p = 0.001).3 As in the previous study, no severe gastrointestinal complications occurred.7 The explanation is that a close surveillance policy is carried out in these referral centers, so low morbidity is expected in this way.
In a recent retrospective study by Yuan et al., they sought to determine risk factors for distal migration in plastic prostheses and duodenal lesions. They studied 248 patients with 402 ERCPs and found that the presence of a benign biliary stricture and the length of the prosthesis above the proximal end of the stenosis were determining factors for distal migration; in addition, they detected 25 cases of distal migration, for a rate of 6.2%8 (Table 1).
Of the 42 cases reported in the literature, only six have been treated with primary closure,9-13 as in our case, and one was performed laparoscopically.14 Primary closure can be performed when an early diagnosis is made or when there is a high index of suspicion. None of the patients treated with primary closure had a fatal outcome (Table 2).
CONCLUSIONS
Distal migration to the colon of a biliary stent is a rare medical event, but most occur without any sequelae; however, they may lead to severe complications.
Sigmoid colon perforation secondary to migration of a biliary prosthesis is a rare complication. It should be suspected in patients with acute abdominal pain and an ERCP history. Early surgery is recommended to avoid potentially dangerous complications that may lead to death. Suppose perforation caused by a stent is confirmed. In that case, a primary closure may be done to avoid a colon resection or the realization of a stoma if the patient's clinical conditions allow it.
Patients with benign bile duct stenosis have a higher frequency of distal migration. In contrast, patients with previous surgeries, wall hernias, stomas, and diverticular colon disease are at risk of developing complications secondary to distal migration of the stents.
REFERENCES
AFFILIATIONS
1 General Surgery Service. Regional Hospital of High Specialty of the Yucatan Peninsula. Merida, Yucatan, Mexico.
Ethical considerations and responsibility: the authors declare that they followed the protocols of their work center on the publication of patient data, safeguarding their right to privacy through the confidentiality of their data.
Funding: no financial support was received for this work.
Disclosure: the authors declare no conflict of interest in carrying out the work.
CORRESPONDENCE
Rubén Rodrigo Lozano-Salazar. E-mail: pancreas.rr@gmail.comReceived: 04/06/2021. Accepted: 11/15/2022