Endoscopic closure of a duodenal perforation secondary to a migrated biliary plastic stent using hemoclips

A 28-year-old female patient was admitted to our hospital with right upper quadrant pain and fever. The patient was diagnosed with acute cholangitis and choledocholithiasis. Stone removal was performed with Endoscopic retrograde cholangiopancreatography (ERCP) as it measured 1cm in size and a 10-Fr 10 cm straight plastic stent (Flexima™, Boston Scientific) was placed in the common bile duct. The patient was discharged after his symptoms subsided and was admitted to our hospital again two months later with abdominal pain, back pain, nausea and vomiting. On physical examination, mild tenderness was detected in the right upper quadrant. Laboratory tests showed a white blood cell (WBC) count of 6.82x109/L, hemoglobin 10.3 g/mL, alanine aminotransferase (ALT) 19 U/L, aspartate aminotransferase (AST) 18 U/L and total bilirubin (TB) 0.76 g/mL. All other laboratory parameters were normal. Abdominal computed tomography (CT) showed that the distal end of the plastic stent migrated to the lower wall of the third part of the duodenum and protruded into the peritoneal cavity. However, there was no evidence of perforation (Fig. 1A). During ERCP, it was observed that the proximal end of the plastic stent was in the bile duct and the distal end perforated the duodenal wall opposite the papilla (Fig. 1B). The plastic stent was held with rat-tooth forceps and removed with a slight upward movement towards the common bile duct and then a downward movement towards the lumen (Fig. 1C). Closure of the defect in the duodenum was performed with three hemostatic clips (Fig. 1D). Oral intake started a few days after the procedure and there were no complications. Duodenal perforation caused by migration of biliary stents is a rare complication. Abdominal CT scanning is usually preferred in these cases, and endoscopic intervention is an effective method for treatment.