Two-stage complications after endoscopic retrograde cholangiopancreatography comprising early retroperitoneal perforation and delayed biliary stent migration: A case report

Abstract

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP)-related complications vary in timing, mechanism, severity, and management strategy. Early suspected perforation requires prompt assessment to determine whether conservative or surgical treatment is appropriate, whereas delayed stent-related complications require planned surveillance and timely intervention. Distinguishing these different complication patterns remains clinically challenging. We report a rare case of sequential post-ERCP complications: Early suspected retroperitoneal perforation successfully managed conservatively, followed by delayed biliary stent migration causing sigmoid colon perforation requiring emergency surgery.

CASE SUMMARY

A 62-year-old woman presented with intermittent abdominal pain and was diagnosed with choledocholithiasis with biliary dilatation. She underwent ERCP with sphincterotomy, balloon dilation, partial stone extraction, and biliary plastic stent placement. During stone extraction, contrast extravasation raised suspicion of perforation. Post-procedure computed tomography showed pneumobilia and extensive retroperitoneal extraluminal gas with mediastinal extension. Because she remained hemodynamically stable without progressive peritoneal signs, conservative management was performed, resulting in clinical and radiological improvement. More than 2 months later, she was readmitted with abdominal pain and peritoneal signs. Imaging revealed distal migration of the biliary stent into the sigmoid colon with free intraperitoneal air. Emergency laparotomy confirmed sigmoid colon perforation caused by the migrated stent. The stent was removed, the colonic defect was repaired, and loop ileostomy and drainage were performed, followed by satisfactory recovery.

CONCLUSION

Stable post-ERCP retroperitoneal perforation may be managed conservatively, but retained biliary stents require timely surveillance.

Key Words: Endoscopic retrograde cholangiopancreatography; Retroperitoneal perforation; Biliary stent migration; Sigmoid colon perforation; Case report

Core Tip: This case illustrates two-stage complications after endoscopic retrograde cholangiopancreatography (ERCP), including early suspected retroperitoneal perforation and delayed biliary stent migration causing sigmoid colon perforation. These complications differ in timing, mechanism, clinical significance, and management strategy. Early suspected retroperitoneal perforation may be treated conservatively in carefully selected stable patients, whereas delayed stent-related bowel perforation requires timely surgical intervention. This case emphasizes the need for close clinical assessment, dynamic radiological evaluation, and planned follow-up after ERCP.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is an established therapeutic modality for choledocholithiasis and biliary obstruction, but it is associated with a spectrum of procedure-related adverse events[1]. Early complications include post-ERCP pancreatitis, bleeding, cholangitis and perforation. Delayed complications are more commonly related to biliary stents, including stent occlusion, infection and stent migration.

Both early and delayed complications after ERCP deserve close attention, as they pose different diagnostic and therapeutic challenges[2]. Early complications require timely clinical assessment and appropriate prompt management, whereas delayed stent-related complications necessitate planned follow-up and device surveillance. Here, we report a case with sequential complications in both phases, encompassing an early suspected retroperitoneal perforation responsive to conservative management, followed by delayed biliary stent migration culminating in perforation of the sigmoid colon.

CASE PRESENTATION

Chief complaints

A 62-year-old woman presented with intermittent abdominal pain for 2 weeks.

History of present illness

The patient had experienced intermittent abdominal pain for 2 weeks before admission. Pre-admission abdominal ultrasonography and computed tomography (CT) demonstrated obstruction of the common bile duct with biliary dilatation and multiple gallstones. She was admitted with a diagnosis of choledocholithiasis.

History of past illness

The patient had no clearly documented relevant history of past illness in the available clinical records.

Personal and family history

No relevant personal or family history was reported.

Physical examination

On admission, scleral icterus and epigastric tenderness were noted. There was no rebound tenderness.

Laboratory examinations

There is no result.

Imaging examinations

Pre-admission abdominal ultrasonography and CT showed common bile duct obstruction with biliary dilatation and multiple gallstones.

FINAL DIAGNOSIS

She was admitted with a diagnosis of choledocholithiasis.

TREATMENT

The patient subsequently underwent ERCP for biliary decompression and gallstone extraction. Selective biliary cannulation was achieved, and cholangiography demonstrated marked dilatation of the mid and upper common bile duct, with an approximately 1.2 cm × 1.5 cm filling defect in the upper common bile duct. Endoscopic sphincterotomy and papillary balloon dilation were performed, followed by lithotripsy and partial gallstone extraction. During stone extraction, contrast extravasation beyond the bile duct was noted, and the gallstone could no longer be clearly delineated, raising concern for possible bile duct perforation. As complete duct clearance could not be achieved, an 8.5 Fr × 10 cm ST-2 Soehendra Tannenbaum plastic biliary stent with multiple anchoring flaps at both ends (Cook Medical, Bloomington, IN, United States) was inserted for drainage (Figure 1A).

Figure 1 Early suspected retroperitoneal perforation after endoscopic retrograde cholangiopancreatography. A: Fluoroscopic image during endoscopic retrograde cholangiopancreatography showing dilatation of the intra- and extrahepatic bile ducts, with an approximately 1.2 cm filling defect in the mid-to-upper common bile duct. During gallstone extraction, contrast extravasation was observed and the stone could no longer be clearly delineated; B and C: Axial computed tomography images obtained the following day showing pneumobilia and extensive retroperitoneal extraluminal gas with mediastinal extension, raising suspicion of early retroperitoneal perforation.

After ERCP, the patient developed abdominal pain. CT on the following day showed pneumobilia and extensive retroperitoneal extraluminal gas with mediastinal extension, raising suspicion of an early ERCP-related retroperitoneal perforation, most consistent with a Stapfer type II injury[3] (Figure 1B and C). As there was no hemodynamic instability or progressive clinical deterioration, this complication was managed conservatively with bowel rest, intravenous fluids, and close observation, resulting in clinical improvement. Follow-up CT demonstrated marked reduction and absorption of the extraluminal gas. A follow-up ERCP was scheduled at 3 months for stent removal and reassessment of the bile duct.

More than 2 months later, the patient was readmitted with abdominal pain for 3 days. Physical examination showed abdominal distension, diffuse tenderness, rebound tenderness, and mild guarding. CT revealed a migrated stent within the sigmoid colon, with free intraperitoneal air and adjacent inflammatory changes, suggesting bowel perforation secondary to delayed biliary stent migration (Figure 2A and B). Emergency laparotomy confirmed a 1.5 cm perforation in the mid sigmoid colon caused by the migrated plastic stent, with feculent contamination and localized abscess formation (Figure 2C). Foreign body removal, repair of the colonic defect, loop ileostomy, abscess drainage, and abdominal drainage were performed. Recovery was satisfactory, and ileostomy closure was completed several months later.

Figure 2 Delayed sigmoid perforation due to biliary stent migration. A: Plain abdominal radiograph showing distal migration of the biliary stent to the sigmoid colon; B: Axial CT image showing the migrated stent, with one portion remaining within the lumen of the sigmoid colon and the other extending beyond the bowel wall into the abdominal cavity, accompanied by multiple free intraperitoneal air collections; C: Intraoperative photograph showing a perforation of the sigmoid colon, with part of the biliary stent protruding outside the bowel lumen.

OUTCOME AND FOLLOW-UP

The patient improved after conservative treatment for the early complication. Although a follow-up ERCP for planned stent removal was scheduled at 3 months, the patient developed delayed sigmoid colon perforation caused by stent migration before the scheduled intervention. After surgical management of the delayed sigmoid colon perforation, recovery was satisfactory, and ileostomy closure was completed several months later.

DISCUSSION

This case is notable because it illustrates two distinct phases of post-ERCP adverse events in the same patient, encompassing an early suspected retroperitoneal perforation that responded to conservative management, followed by delayed biliary stent migration culminating in sigmoid colon perforation. This case report highlights that early and delayed complications after ERCP differ not only in timing, but also in diagnostic focus, management priorities and follow-up requirements.

ERCP-related perforation is an uncommon but potentially serious adverse event, with reported incidence ranging from 0.09% to 1.67% among studies[4-6]. In the present case, CT demonstrated extensive retroperitoneal extraluminal gas with mediastinal extension shortly after ERCP, raising suspicion of a retroperitoneal perforation that was considered most consistent with a Stapfer type II injury. According to current reviews integrating multiple guideline recommendations[7], conservative management may be appropriate in carefully selected patients with isolated retroperitoneal air and no radiological evidence of significant contrast extravasation or fluid collection. As this patient had no hemodynamic instability, progressive peritoneal signs, or evidence of uncontrolled sepsis, together with subsequent clinical and radiological improvement, a cautious non-operative approach was considered justified. This suggests that even striking post-ERCP radiological abnormalities may not automatically be an indication for surgery. Management should instead be guided by the overall clinical picture, including hemodynamic status, abdominal signs and interval progression.

However, the later course of our patient was characterized by distal migration of a retained biliary plastic stent, resulting in sigmoid perforation with localized abscess formation, ultimately requiring emergency surgery. A recent systematic review[8] found the incidence of biliary stent migration after ERCP to range between 4.14 and 13.5% among studies, while bowel perforation developed in approximately 1% of migrated stents. Among 132 reported cases of bowel perforation secondary to stent migration, most involved plastic biliary stents (87.1%), typically occurred within 44.5 days, and carried an overall mortality risk of 17.4%. Colonic perforation accounted for 34.8% of cases, with the sigmoid colon being the most frequent colorectal site, accounting for 22.7%[8]. Proposed predisposing factors include diverticula, adhesions, hernias, and other conditions that distort the bowel lumen, as well as stent-related factors such as stent selection and configuration, which may influence distal migration and subsequent stent impaction or extraluminal penetration. In the present case, the sigmoid perforation was likely related to local adhesions and luminal angulation of the sigmoid colon, which may have impeded smooth passage of the stent leading to persistent focal pressure on the colonic wall. The resulting perforation was accompanied by free intraperitoneal air, localized abscess formation, and peritoneal contamination, necessitating prompt surgical management. This case indicates that follow-up and stent removal schedules should be individualized according to the patient’s clinical condition and potential risk factors for stent migration.

CONCLUSION

Overall, this case report offers two complementary clinical insights. Firstly, suspected retroperitoneal perforation after ERCP may not necessitate surgery in stable patients, but careful selection is key. Secondly, delayed biliary stent migration can result in life-threatening sigmoid perforation and therefore mandates planned surveillance as well as timely surgical intervention.