S3632 Biliary Stent Migration Causing Small Bowel Obstruction

Introduction: Endoscopic biliary stenting is a widely used intervention for biliary obstruction. Fully covered self-expandable metal stents (SEMS) offer prolonged patency but carry a higher risk of migration compared to plastic stents. Although often asymptomatic, stent migration can rarely cause serious complications. We report a case of small bowel obstruction (SBO) resulting from a distally migrated fully covered SEMS. Case Description/Methods: A 64-year-old man underwent laparoscopic cholecystectomy for gangrenous cholecystitis. He presented 4 weeks later with painless jaundice. Laboratory tests showed ALP 708 U/L, AST 64 U/L, ALT 728 U/L, total bilirubin 8.9 mg/dL, and direct bilirubin 6.4 mg/dL. Abdominal ultrasound revealed a dilated common bile duct (CBD) measuring 11 mm. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) confirmed choledocholithiasis. He underwent biliary sphincterotomy and stone removal, complicated by bleeding, followed by placement of a 10 mm × 6 cm fully covered SEMS. Within 24 hours, he developed abdominal distension and bilious vomiting. Computed tomography imaging revealed the stent had migrated into the proximal jejunum, causing a high-grade small bowel obstruction. Emergent esophagogastroduodenoscopy did not visualize the stent, suggesting further distal migration. A second ERCP was performed for new stent placement and hemostasis. Conservative management with nasogastric decompression, intravenous fluids, and antibiotics was initiated. Serial KUB imaging over 5 days tracked the migrated stent as it progressed through the bowel to the rectum. His symptoms improved, and he was discharged in stable condition. Discussion: Biliary stent migration occurs in up to 10% of cases, with rates as high as 20% for fully covered metal stents. Risk factors include sphincterotomy, large-diameter CBDs, straight stent design, and recent surgery. Although most migrated stents pass spontaneously, fewer than 1% cause complications like SBO, usually when lodged in fixed or narrowed bowel segments, often due to adhesions. Our patient had multiple risk factors—a large, fully covered SEMS, recent sphincterotomy, and recent abdominal surgery—all predisposing to distal migration and obstruction. Conservative management with serial imaging often suffices, as in our case, where the stent eventually passed without intervention. Endoscopic or surgical intervention is reserved for complications or failure of expectant therapy. Prompt recognition and appropriate management are key to ensuring favorable outcomes while preserving the benefits of endoscopic stenting.