Duodenal Perforation from Dislodged Prophylactic Pancreatic Stent Following ERCP for Hilar Cholangiocarcinoma: A Rare Adverse Event

We report a rare complication of prophylactic pancreatic duct stenting during ERCP for suspected hilar cholangiocarcinoma. A 47-year-old woman presented with two weeks of painless jaundice, total bilirubin 18 mg/dL, and cholestatic enzymes. Imaging revealed intrahepatic biliary dilation without CBD dilation. ERCP with cholangioscopy identified a right hepatic duct stricture; biopsies were obtained. A 10 mm × 4 cm covered metal stent was placed in the CBD, a 7 Fr × 12 cm plastic stent in the right hepatic duct, and a 4 Fr × 5 cm pancreatic stent was prophylactically inserted after inadvertent duct cannulation. Two days later, she developed acute abdominal pain. CT revealed stent migration with duodenal perforation. Repeat ERCP removed the dislodged stent, closed the defect endoscopically, and replaced the metal biliary stent with plastic. Biopsies confirmed perihilar cholangiocarcinoma. This case emphasizes that although prophylactic stenting reduces the risk of post-ERCP pancreatitis, migration and perforation can occur, underscoring the importance of vigilance and early recognition of post-procedural complications.