Common Bile Duct perforation by Biliary Stents post-ERCP: Case-reports and literature review of management.

Nehemiah Samuel, Mr, Alex Wheeler, Dr, Muhammad H Shiwani, Mr, Ahmed Masri, Mr. Barnsley Hospital NHS Foundation Trust

Background: Common bile duct (CBD) stones are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion; followed usually by laparoscopic cholecystectomy for gallstones. Iatrogenic CBD injury is a recognised complication associated with high morbidity.

Patients & Methods: We report on two patients (A and B) who both had ERCPs for CBD stones and a 7fr. polyethylene pigtail biliary stent inserted prior to elective laparoscopic cholecystectomy. Intraoperatively, in patient A the stent was seen perforating the proximal CBD; and in patient B the stent had perorated the distal CBD with its intraperitoneal tip found to be fistulating into the duodenum. Patient A was managed with laparoscopic closure of duct perforation site, distal choledochotomy for T-tube insertion and a tube drain placed in the subhepatic space. In Patient B the laparoscopic procedure had to be converted to open and T-tube inserted via the perforation site. In both cases the T-tube was clamped on day 5 followed by cholangiogram to confirm no bile leakage prior to taking out the drains.  

Results: Post-ERCP, CBD perforations are relatively rare with the incidence ranging from 0.3-2.1%. The majority are caused during the procedure due to guide-wire insertion. A small number are caused at the time of stent placement or its subsequent migration. CBD perforation by stents could be speculated to be caused by the nature and type of stent or the duration between ERCP and laparoscopic cholecystectomy when left in-situ.

Conclusion: Despite little evidence on the management of perforations, T-tube placement seems a rational option for allowing perforations to heal and for further assessment of on-going leaks through cholangiography.

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