Duodenal transmural perforation caused by a dislodged pigtail plastic stent in a patient with benign biliary stricture

Stent migration occurs in endoscopic retrograde cholangiopancreatography (ERCP)-related procedures with a frequency of 5%–10%,1 but gastrointestinal or transmural perforation is rare.2 Here, we report a case of duodenal transmural perforation caused by a dislodged pigtail plastic stent with benign biliary stricture. A 73-year-old man was referred for examination of biliary stricture. Cholangiography showed a short-segment stricture in the lower bile duct (Figure 1a). Biopsy specimens were collected and a 7 Fr × 7 cm pigtail plastic stent was placed through the stricture (Figure 1b). The biopsy showed no malignancy. One month later, the patient presented with transient tarry stools and abdominal pain. X-ray showed stent dislodgement and computed tomography showed the stent apparently caught in the duodenal mucosa (Figure 1c–f). With a single-balloon endoscope, the proximal and distal tips were visible in the ascending duodenum, but the middle portion had penetrated the duodenal mucosa (Figure 2a). The stent was retrieved using grasping forceps, and there was no contrast medium leakage into the retroperitoneal space (Figure 2b–f). Compared with straight stents, pigtail stents have a lower risk of perforation due to their tip shape.3 There have been two reported cases of pigtail stent perforation. In one,4 the stent was placed for common bile duct stones and became lodged in multiple small bowel diverticula, leading to perforation. In the other,5 following stent placement for post-liver transplantation anastomosis stricture, the proximal tip migrated deep into the intrahepatic bile duct and the distal tip perforated the duodenal mucosa. In our case, no malignancy was detected and the stricture was loose, suggesting distal migration. The distal tip likely lodged into the duodenal mucosa, and peristaltic movements exerted pressure on the stent tip, causing submucosal perforation. After migrating into the submucosa, the stent perforated into the intestinal lumen. To prevent the stent from dislodging, placing the proximal end in the intrahepatic bile duct is recommended. Conception and design: Noriyuki Hirakawa, Kenjiro Yamamoto and Takao Itoi. Manuscript preparation: Noriyuki Hirakawa and Kenjiro Yamamoto. Endoscopic procedures: Noriyuki Hirakawa and Kenjiro Yamamoto. Author T.I. has received consulting fees from Gadelius Medical Co and Boston Scientific.