Retrograde migration of a fractured plastic biliary stent fragment after percutaneous displacement into the bowel in a patient with hepaticojejunostomy requiring repeat percutaneous retrieval

Abstract

Biliary stent fragments are sometimes advanced into the bowel during percutaneous procedures with the expectation of spontaneous passage. We present a 67-year-old woman who underwent open left hepatectomy with en bloc resection of the common hepatic duct, Roux-en-Y hepaticojejunostomy, and cholecystectomy for hilar cholangiocarcinoma, and was subsequently found to have a retained fractured plastic biliary stent fragment within the intrahepatic bile ducts. During percutaneous transhepatic cholangiography (PTC), the fragment was captured with a snare and advanced into the small bowel, with the final cholangiogram confirming the fragment within the bowel. Surveillance imaging, however, demonstrated the fragment back within the intrahepatic bile ducts. It was definitively removed at a second PTC, after which an internal-external biliary drain was placed. The patient recovered well; the drain was later capped and removed at the bedside, and she remained asymptomatic with normal white-cell counts on follow-up. This case demonstrates that, in patients with hepaticojejunostomy, advancement of a stent fragment into the bowel may not be definitive, and that confirmatory imaging and consideration of complete retrieval are warranted.

Introduction

Biliary stents are commonly used to treat obstruction and strictures in the biliary system. During prior biliary procedures, fragments of these stents can occasionally be left behind within the bile ducts. This is particularly true when a plastic stent fractures, which is itself a rare complication [1,2]. Plastic stents are generally exchanged or removed within approximately three to six months, and fracture is reported mainly with prolonged indwelling times or as a consequence of stent exchange [3].

When retained fragments are advanced into the bowel during percutaneous procedures, they are generally expected to pass spontaneously through the gastrointestinal tract [4]. This applies to both plastic and metallic fragments, although plastic stents are more prone to fracture and fragmentation. Biliary stents that migrate distally are usually eliminated by natural means, and failure to pass is uncommon. Retrograde movement of a fragment back into the biliary system is rarely described and may be more relevant in patients with altered anatomy, such as Roux-en-Y hepaticojejunostomy, in which the absence of a competent sphincter permits bidirectional flow. There is limited literature describing management when a fragment fails to pass and re-enters the biliary system.

In patients with normal anatomy, retrograde-migrated or proximally displaced fragments are usually retrieved endoscopically by ERCP [5]. However, in patients with Roux-en-Y hepaticojejunostomy, endoscopic access to the biliary system is significantly limited due to the long Roux limb and surgically altered anatomy [6]. As a result, standard endoscopic techniques such as ERCP are often not feasible, and alternative approaches are required. Percutaneous transhepatic cholangiography (PTC) serves as an important alternative, allowing direct access to the biliary system through the liver, evaluation of biliary anatomy, and therapeutic interventions including biliary decompression, foreign body retrieval, and stent management [7].

Case report

A 67-year-old woman with a history of hypothyroidism, gastroesophageal reflux disease, prior colonic polyps, lumbosacral radiculopathy, treated Lyme disease, migraine with aura, and depression presented with several months of pruritus followed by diarrhea and an approximately 15-pound weight loss, and was found to be jaundiced. She denied fever, chills, or abdominal pain. Laboratory studies showed an obstructive pattern, with a total bilirubin of 15 mg/dL (reference 0.1-1.2), alkaline phosphatase of 503 U/L (reference approximately 40-130), and AST and ALT of approximately 70 U/L each; CA 19-9 was markedly elevated at 1942 U/mL (reference < 37). CT demonstrated severe intrahepatic biliary ductal dilatation and an enhancing soft-tissue mass at the biliary confluence concerning for a hilar cholangiocarcinoma. Family history was notable for breast cancer (her daughter, a maternal aunt, and her maternal grandmother) and prostate cancer (her father), with no known family history of hepatobiliary malignancy.

At presentation she underwent ERCP, which demonstrated a proximal common hepatic duct and hilar stricture; the left system could not be cannulated, a 10 Fr plastic stent was placed in the right hepatic duct, brushings were obtained (atypical ductal cells), and a sphincterotomy was performed, after which the bilirubin improved. Approximately six weeks later she underwent open left hepatectomy with en bloc resection of the common hepatic duct, biliary reconstruction with Roux-en-Y hepaticojejunostomy, and cholecystectomy. Final pathology showed a pT1N0, well-differentiated cholangiocarcinoma arising in association with an intraductal papillary neoplasm of the bile duct, mismatch-repair proficient (Fig. 1, Fig. 2).

Fig. 1.

Plain radiograph showed a broken plastic stent (black arrow) in the liver (A). Percutaneous transhepatic cholangiogram (B) showed the plastic stent (black arrow) in the upper biliary branch away from the hepaticojejunostomy (white arrow). The stent (black arrow) was snared and pushed into the jejunal loops (C). Post procedure (D), the internal-external biliary catheter (white arrow) was placed and the plastic biliary stent (black arrow) was left in the bowel loops.

Fig. 2.

Follow-up CT (A) showed the plastic stent (white arrow) migrated back into the bile ducts from the bowel loop (black arrow). Percutaneous transhepatic cholangiogram (B) showed the plastic stent (white arrow) migrated back into the bile duct. Post procedure (C), the stent was snared and taken out of the body and an internal-external biliary catheter was left behind.

In the early postoperative period she developed leukocytosis (white-cell count up to 13.7 × 10⁹/L; reference 4.0-11.0) with neutrophilia (absolute neutrophil count up to 9.8 × 10⁹/L) and a normocytic anemia (hemoglobin nadir 8.6 g/dL), while she remained afebrile. Contrast-enhanced CT demonstrated two rim-enhancing fluid collections in the right upper quadrant concerning for abscess; percutaneous aspiration yielded approximately 4 cc of bloody, purulent fluid that was too small in volume for catheter drainage, and cultures grew Candida species, treated with a 14-day course of fluconazole. CT also demonstrated a retained plastic biliary stent fragment within the intrahepatic ducts that did not extend to the hepaticojejunostomy, indicating that a fragment of the previously placed stent had fractured and been retained. Liver chemistries during this period showed persistent mild cholestasis, with alkaline phosphatase ranging from approximately 180 to 255 U/L and only mild aminotransferase elevation, while the total bilirubin remained near normal.

Because of the Roux-en-Y hepaticojejunostomy, with its long Roux limb and altered anatomy, endoscopic (ERCP) access to the biliary system was not feasible, and a percutaneous transhepatic approach was selected.

At the initial PTC, performed approximately two months after surgery under general anesthesia and with periprocedural ceftriaxone, a right intrahepatic duct was accessed under ultrasound and fluoroscopic guidance, and a guidewire was advanced through the bile ducts into the small bowel. Cholangiography demonstrated irregularity and narrowing of the accessed right-sided duct with minimal ductal dilatation, free flow of contrast through the biliary anastomosis, and the retained fractured plastic stent fragment lying within the duct. Through a vascular sheath, a 15-mm Amplatz Goose Neck snare was used under fluoroscopic guidance to capture the fragment, which was withdrawn from the duct and advanced antegrade across the hepaticojejunostomy into the small bowel, with the expectation of spontaneous passage; an antegrade (push) technique was chosen rather than transhepatic extraction to avoid the bleeding risk of pulling the fragment through the hepatic parenchyma. The final cholangiogram confirmed the stent fragment within the small bowel and the drainage catheter appropriately positioned, and an 8.5 Fr internal-external biliary drain was placed and secured with a non-absorbable suture.

Approximately ten weeks later, surveillance CT demonstrated that the stent fragment had returned to a position near the biliary confluence within the intrahepatic ducts rather than progressing distally through the bowel. The treating team attributed this to the fragment not having been advanced sufficiently far downstream for peristalsis to carry it through, allowing it to retract proximally across the sphincterless anastomosis. Given the risk of persistent biliary obstruction and infection, definitive removal was undertaken. At a second PTC, approximately five weeks after that CT, the biliary tree was again accessed percutaneously; cholangiography redemonstrated the retained fragment within the intrahepatic ducts with free flow of contrast into the bowel. Through a 7 Fr sheath, the fragment was captured with a 15-mm Amplatz Goose Neck snare and removed in its entirety through the access. Final cholangiography confirmed complete removal, and an 8.5 Fr internal-external biliary drain was inserted, left in place, and secured with a non-absorbable suture.

Both procedures were tolerated well, with an estimated blood loss of less than 10 cc on each occasion. At a drain exchange about a week after the second PTC, cholangiography showed that the catheter had slipped into the jejunal loop; it was exchanged over a wire and repositioned across the anastomosis into the intrahepatic ducts. The internal-external drain was managed to gravity and then capped, which the patient tolerated without recurrent symptoms, and it was removed at the bedside at a follow-up site check approximately four weeks after the definitive procedure. The patient remained clinically well thereafter, with normal white-cell counts and near-normal liver chemistries on surveillance over the following months.

Discussion

The management of retained biliary stent fragments depends on patient anatomy and available access routes. In patients with normal anatomy, endoscopic removal via ERCP can be used [3]. However, in patients with Roux-en-Y hepaticojejunostomy, endoscopic access to the biliary system is limited because of the long Roux limb and altered anatomy [4]. As a result, standard ERCP is generally not feasible, and a percutaneous approach is often preferred [7].

PTC allows direct access to the biliary system through the liver and can be used for both drainage and intervention [1]. A variety of devices may be used for percutaneous or endoscopic retrieval of biliary foreign bodies and stent fragments, including snares (for example, gooseneck snares), Dormia or spiral retrieval baskets, retrieval forceps, and balloon catheters, with the choice guided by fragment size, location, and orientation [8,9]. In cases of retained stent fragments, there are two broad management strategies. The first is advancement of the fragment into the bowel, which is technically simpler and avoids more complex retrieval maneuvers [8]; this relies on normal bowel peristalsis for spontaneous passage. In contrast, complete removal requires capturing and extracting the fragment, which can be more technically challenging depending on its location and orientation [10]. Fragments that are small, embedded within intrahepatic ducts, or aligned along the duct can be difficult to grasp with a snare or retrieval device. Access angles may also be limited, particularly in peripheral ducts, making stable capture more difficult [5], and there is a risk of ductal injury or displacement into less accessible locations during manipulation [11].

In the present case, cholangiography at the conclusion of the initial procedure documented the fragment within the small bowel, and surveillance cross-sectional imaging subsequently showed it back within the intrahepatic ducts, supporting true retrograde migration rather than simple non-displacement. The most plausible explanation is that the fragment was not carried far enough downstream for peristalsis to clear it, permitting retrograde return across the sphincterless hepaticojejunostomy. Several additional factors may have contributed, including decreased postoperative bowel motility, the size or rigidity of the fragment, and pressure gradients between the bowel and biliary system. Notably, in this same patient a biliary drainage catheter was later found on cholangiography to have slipped from the intrahepatic ducts into the jejunal loop, independently demonstrating that foreign material can move across this anastomosis in either direction in this anatomy.

Confirming definitive intraluminal bowel position can nonetheless be challenging when a fragment is advanced antegrade across a surgically altered anastomosis rather than withdrawn from below, and apparent passage should be corroborated with cholangiography or cross-sectional imaging. This experience suggests that, in such anatomy, a fragment should be advanced well downstream into the efferent limb, or preferably fully extracted, and that confirmatory imaging is valuable before advancement is assumed to be definitive.

Although advancing fragments into the bowel is a commonly used strategy, failure of passage with subsequent return into the biliary system appears to be rare and is not well described. This case highlights that, while initial advancement may be reasonable, definitive removal should be considered when there is concern for non-passage or risk of recurrent obstruction and infection.

Conclusion

Advancement of a fractured plastic biliary stent fragment into the bowel may not result in definitive clearance in patients with Roux-en-Y hepaticojejunostomy, in whom the absence of a competent sphincter permits bidirectional flow and retrograde migration. This case illustrates that confirmatory imaging is valuable and that percutaneous retrieval may be a reasonable consideration when there is concern for non-passage or recurrent obstruction and infection.

Patient consent

The patient was informed and consent was obtained before the submission of this article.