Duodenal Perforation From Dislodged Prophylactic Pancreatic Stent Following ERCP for Hilar Cholangiocarcinoma: A Rare Adverse Event
aGastroenterology Department, Saint Joseph’s University Medical Center, Paterson, NJ, USA
bInternal Medicine Department, Ain Shams University, Cairo, Egypt
cGeneral and Colorectal Surgery Department, Royal United Hospital, Bath, UK
*Corresponding author at: Saint Joseph University Medical Center, 703 Main Street, Paterson, NJ, 07503, USA. E-mail address: Minafransawyalkomos@gmail.com (M. Alkomos), Joliegeorge15@yahoo.com (J. Ibrahim), Karandesai09@gmail.com (K. Desai), Beshoy.Elkomos@nhs.net (B.E. Elkomos), baddourw@sjhmc.org (W. Baddoura), gibotros1@gmail.com (Y. Botros).Abstract
We report a rare complication of prophylactic pancreatic duct stenting during ERCP for suspected hilar cholangiocarcinoma. A 47-year-old woman presented with two weeks of painless jaundice, total bilirubin 18 mg/dL, and cholestatic enzymes. Imaging revealed intrahepatic biliary dilation without CBD dilation. ERCP with cholangioscopy identified a right hepatic duct stricture; biopsies were obtained. A 10 mm × 4 cm covered metal stent was placed in the CBD, a 7 Fr × 12 cm plastic stent in the right hepatic duct, and a 4 Fr × 5 cm pancreatic stent was prophylactically inserted after inadvertent duct cannulation.
Two days later, she developed acute abdominal pain. CT revealed stent migration with duodenal perforation. Repeat ERCP removed the dislodged stent, closed the defect endoscopically, and replaced the metal biliary stent with plastic. Biopsies confirmed perihilar cholangiocarcinoma.
This case emphasizes that although prophylactic stenting reduces the risk of post-ERCP pancreatitis, migration and perforation can occur, underscoring the importance of vigilance and early recognition of post-procedural complications.
1.Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) remains central in the diagnosis and palliation of cholangiocarcinoma. In patients at high risk of post-ERCP pancreatitis (PEP)—especially after inadvertent pancreatic duct cannulation—placement of prophylactic pancreatic stents is widely recommended by ASGE, ESGE, and JGES guidelines. 1,2 Prophylactic stents reduce PEP incidence from 15 to 20% to <5% in high-risk populations.3
Despite its benefits, pancreatic and biliary stenting carries known risks, including migration, occlusion, and fracture. Stent migration occurs in approximately 5–10% of cases, though most are clinically silent. Clinically significant complications such as bowel perforation are rare but potentially life-threatening. A large cohort study reported migration in 8.4% of patients undergoing biliary stenting, highlighting that this is not an uncommon mechanical event, though severe complications remain rare.4–7
Duodenal perforation due to migrated pancreatic stents is exceedingly rare, with only isolated case reports described. We present a unique case of intraperitoneal duodenal perforation following prophylactic pancreatic duct stent placement in the setting of suspected hilar cholangiocarcinoma, highlighting both a rare complication and its successful endoscopic management.
2.Case description
A 47-year-old woman presented with two weeks of painless jaundice. Labs revealed total bilirubin of 18 mg/dL and elevated alkaline phosphatase and GGT. CT showed intrahepatic ductal dilation without CBD enlargement. ERCP with SpyGlass cholangioscopy identified a dominant right hepatic duct stricture; targeted biopsies were obtained. A covered metal biliary stent (10 mm × 4 cm) and a right hepatic plastic stent (7 Fr × 12 cm) were placed. Due to inadvertent dorsal pancreatic duct cannulation, a prophylactic 4 Fr ×5 cm plastic stent was placed. Two days post-ERCP, the patient developed abdominal pain. CT demonstrated free air and migration of the pancreatic stent into the peritoneum (Fig. 1). Repeat ERCP confirmed duodenal perforation from the stent tip. The stent was removed, and the defect was closed endoscopically (Fig. 1). The metal CBD stent was replaced with a plastic stent to facilitate closer follow-up. Biopsies confirmed moderately differentiated perihilar cholangiocarcinoma. The patient recovered and proceeded with further oncologic care (see Fig. 2).
3.Discussion
3.1. Role of prophylactic pancreatic stents
3.2. Mechanisms of migration and perforation
Stent migration occurs in up to 5–10% of cases.4 Risk factors include:
- Stent characteristics: larger caliber, straight design, or excessive length.4,5
- Anatomical factors: duct angulation, sphincterotomy, or high duodenal motility.6
- Procedure-related: prolonged manipulation, difficult cannulation, or concurrent biliary stenting.
Perforation typically results from the distal stent tip eroding through the duodenal wall. While most migrations are benign, intraperitoneal perforations can lead to peritonitis and sepsis if unrecognized.8,9
3.3. Clinical presentation and management
Patients often present with delayed abdominal pain, peritonitis, or free air on imaging within days of ERCP.8 In our case, the patient developed pain 48 h after stent placement, consistent with other reports.
Management depends on perforation size, location, and patient stability:
- Endoscopic therapies: Through-the-scope (TTS) clips, over-the-scope clips (OTSC), covered metal stents, or endoscopic suturing are first-line for contained defects.9,10
- Surgical intervention: Reserved for large, uncontained perforations or failed endoscopic closure. Our patient was successfully managed with endoscopic removal and OTSC closure, avoiding laparotomy.
3.4. Lessons and preventive considerations
- Careful stent selection: Small-caliber (3–4 Fr), short (<5 cm), and single-pigtail designs minimize migration.8
- Timing of removal: ESGE recommends confirming passage or removing prophylactic stents within 5–10 days.2
- Post-ERCP vigilance: Any delayed abdominal pain warrants imaging to exclude migration, perforation, or pancreatitis.
This case adds several unique elements to the existing literature. First, the complication occurred after placement of a small-caliber (4 Fr) prophylactic pancreatic stent, which is typically considered low risk and is designed to migrate spontaneously without adverse consequences. Second, the perforation occurred during concurrent complex biliary intervention for suspected hilar cholangiocarcinoma, a scenario not commonly described in prior reports. Compared with previously published cases (Table 1),11–14 which often involve larger biliary stents or delayed migration, this case demonstrates that even short, small-caliber pancreatic stents can result in early intraperitoneal perforation.
4.Conclusion
Prophylactic pancreatic duct stents remain essential in PEP prevention, yet clinicians must recognize the small but real risk of stent migration and duodenal perforation. Early recognition, imaging, and prompt endoscopic intervention are critical to avoid morbidity. Our case highlights that even appropriately placed, small-caliber stents can migrate intraperitoneally, emphasizing the need for vigilant monitoring.
| Study | Indication | Stent type | Location of perforation | Timing | Management | Unique Feature |
|---|---|---|---|---|---|---|
| Bharathi et al., 2008.11 | Malignant biliary obstruction | Biliary stent | Duodenum | Delayed | Surgery | Late migration |
| Gromski et al., 2020.12 | Biliary stricture management | Biliary stent | Duodenum | Variable | Endoscopic | Migration-related |
| Pachhai et al., 2022.13 | Cholangitis | Biliary stent | Duodenum | Early | Surgery | Severe peritonitis |
| Asghari et al., 2025.14 | Acute biliary pancreatitis | Biliary stent | Duodenum | Variable | Endoscopic | Migration-related |
| Present Case | Cholangiocarcinoma | 4 Fr pancreatic stent | Duodenum (intraperitoneal) | 48 h | Endoscopic (OTSC) | Small-caliber prophylactic stent; cholangiocarcinoma setting |