Unraveling the Complications: Stent Migration and Duodenal Fistula in a Metastatic Desmoplastic Round Cell Tumor

CASE REPORT Biliary stent migration is a recognized complication of endoscopic retrograde cholangiopancreatography.1–5 Although plastic biliary stent migration occurs in approximately 5%–10% of cases, intestinal perforation is rare, with duodenal involvement reported in <1%.1 We report a 30-year-old man with metastatic desmoplastic round cell tumor who required a 10Fr × 12-cm plastic biliary stent for a malignant stricture (Figure 1). Two months later, he presented with right upper quadrant pain and sepsis; imaging demonstrated gallbladder perforation, which was managed conservatively with percutaneous drainage and antibiotics. Four months after initial placement, the stent migrated, penetrating the posterior duodenal wall and right renal cortex, resulting in a duodenorenal fistula (Figure 2).Figure 1.: Endoscopic retrograde cholangiopancreatography revealed choledocholithiasis and a biliary stricture at the hepatic duct bifurcation, which was dilated and stented.Figure 2.: Computed tomography of the abdomen revealed that the plastic biliary stent had penetrated the posterior duodenal wall and right renal cortex, creating a 5-mm fistula.Subsequent imaging and endoscopic retrograde cholangiopancreatography confirmed the fistula. Endoscopic management was successfully performed with removal of the migrated stent, closure of the duodenal fistula using suturing and an over-the-scope clip, and placement of an uncovered metal stent in the common bile duct to restore biliary drainage (Figures 3–5; Video 1). The patient was discharged 2 days later without complications.Figure 3.: Upper endoscopy revealing plastic biliary stent had penetrated the posterior duodenal wall.Figure 4.: Enterogram confirming no extravasation after placement of the over the scope clip for fistula closure.Figure 5.: Liver function test trends across the patient's clinical course. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Plastic biliary stent migrated, leading to biliary, renal, and duodenal perforation. Successfully treated using OTS clip endoscopic approach, with enterogram confirming no extravasation.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_2b7vjn9i"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} This case highlights the rare but serious complication of duodenal perforation from biliary stent migration and demonstrates that complex perforations involving adjacent organs can be effectively managed endoscopically.1–5 DISCLOSURES Author contributions: M. Cymbal; A. Chatterjee: drafting the article. R. Prado; L. Sierra; SA Firkins; R. Patel; A. Khurana: critical revision of the manuscript. R. Simons-Linares: final approval of manuscript and is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.