Original reportRetroperitoneal Perforation of the Duodenum from Biliary Stent Erosion
Introduction
Duodenal perforation into the retroperitoneum is an unusual complication of an indwelling biliary stent. In this paper, we describe the case of a patient who presented in a toxic state from biliary stent erosion through the wall of the second portion of the duodenum. The patient was successfully treated by performing a pyloric exclusion and a Roux-en-Y hepaticojejunostomy. We review the incidence of this complication, its variable clinical presentation, and the optimal means of diagnosis. We also discuss the indications for both operative and nonoperative management as well as the surgical options for patients who require operative repair.
Section snippets
Case Report
A 69-year-old man presented to the emergency department after experiencing the sudden onset of abdominal pain associated with nausea, vomiting, and rigors after the ingestion a large meal. On examination, he was febrile (40 °C), tachycardic (130 beats/minute), and had a distended abdomen that was diffusely tender. His blood tests revealed a white blood cell count of 17,800 and a total serum bilirubin of 2.7 mg/dl. His medical history was notable for an exploratory laparotomy at another
Discussion
Since the advent of biliary stents as an alternative to surgical decompression for obstructive jaundice, there have been scarcely few reports of late duodenal injury from stent migration.1, 2, 3, 4, 5 However, this complication may occur more frequently than actually reported. A series by Gould et al5 found that late duodenal perforation from common bile duct stents occurred in 4 of 50 patients after initial satisfactory biliary stent placement. Three perforations were into the retroperitoneum,
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2008, International Journal of SurgeryCitation Excerpt :Early diagnosis and management is imperative, as delay beyond 24 h adversely affects the chances of survival and quality of life, especially, in the elderly with advanced malignancy.2,4,6 Management options in retroperitoneal perforations (II, III) vary from conservative management with antibiotics, bowel rest, and parenteral alimentation with percutaneous/endoscopic repair and retrieval of stent, in stable patients, to definitive surgery with diversion of gastric and biliary contents from the affected area, in patients with deteriorating clinical features or radiologic evidence suggestive of extensive contamination.2,4,7,10–12,14,15 Intra-peritoneal perforations (I) are best managed by immediate and aggressive surgical intervention, either conventionally or laparoscopically, as mentioned above, including tube duodenostomy.4,12,14,15
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