ANZ J. Surg.

2003;

73

: 669–670

CASE REPORT

CASE REPORT

SIGMOID COLON PERFORATION FOLLOWING A MIGRATED BILIARY STENT

M

ICHAEL

E

LLIOTT

AND

S

TUART

B

OLAND

Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia

Key words: biliary stent migration, sigmoid perforation.

Abbreviations

: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CBD, commonbile duct; ERCP, endoscopic retrograde cholangiopancreatography; GGT,

γ

-glutamyl transferase; LFT, liver function test.

CASE REPORT

An 80-year-old woman initially presented with a 1 day historyof right upper quadrant abdominal pain, nausea and vomiting.On examination she was afebrile and tender in the right upperquadrant with a positive Murphy’s sign. Laboratory testsrevealed altered liver function tests (LFT) with bilirubin,11

µ

mol/L (3–18

µ

mol/L); alkaline phosphatase (ALP), 109 U/L(50–140 U/L);

γ

-glutamyl transferase (GGT), 155 U/L (5–65 U/L);alanine aminotransferase (ALT), 244 U/L (5–40 U/L); andaspartate aminotransferase (AST), 306 U/L (<37 U/L). Anabdominal ultrasound demonstrated features consistent withacute cholecystitis and a dilated common duct to the ampullawith a diameter of 12 mm.

Endoscopic retrograde cholangiopancretography (ERCP) per-formed 2 days later failed to cannulate the ampulla so a percuta-neous transhepatic cholangiography (PTC) was performed and an8 Fr drainage catheter was placed via the right main hepatic ductand exchanged via a repeat ERCP with a 10 Fr 10 cm stent. Con-trast studies showed a dilated common bile duct (CBD) to theampulla with no filling defect.

The patient made an uneventful postoperative recovery andwas discharged home. She refused recommendation for cholecys-tectomy at this time.

Four months later the patient re-presented with a 5 day historyof abdominal pain, nausea, vomiting, abdominal distension andobstipation. On examination she was febrile and abdominalexamination revealed a distended abdomen that was tender gener-ally with no evidence of peritonism. Plain abdominal X-raysrevealed the stent positioned in the pelvis and multiple distendedloops of small bowel consistent with a small bowel obstruction.The situation failed to resolve with conservative measures and onday 2 a laparotomy was performed. At laparotomy the sigmoidcolon was perforated due to a migrated biliary stent (Fig. 1) withadherent small bowel causing the obstruction. A Hartmann’s pro-cedure was performed and the patient had a non-complicatedpostoperative course.

Three months later the patient re-presented with a furtherattack of cholecystitis. Her LFT were normal and a repeat ultra-sound revealed a thickened gall bladder full of stones and a CBDwith a diameter of 13 mm. A magnetic resonance cholangiogramwas performed and showed the CBD dilated to the ampullabut did not demonstrate a cause for the dilated CBD. The patientsettled with conservative measures and was discharged with aplan for an open cholecystectomy, exploration of CBD andreversal of Hartmann’s procedure in the near future.

Unfortunately prior to her planned procedure the patient re-presented with a further attack of acute cholecystitis and obstruc-tive LFT with bilirubin, 33

µ

mol/L (3–18

µ

mol/L); ALP, 287 U/L (50–140 U/L); GGT, 1185 U/L (5–65 U/L); ALT, 329 U/L(5–40 U/L); and AST, 513 U/L (<37 U/L). An ERCP and sphinc-terotomy were performed on day 2 that demonstrated no filling

M. Elliott

MB BS;

S. Boland

FRACS.

Correspondence: Dr M. Elliott, 62 Plunkett Street, Paddington, Qld 4064,Australia.Email: mselliott@optusnet.com.au

Accepted for publication 20 February 2002.

Fig. 1.

Resection specimen showing biliary stent perforation of thesigmoid colon.

670 ELLIOTT AND BOLAND

defect and excellent drainage. The patient symptomaticallyimproved and the LFT normalized. A laparotomy, open chole-cystectomy and reversal of Hartmann’s procedure was per-formed on day 6 and she made an uneventful postoperativerecovery.

DISCUSSION

Endoscopic placement of biliary stents is an established pro-cedure for the treatment of biliary outflow obstruction due tobenign and malignant disease processes. The procedure was firstdescribed in 1980 by Soehendra and Reynders-Frederix.

1

Biliary stent migration is a rare complication occurring inapproximately 5% of cases.

2

Proximal migration of stents is asso-ciated with malignant strictures and short stents whereas distalmigration is associated with benign disease.

3

More common com-plications include cholangitis, cholecystitis, cholestasis, bile ducterosion, pancreatitis, stent occlusion and stent fracture.

4

Perfora-tion secondary to migration most often occurs in the duodenumrelated to the procedure itself or stent migration.

Colonic perforation is exceedingly rare. Five previous caseshave been reported.

2,5–8

Laparoscopic and open treatment ofcolonic perforation with overseeing of the perforation and perito-neal lavage have been described. Due to contamination of theperitoneal cavity and unprepared bowel, the present patient wastreated with a laparotomy and Hartmann’s procedure.

Sometimes during exchange of biliary stents, the initial stentcannot be retrieved. In the majority of cases these stents will passwithout incident. However, due to the complication of perforationit is recommended that these patients are followed and when

migration into the colon is indicated by X-ray, then retrieval beperformed via colononscopy.

2,5

With the increasing use of biliary stents, perforation of theintestine is a diagnosis to consider in anyone with acute abdomi-nal pain and radiology demonstrating a migrated biliary stent.

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