A Rare case of Forgotten CBD stent with secondary biliary calculi
2024-06-06ABSTRACT:
Endoscopicbiliarystentingisacommonlyperformedprocedureininterventionalgastroenterology,typically utilizingplasticstentsfor short-termbiliarydrainage.
Stentolith refers to a forgotten stent post-ERCP that serves as anidus for stone formation.Stentsshould ideally be removed within 6 weeks to avoid complications such ascholangitis,pancreatitis, biliarystricture, and biliary cirrhosis. Failure to attend to stents for extendedperiodscan lead to a widerangeof complications.
Our 33-year-old patient presented with a long-standing forgottenbiliary stent with stentolith.Diagnosticconfirmation was achieved through a combination of abdominal ultrasonographyand MRCP.
Keywords:ForgottenCBDStent,SecondaryBiliaryCalculi,Stentolith
INTRODUCTION:
The occurrenceof choledocholithiasis is approximately 10% in patients with symptomatic gallstonesand increases to 15% in those diagnosed with acute cholecystitis. The establishedapproach for managing common bile duct (CBD) stones involves endoscopic retrograde cholangiography (ERCP) and subsequent stone removal,with or without stent placement. (1) Typically, the sequence of events includesERCP management of CBD stones followed by cholecystectomy, and then removal of thestent. Gastroenterologists commonly remove the CBD stent approximately 3-4 weeksafter placement, and in some cases, the stent may pass out spontaneously in thestool.
However,if stent removal is delayed for anyreason,itcanleadtocomplications.(2-3) We present a case of a forgottenbiliary stentdiscovered after 6years, which resulted intheformation of a stentolith and associatedcalculiinthecommonbileandhepaticducts.
CASE REPORT:
33yrs.adultpresentedwithpaininepigastricregionsince4monthswhichaggravatesontakingfood.Healsocomplained of fever which was intermittentinnatureandgetsresolvedontakingmedication.Itwasalsoassociatedwithvomitingand yellowish discoloration of eyesforone month. He lost 5 kgs in 4 months duetopainaftertakingfood.Hewasonliquid diet for 4 months. On clinicalexamination,tendernesspresentinepigastricregion. Onbiochemistry Deranged LFT was found withraisedconjugatedbilirubinandmarkedlyraisedalkalinephosphatase. OnUSGandMRCP choledocholithiasis with CBD stentseeninsitu (figure1.). ERCPwasdoneforcholedocholithiasis6yearsback.Laparoscopiccholecystectomy was done forcholelithiasis2yearsback. Patientwasadvised 6 yearsback for stent removal butpatientignored the advice. Gastroenterologist failed to remove stent through ERCP duetomultiple stentolith. Therefore,decision wastaken to perform openCBD exploration andstentremoval.Intraoperatively,DilatedCBD
2.5 cm seen adhered to duodenum (figure2.)& liver, CBD explored for stent removal andsamewasremovedundervision&CBDcalculusextracted (figure3.). Ureter scopewasusedforvisualizationofintraluminalimpaction of calculi in the common bileducttill sphincter of ODI distally(figure4.) also,commonhepaticductproximally(figure5.). Noimpactedcalculiseen;minimalsludge seen & removed withforceps. Normal Saline wash given. T tubeplaced. After 6 weeks T-tube cholangiogramdoneandT-tubewasremoved.Patientreviewed after onemonth had no symptomsanddoing well.
DISCUSSION:
Endoscopic retrogradecholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (EST) andstone extraction is widely regarded as the preferred treatment for patients of anyage diagnosed with choledocholithiasis. (4-6) This approach has demonstrated successrates ranging from 80% to 95%. Despite advancements in ERCP techniques, thereare instances where endoscopic removal of biliary stones may prove challenging especiallyin cases forgotten and retained stents. Surgical interventions may be consideredfor these patients (7-10)
CBD stents are generally classified into twomaincategories:plasticandmetallic.Metallicstentsaretypicallyconstructedfrom stainlesssteel or nickel-titanium alloy.Theygenerallyusedforlongstandingdrainagelikemalignantbiliarystricture.Plasticstentsarecommonlyusedtemporarily for post-ERCPCBD clearance,palliativestentinginmetastaticdiseaseswithalifeexpectancyoflessthanthreemonths,ortemporarybiliarydrainageprecedingsurgery.Despitetheircost
Effectiveness,plasticstentsarepronetoocclusion,primarilyduetomicrobialcolonies,bacterialbyproducts,calcium bilirubinate, and calcium palmitate crystals,which foster bacterial adherence and biofilmformation. Bacterial β-glucuronidasereleasealsocontributestocalciumbilirubinateprecipitation,which aggregates into stonesduetoglycoproteins.Thepresenceofaretainedstentactsasaforeignbody,promotingbacterialcolonization.Ideally,stents should be removed within three tosixmonths. The most prevalentcomplicationsassociatedwithretainedendoscopicstentsincludejaundice, cholangitis,choledocholithiasis,pancreatitis,andinternalmigration.Theincidenceofstentolithformation isapproximately 18%incaseswhere stentshavebeenforgottenforovertwoyears.CBDstentolithmaymanifestwith symptoms such as pain, fever,jaundice,or recurrent cholangitis. Strategiestopreventordelaystentocclusionor stentolithformationmayinvolveprophylacticantibiotics,antibiotic-impregnatedstents,bile-thinningcompoundslikeursodeoxycholicacid,placementofCBDstentswith sphincterotomywhenfeasible,andutilizationoflargerdiameterstents.Managementtypicallyentailsendoscopicstentremoval.However,patientsexperiencingsymptomsmayrequirelaparoscopic or open CBD exploration andstent removal. Bilioenteric bypass withside-to-side Roux-en-Ycholedochojejunostomy,CBD exploration with choledochoduodenostomy,andendoscopicclearanceofstentolithshavealsobeenperformedin selectcases(11-13).
CONCLUSION:
Patientsoftenoverlookthepotentialcomplicationsassociatedwithprolongedretentionofbiliarystents.Itiscrucialtoprovidethoroughpatientcounselling,education,anddocumentationtopreventthisscenario.
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