- Email: [email protected]
Bile duct–duodenum and pancreatic-gastric fistulas: two exceptional complications of biliary and pancreatic stenting
Stenting complications: bile duct–duodenum and pancreatic-gastric fistulas
Bile duct–duodenum and pancreaticgastric fistulas: two exceptional complications of biliary and pancreatic stenting Laurent Heyries, MD, Ariadne Desjeux, MD, Jose Sahel, MD
Endoscopic treatment of bile duct and pancreatic strictures remains a matter of some debate. Stent migration is a rare complication (5% of cases), particularly migration proximally into the duct.1 In such cases it is necessary to remove the stent endoscopically or surgically. Late sequelae of proximal stent migration have not been emphasized. We report on 2 cases, one of bile duct–duodenal and the other of pancreatic-gastric fistula following inserFrom the Department of Gastroenterology and Hepatology, Sainte Marguerite Hospital, Marseille, France. Reprint requests: Laurent Heyries, MD, Service d’hepato-gastroenteterologie, Hopital Sainte Marguerite, 270 Bd Sainte Marguerite BP 2913274 Marseille Cedex 9, France. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/4/97775 VOLUME 50, NO. 4, 1999
L Heyries, A Desjeux, J Sahel
tion of stents into the bile duct and pancreatic duct, respectively. CASE REPORTS Case 1 A 56-year-old man with calcifying chronic pancreatitis, associated diabetes mellitus, and a pancreatic cyst underwent endoscopic treatment because he refused surgery. In March 1991, ERCP revealed biliary stenosis associated with a pancreatic cyst in communication with the pancreatic duct. Biliary and endoprostheses were inserted and exchanged systematically every 4 to 6 months during an 11-month period. In December 1992, it was decided to place pancreatic and bile duct stents for a second time because of recurrent pain associated with ductal stenosis in the head of the gland and jaundice. Stents were exchanged systematically every 4 to 6 months. In January 1994, ERCP revealed proximal migration of the 10F, 9 cm long biliary stent. Several attempts to remove the stent using a basket, extraction balloon and foreign body grasping forceps extracted some calculus debris but not the stent. Another stent was inserted beside the first one. Subsequent to the ERCP the patient developed a perforation of a duodenal ulcer and underwent emergency surgery that included oversewing of the ulcer, pyloroplasGASTROINTESTINAL ENDOSCOPY
571
L Heyries, A Desjeux, J Sahel
Stenting complications: bile duct–duodenum and pancreatic-gastric fistulas
cystic tumor of the inferior aspect of the head of the pancreas. The patient refused other diagnostic studies. Six months later, chronic pancreatitis with a pancreatic cyst was diagnosed; there was no history of alcoholic abuse and serum calcium was within normal limits. In September 1994, the patient was admitted to our hospital because of jaundice, elevated liver enzymes and dilation of the biliary ducts. ERCP revealed a hypertrophic minor papilla with a large ulceration at the orifice. Opacification via the minor papilla showed dilation of the main pancreatic duct (10 mm) proximal to a stricture. At this level there was a filling defect suggestive of a calculus or intraductal tumor. The bile ducts, opacified by cannulation of the major duodenal papilla, were dilated proximal to a stenosis classified as type 3 according to Sarles et al.2 A 10F pancreatic stent was inserted through the minor papilla and a 10F stent was inserted into the bile duct through the main papilla. Analysis of pancreatic fluid led to the diagnosis of an intraductal papillary neoplasm. Because of the patient’s poor general condition, we opted for a palliative treatment by exchange of the pancreatic and biliary stents every 4 to 6 months. In November 1996, the patient was admitted for cholangitis, which resulted in another ERCP. Surprisingly, the end of a stent was seen to be emerging from the posterior aspect of the gastric antrum. After retrieval of the stent, opacification of the pancreatic duct showed a fistula between the pancreatic duct and the antrum (Figs. 2 and 3). The stent had probably migrated proximally into the pancreatic duct and then through the gastric wall, thereby creating a fistula between the main pancreatic duct and the stomach. Biliary and pancreatic stents were exchanged. The postprocedure course was uneventful. Figure 1. Endoscopic retrograde cholangiogram made by opacification via the suprapapillary fistula. The stent has migrated into the left hepatic duct. ty and vagotomy. In April 1994, another attempt at stent extraction failed. The second most recently placed stent was then retrieved and not exchanged. The patient refused another laparotomy to remove the stent. In March 1995, a cholestatic pattern of liver function test elevations and dilation of the bile duct led to another ERCP. A small orifice covered by pus was then discovered just proximal to the main duodenal papilla. Through this orifice it was possible to opacify the bile duct (Fig. 1). During pneumatic dilation of this orifice (MaxForce, Microvasive, Boston Scientific, Watertown, Mass.) when the balloon had been deflated, the distal tip of the stent emerged allowing retrieval of the stent with a biopsy forceps. A new biliary stent was inserted through the major main duodenal papilla. At ERCP 4 months later the fistula was healed. This patient has had no further cholestasis or pain, and his diabetes is under control with insulin therapy. Case 2 An 85-year-old man, monitored since 1993 for myopathy associated with a malignant thymoma and new onset diabetes mellitus, underwent abdominal US that revealed a 572
GASTROINTESTINAL ENDOSCOPY
DISCUSSION Endoscopic biliary stent drainage has been widely applied to palliative treatment of malignant strictures in patients who are not candidates for surgery and those with nonresectable tumors. Johanson et al.1 reported stent migration in 5% of 807 stents. Migration of pancreatic stents is slightly more frequent than for biliary stents (6.3% versus 5.4%) and distal migration (into the gut) is also more frequent than intraductal migration (6.6% versus 5.5%). The cause(s) of proximal migration remains unknown. It is not clear whether the type of biliary stricture influences migration. According to Johanson et al.,1 proximal stent migration is significantly associated with malignant stricture. However, Devière et al.3 have reported a high incidence of migration (40%) in 25 cases of bile duct strictures associated with chronic pancreatitis. This is probably due to the nature of the stricture, which is not as tight as a malignant obstruction, and perhaps the regression of an inflammatory component. Other factors related to the stent itself have been reported. Large diameter (12F versus 10F) and short length (less than 7 cm) have been found to be associated with an increased risk of migration.1 VOLUME 50, NO. 4, 1999
Stenting complications: bile duct–duodenum and pancreatic-gastric fistulas
L Heyries, A Desjeux, J Sahel
Figure 2. Endoscopic view of the tip of the stent emerging from the posterior aspect of the gastric antrum.
In case 1 the biliary stenosis was associated with chronic pancreatitis and the stent was 10F and 7 cm. A possible explanation for the creation of the unusual suprapapillary bile duct–duodenal fistula is that, following proximal migration of the stent, the distal tip impacted above the stricture and secondarily penetrated the duodenum wall to form a fistula. Proximal pancreatic stent migration is significantly associated with sphincter of Oddi dysfunction.1 Long (more than 7 cm) stents also more frequently have been found to be associated with proximal migration.1 Diameter of the stent and site of stenting (major or minor papilla) were not found to be significantly associated with stent migration.1 In case 2 the length of the stent was 9 cm. To our knowledge this is the first report of a pancreaticgastric fistula secondary to a pancreatic stent. A postulated hypothesis for this exceptional complication is that after intrapancreatic migration, the proximal end of the prosthesis became impacted against the main pancreatic duct wall. Because of parenchymal atrophy secondary to the underlying intraductal tumor, the impaction led to pancreatic rupture and fistula formation into the posterior aspect of the gastric wall. Proximal stent migration may cause serious complications. Intrahepatic migration can lead to cholangitis or hepatic abscess.4 Intrapancreatic migration can result in acute pancreatitis, pseudocyst formation and pancreatic abscess. Two cases in which stents were left in the pancreatic duct for 2 and 4 years have been reported; the patients remained asymptomatic.5,6 Retrieval of migrated stents has been accomplished with a variety of endoscopic devices: small or standard snares, basket, occlusion balloon, biopsy forceps, foreign body forVOLUME 50, NO. 4, 1999
Figure 3. Radiograph showing retrieval of the stent with a biopsy forceps with the endoscope in the gastric antrum.
ceps and a metal spiral-tipped retrieval device.7 When all measures fail, an additional stent should be placed to ensure adequate drainage. If another retrieval attempt is not successful, surgical removal is usually recommended.8,9 Tarnasky et al.8 reported successful endoscopic retrieval in 86% of 44 cases of proximal biliary stent migration. In half of the cases, a guidewire was first passed through the stent lumen, and the stent was retrieved with the Soehendra device (Wilson-Cook, Medical Inc., Winston-Salem, N.C.). One third of migrated stents were retrieved by grasping the stent with a basket or biopsy forceps. The remaining stents were recovered by placing an extractor balloon beside the stent to provide ductal traction. REFERENCES 1. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992;38:341-6. 2. Sarles H, Sarles JC, Guien C. Etude des voies biliaires et pancreatiques au cours de la pancreatite chronique. Arch Fr Mal App Dig Nutr 1958;47:664-83. 3. Deviere J, Devaere S, Baize M, Cremer M. Endoscopic biliary drainage in chronic pancreatitis. Gastrointest Endosc 1990; 36:96-100. 4. Siegel J, Veerappan A. Endoscopic management of pancreatic disorders: potential risks of pancreatic prostheses. Endoscopy 1991;23:177-80. GASTROINTESTINAL ENDOSCOPY
573
5. Rossos PG, Kortan P, Haber GB. Complications associated with pancreatic duct stenting [abstract]. Gastrointest Endosc 1992;38:252-A107. 6. Barthet M, Bordes G, Bernard JP, Pagliero PH, Sahel J. Removal of a pancreatic stent into the dorsal duct of a pancreas divisum. Gastrointest Endosc 1994;40:243-4. 7. Waxman I, Fockens P, Huibregtse K, Tytgat GNJ. Removal of a broken pancreatic stent using a new stent retrieval device. Gastrointest Endosc 1991;37:631-2.
574
GASTROINTESTINAL ENDOSCOPY
8. Tarnasky PR, Cotton PB, Baillie J, Branch SM, Affronti J, Jowell P, and al. Proximal migration of biliary stents: attempted endoscopic retrieval in forty-one patients. Gastrointest Endosc 1995;42:513-9. 9. Schmalz MJ, Johanson JF, Geenen JE, Venu RP, Johnson GK. Migrated biliary and pancreatic stents: complications and techniques for retrieval [abstract]. Gastrointest Endosc 1991; 37:252.
VOLUME 50, NO. 4, 1999
Bile duct–duodenum and pancreaticgastric fistulas: two exceptional complications of biliary and pancreatic stenting Laurent Heyries, MD, Ariadne Desjeux, MD, Jose Sahel, MD
Endoscopic treatment of bile duct and pancreatic strictures remains a matter of some debate. Stent migration is a rare complication (5% of cases), particularly migration proximally into the duct.1 In such cases it is necessary to remove the stent endoscopically or surgically. Late sequelae of proximal stent migration have not been emphasized. We report on 2 cases, one of bile duct–duodenal and the other of pancreatic-gastric fistula following inserFrom the Department of Gastroenterology and Hepatology, Sainte Marguerite Hospital, Marseille, France. Reprint requests: Laurent Heyries, MD, Service d’hepato-gastroenteterologie, Hopital Sainte Marguerite, 270 Bd Sainte Marguerite BP 2913274 Marseille Cedex 9, France. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/4/97775 VOLUME 50, NO. 4, 1999
L Heyries, A Desjeux, J Sahel
tion of stents into the bile duct and pancreatic duct, respectively. CASE REPORTS Case 1 A 56-year-old man with calcifying chronic pancreatitis, associated diabetes mellitus, and a pancreatic cyst underwent endoscopic treatment because he refused surgery. In March 1991, ERCP revealed biliary stenosis associated with a pancreatic cyst in communication with the pancreatic duct. Biliary and endoprostheses were inserted and exchanged systematically every 4 to 6 months during an 11-month period. In December 1992, it was decided to place pancreatic and bile duct stents for a second time because of recurrent pain associated with ductal stenosis in the head of the gland and jaundice. Stents were exchanged systematically every 4 to 6 months. In January 1994, ERCP revealed proximal migration of the 10F, 9 cm long biliary stent. Several attempts to remove the stent using a basket, extraction balloon and foreign body grasping forceps extracted some calculus debris but not the stent. Another stent was inserted beside the first one. Subsequent to the ERCP the patient developed a perforation of a duodenal ulcer and underwent emergency surgery that included oversewing of the ulcer, pyloroplasGASTROINTESTINAL ENDOSCOPY
571
L Heyries, A Desjeux, J Sahel
Stenting complications: bile duct–duodenum and pancreatic-gastric fistulas
cystic tumor of the inferior aspect of the head of the pancreas. The patient refused other diagnostic studies. Six months later, chronic pancreatitis with a pancreatic cyst was diagnosed; there was no history of alcoholic abuse and serum calcium was within normal limits. In September 1994, the patient was admitted to our hospital because of jaundice, elevated liver enzymes and dilation of the biliary ducts. ERCP revealed a hypertrophic minor papilla with a large ulceration at the orifice. Opacification via the minor papilla showed dilation of the main pancreatic duct (10 mm) proximal to a stricture. At this level there was a filling defect suggestive of a calculus or intraductal tumor. The bile ducts, opacified by cannulation of the major duodenal papilla, were dilated proximal to a stenosis classified as type 3 according to Sarles et al.2 A 10F pancreatic stent was inserted through the minor papilla and a 10F stent was inserted into the bile duct through the main papilla. Analysis of pancreatic fluid led to the diagnosis of an intraductal papillary neoplasm. Because of the patient’s poor general condition, we opted for a palliative treatment by exchange of the pancreatic and biliary stents every 4 to 6 months. In November 1996, the patient was admitted for cholangitis, which resulted in another ERCP. Surprisingly, the end of a stent was seen to be emerging from the posterior aspect of the gastric antrum. After retrieval of the stent, opacification of the pancreatic duct showed a fistula between the pancreatic duct and the antrum (Figs. 2 and 3). The stent had probably migrated proximally into the pancreatic duct and then through the gastric wall, thereby creating a fistula between the main pancreatic duct and the stomach. Biliary and pancreatic stents were exchanged. The postprocedure course was uneventful. Figure 1. Endoscopic retrograde cholangiogram made by opacification via the suprapapillary fistula. The stent has migrated into the left hepatic duct. ty and vagotomy. In April 1994, another attempt at stent extraction failed. The second most recently placed stent was then retrieved and not exchanged. The patient refused another laparotomy to remove the stent. In March 1995, a cholestatic pattern of liver function test elevations and dilation of the bile duct led to another ERCP. A small orifice covered by pus was then discovered just proximal to the main duodenal papilla. Through this orifice it was possible to opacify the bile duct (Fig. 1). During pneumatic dilation of this orifice (MaxForce, Microvasive, Boston Scientific, Watertown, Mass.) when the balloon had been deflated, the distal tip of the stent emerged allowing retrieval of the stent with a biopsy forceps. A new biliary stent was inserted through the major main duodenal papilla. At ERCP 4 months later the fistula was healed. This patient has had no further cholestasis or pain, and his diabetes is under control with insulin therapy. Case 2 An 85-year-old man, monitored since 1993 for myopathy associated with a malignant thymoma and new onset diabetes mellitus, underwent abdominal US that revealed a 572
GASTROINTESTINAL ENDOSCOPY
DISCUSSION Endoscopic biliary stent drainage has been widely applied to palliative treatment of malignant strictures in patients who are not candidates for surgery and those with nonresectable tumors. Johanson et al.1 reported stent migration in 5% of 807 stents. Migration of pancreatic stents is slightly more frequent than for biliary stents (6.3% versus 5.4%) and distal migration (into the gut) is also more frequent than intraductal migration (6.6% versus 5.5%). The cause(s) of proximal migration remains unknown. It is not clear whether the type of biliary stricture influences migration. According to Johanson et al.,1 proximal stent migration is significantly associated with malignant stricture. However, Devière et al.3 have reported a high incidence of migration (40%) in 25 cases of bile duct strictures associated with chronic pancreatitis. This is probably due to the nature of the stricture, which is not as tight as a malignant obstruction, and perhaps the regression of an inflammatory component. Other factors related to the stent itself have been reported. Large diameter (12F versus 10F) and short length (less than 7 cm) have been found to be associated with an increased risk of migration.1 VOLUME 50, NO. 4, 1999
Stenting complications: bile duct–duodenum and pancreatic-gastric fistulas
L Heyries, A Desjeux, J Sahel
Figure 2. Endoscopic view of the tip of the stent emerging from the posterior aspect of the gastric antrum.
In case 1 the biliary stenosis was associated with chronic pancreatitis and the stent was 10F and 7 cm. A possible explanation for the creation of the unusual suprapapillary bile duct–duodenal fistula is that, following proximal migration of the stent, the distal tip impacted above the stricture and secondarily penetrated the duodenum wall to form a fistula. Proximal pancreatic stent migration is significantly associated with sphincter of Oddi dysfunction.1 Long (more than 7 cm) stents also more frequently have been found to be associated with proximal migration.1 Diameter of the stent and site of stenting (major or minor papilla) were not found to be significantly associated with stent migration.1 In case 2 the length of the stent was 9 cm. To our knowledge this is the first report of a pancreaticgastric fistula secondary to a pancreatic stent. A postulated hypothesis for this exceptional complication is that after intrapancreatic migration, the proximal end of the prosthesis became impacted against the main pancreatic duct wall. Because of parenchymal atrophy secondary to the underlying intraductal tumor, the impaction led to pancreatic rupture and fistula formation into the posterior aspect of the gastric wall. Proximal stent migration may cause serious complications. Intrahepatic migration can lead to cholangitis or hepatic abscess.4 Intrapancreatic migration can result in acute pancreatitis, pseudocyst formation and pancreatic abscess. Two cases in which stents were left in the pancreatic duct for 2 and 4 years have been reported; the patients remained asymptomatic.5,6 Retrieval of migrated stents has been accomplished with a variety of endoscopic devices: small or standard snares, basket, occlusion balloon, biopsy forceps, foreign body forVOLUME 50, NO. 4, 1999
Figure 3. Radiograph showing retrieval of the stent with a biopsy forceps with the endoscope in the gastric antrum.
ceps and a metal spiral-tipped retrieval device.7 When all measures fail, an additional stent should be placed to ensure adequate drainage. If another retrieval attempt is not successful, surgical removal is usually recommended.8,9 Tarnasky et al.8 reported successful endoscopic retrieval in 86% of 44 cases of proximal biliary stent migration. In half of the cases, a guidewire was first passed through the stent lumen, and the stent was retrieved with the Soehendra device (Wilson-Cook, Medical Inc., Winston-Salem, N.C.). One third of migrated stents were retrieved by grasping the stent with a basket or biopsy forceps. The remaining stents were recovered by placing an extractor balloon beside the stent to provide ductal traction. REFERENCES 1. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992;38:341-6. 2. Sarles H, Sarles JC, Guien C. Etude des voies biliaires et pancreatiques au cours de la pancreatite chronique. Arch Fr Mal App Dig Nutr 1958;47:664-83. 3. Deviere J, Devaere S, Baize M, Cremer M. Endoscopic biliary drainage in chronic pancreatitis. Gastrointest Endosc 1990; 36:96-100. 4. Siegel J, Veerappan A. Endoscopic management of pancreatic disorders: potential risks of pancreatic prostheses. Endoscopy 1991;23:177-80. GASTROINTESTINAL ENDOSCOPY
573
5. Rossos PG, Kortan P, Haber GB. Complications associated with pancreatic duct stenting [abstract]. Gastrointest Endosc 1992;38:252-A107. 6. Barthet M, Bordes G, Bernard JP, Pagliero PH, Sahel J. Removal of a pancreatic stent into the dorsal duct of a pancreas divisum. Gastrointest Endosc 1994;40:243-4. 7. Waxman I, Fockens P, Huibregtse K, Tytgat GNJ. Removal of a broken pancreatic stent using a new stent retrieval device. Gastrointest Endosc 1991;37:631-2.
574
GASTROINTESTINAL ENDOSCOPY
8. Tarnasky PR, Cotton PB, Baillie J, Branch SM, Affronti J, Jowell P, and al. Proximal migration of biliary stents: attempted endoscopic retrieval in forty-one patients. Gastrointest Endosc 1995;42:513-9. 9. Schmalz MJ, Johanson JF, Geenen JE, Venu RP, Johnson GK. Migrated biliary and pancreatic stents: complications and techniques for retrieval [abstract]. Gastrointest Endosc 1991; 37:252.
VOLUME 50, NO. 4, 1999