Unusual migration of a straight Amsterdam-type endoprosthesis for bile duct stones

We describe an 84-yr-old woman in whom a straight Amsterdam-type biliary endoprosthesis was inserted because of endoscopically unremovable large common duct stones. After 18 months, the prosthesis migrated through the duodenum and the intrapancreatic portion of the bile duct, with its distal tip close to the vena cava and the aorta. In view of this high-risk complication, the authors avoid placing straight biliary endoprotheses for common bile duct stones in patients who might be lost to follow-up.