Elsevier

Current Surgery

Volume 62, Issue 5, September–October 2005, Pages 512-515
Current Surgery

Original report
Retroperitoneal Perforation of the Duodenum from Biliary Stent Erosion

https://doi.org/10.1016/j.cursur.2005.03.011Get rights and content

Endoscopically placed biliary stents have supplanted surgical decompression as the preferred treatment option for patients with obstructive jaundice from advanced pancreatic cancer. An unusual complication of indewelling biliary stents is duodenal perforation into the retroperitoneum. We describe the case of a patient with end-stage pancreatic cancer who presented with an acute abdomen from erosion of a previously placed bile duct stent through the wall of the second portion of the duodenum. Although our patient presented with advanced symptoms, clinical presentations can vary from mild abdominal discomfort and general malaise to overt septic shock. Definitive diagnosis is best made with computed tomography (CT) imaging, which can detect traces of retroperitoneal air and fluid. Treatment options vary from nonoperative management with antibiotics, bowel rest, and parenteral alimentation in the most stable patients to definitive surgery with complete diversion of gastric contents and biliary flow from the affected area in patients with clinical symptoms or radiologic evidence suggesting extensive contamination. Complications of management can include duodenal fistulization, residual retroperitoneal or intrabdominal abscess, and ongoing sepsis. This report highlights the salient issues in the presentation, diagnosis, and modern management of patients with this rare complication of indwelling biliary stents.

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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  • Intra-peritoneal duodenal perforation caused by delayed migration of endobiliary stent: a case report

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    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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