S3511 Early Duodenal Perforation Following Biliary Stent Placement in Cholangiocarcinoma: A Rare and Important Complication

Introduction: Endoscopic biliary drainage (EBD) is widely used for malignant biliary obstruction. Early complications such as stent migration occur in approximately 5% of cases. Most complications involve infection, pancreatitis, or bleeding, while duodenal perforation due to stent migration remains exceedingly rare, especially within the first month after the procedure. We present a case of duodenal perforation 48 hours after plastic biliary stent placement in a patient with metastatic cholangiocarcinoma (CCA), highlighting an under-recognized risk in this vulnerable population. Case Description/Methods: A 63-year-old woman with type 2 diabetes and hypertension presented with 10 days of jaundice and decreased appetite. On exam, she was found to have scleral icterus and abdominal distention. Laboratory studies demonstrated a total bilirubin of 28.1 mg/dL, Alk Phos 1718 U/L, AST 466 U/L, and ALT 621 U/L. Computed tomography imaging notable for a hilar mass with multiple hepatic lesions, consistent with metastatic CCA. She underwent endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and placement of 2 plastic stents (10 Fr × 10 cm and 7 Fr × 15 cm). The patient was discharged the next day. Within 48 hours, she returned with abdominal pain and leukocytosis. Computed tomography imaging revealed stent migration with duodenal perforation. Urgent endoscopy confirmed a stent eroding through the posterior duodenal wall, which was subsequently removed, and the 4 mm perforation was closed with hemostatic clips. One week later, a repeat ERCP was performed with placement of an uncovered metal stent. The patient was discharged on antibiotics. Discussion: Duodenal perforation from biliary stent migration in patients with CCA is extremely uncommon, with only 9 cases described in the literature to date. Among these, most occurred within the first month of stent placement, and 5, including this case, developed perforation within just 48 hours. Tumor-related fixation of the proximal stent segment may predispose to distal trauma and perforation, while malignant infiltration and altered mucosal integrity further increase patient vulnerability. This case emphasizes the importance of individualized stent selection and early post-procedural monitoring in patients with cholangiocarcinoma. Given the increased risk of early, severe complications in this group, clinicians should consider prolonged observation or early follow-up imaging after stent placement, particularly when using plastic stents in patients with extensive hilar or perihilar disease.