An Interesting Case of a Long-forgotten Bile Duct Stent Causing Obstructive Jaundice

Obstructive jaundice is a serious complication that can occur when a common bile duct (CBD) stent is forgotten or left in place for an extended period. We report a case of a 46-year-old male patient who presented with obstructive jaundice due to a forgotten CBD stent that had been placed 11 years before the presentation. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis and large bile duct stone. A plastic stent was deployed for biliary drainage and advised ERCP for definitive procedure 2 weeks later but the patient did not come for treatment. CT abdomen was done during the present admission which showed fragmented stent fragments in CBD, and Gall bladder and also a large stone at the hilum of the hepatic duct which was proximal to the stent causing obstructive jaundice. We reviewed the literature on forgotten CBD stents and discussed how to manage forgotten biliary stents and the importance of proper follow-up and monitoring of patients with CBD stents to prevent cholangitis and jaundice. We also highlight the need for improved patient education and awareness of the potential risks associated with CBD stents.

Common bile duct (CBD) stents are important in managing bile duct obstruction due to stones, tumors, and stricture. While CBD stents are generally effective in relieving obstruction, they can also be associated with complications, such as stent occlusion, migration, and fragmentation. [1] Forgotten or retained CBD stents are a particularly significant concern, as they can lead to serious complications, including obstructive jaundice, cholangitis, and pancreatitis [2].

A 46-year-old male presented with symptoms of obstructive jaundice and cholangitis for two months. He had undergone endoscopic retrograde cholangiopancreatography (ERCP) on multiple occasions, with the initial procedure performed in 2013 to remove a large common bile duct (CBD) calculus. At that time, only a plastic stent was deployed as a CBD stone could not be removed. He was advised to undergo a laparoscopic CBD exploration in 2 weeks. However, he did not return for follow-up. In November 2024 he once again developed acute cholangitis and septic shock, necessitating another ERCP at a local hospital, and had the insertion of 2 double-pigtail 10 French 10 cm plastic stents. Despite this intervention, the jaundice persisted, prompting him to seek further evaluation and management from our institution after 11 years since the first intervention. Blood investigations showed findings consistent with biliary obstruction. At the same time, imaging studies, specifically a CT scan of the abdomen, demonstrated the presence of two stents within the CBD and a large calculus in the common hepatic duct proximal to the stents. Multiple fragmented stent remnants were identified within the CBD, common hepatic duct (CHD), and gallbladder. (Figure 1,2,3). 

Figure 1: CT-coronal section shows two double CBD stents along with multiple broken stent fragments, and a large stone at the common hepatic duct proximal to the stent.

Figure 2: CT coronal sections show stent fragment in the gall bladder

Figure 3: CT 3D reconstruction showed 2 full-length double pigtail stents along with multiple stent fragments in CBD, CHD, and gallbladder.

Based on these findings, we arrived at a definitive diagnosis of obstructive jaundice due to CBD calculus and fragmented biliary plastic stents. Consequently, we recommended that this patient undergo a definitive surgical procedure to remove the bile duct stone and all the stents and stent fragments. stents. 

Given the previous unsuccessful attempts to remove CBD stones via ERCP, along with the presence of multiple stent fragments in the CBD, and gallbladder, as well as rocks located in the proximal CBD, we planned a laparoscopic cholecystectomy in conjunction with lap/open CBD exploration. Following informed consent under general anaesthesia, a four-port technique was employed to perform the laparoscopic cholecystectomy as an initial step. The Calot's triangle was meticulously dissected, and the critical view of safety was achieved, after which both the cystic artery and cystic duct were clipped and divided. The gall bladder was retracted upwards to expose the supra-duodenal part of the bile duct.  After this, CBD exploration was initiated. Due to recurrent inflammation impacting the biliary tract over 11 years, significant adhesions were encountered, complicating the dissection; hence, we opted to convert to open CBD exploration. Following adequate exploration of the CBD. A 1.5cm vertical choledochotomy was done after the needle aspiration of bile. Utilizing Desjardins Stone forceps, we successfully removed the stone, both the recently deployed stents and 11-year-old stent fragments from the CBD. A notable aspect of our surgical approach involved performing choledochectomy using a conventional 9.2 mm gastroscope (Olympus CV 170) which was facilitated by the 15 mm diameter of the CBD, thereby allowing for unobstructed passage of the gastroscope. Through this technique, we were able to identify 2 fragments of residual stones located within both the proximal and distal CBD [Figure 4].

Figure 4: Choledochoscopy by conventional gastroscopy showed a large stone fragment at hilum in the left hepatic duct.

The stone fragments were extracted from the common bile duct (CBD) utilizing a Fogarty biliary balloon. Subsequently, a check choledochectomy was performed with the gastroscope to confirm complete clearance of the bile duct. The distal obstruction was successfully resolved, allowing the guide wire to traverse effortlessly into the duodenum. Given the history of previous biliary sphinctermy, the choledochotomy wound was primarily closed by interrupted 3-0 Vicryl sutures. Mini laparotomy wound was closed in layers with a subhepatic 20 F drain.  The final specimen comprised two full-length 10 French 10 cm double pig-tail stents and four stone fragments from the CBD, three from the proximal bile duct, and one calculus from the distal bile duct. Furthermore, multiple stent fragments in CBD and the gallbladder [Figure 5].

Figure 5: Retrieved Stents and stone and stent fragments kept in a diagrammatic representation showing patient’s biliary anatomy.

Postoperatively, the patient made an uneventful recovery with resolution of sepsis and jaundice. The drain output was negligible and hence removed on Day 3 and the patient was discharged on Day 5. Upon review one week later, there was a significant reduction in bilirubin levels, and the patient continued to do well. [Table 1].

Table 1: Bilirubin level showed significant improvement after the CBD exploration and removal of stone and stent fragments.

A forgotten common bile duct (CBD) stent can indeed lead to obstructive jaundice, as evidenced by multiple case studies and clinical insights. The primary issue arises when a stent, initially placed for biliary drainage, is not removed within the recommended time frame [3].

Complications of forgotten biliary stent

(i)Stent Obstruction and Stone Formation: Forgotten stents can become obstructed or serve as a nidus for stone formation, known as stentolith, leading to obstructive jaundice. (ii)Cholangitis and Biliary Strictures: Retained stents can cause cholangitis and biliary strictures, further complicating the clinical picture and contributing to jaundice [4].  ESGE (European Society of Gastrointestinal Endoscopy) recommends endoscopic placement of a temporary biliary plastic stent in patients where the bile duct stones are not completely cleared. The stents are made up of polyethylene, polyurethane, polyethylene/polyurethane or Teflon. These plastic stents if kept for a prolonged period, could promote bacterial proliferation, and release of bacterial beta-glucuronidase, which results in the precipitation of calcium bilirubinate. Calcium bilirubinate is then aggregated into stones by an anionic glycoprotein. Thus, the stents themselves become a nidus for stone formation! (choledocholithiasis) 5. 

ESGE recommends that a plastic stent placed because of incomplete common bile duct stone clearance should be removed or exchanged within 3-6 months to avoid infectious complications like cholangitis. [6] Common bile duct obstruction by a foreign body is a rare cause of obstructive jaundice, especially when it occurs due to a biliary stent on which de novo gallstones have formed. There are many studies about the biliary stents, however, there is little information about the long-term stayed or forgotten biliary stents except a few case reports. [7] Patients with forgotten stents commonly present with abdominal pains, obstructive jaundice, and cholangitis. They usually have deranged liver function tests and dilated biliary tracts on abdominal ultrasound. [8] Biliary stents are foreign bodies and, therefore, form a nidus of infection particularly if not removed within 4-6 weeks from insertion. [9] The de novo formation of biliary stones around the stent was reported in a few case reports. These may lead to a stone-stent complex assuming a lollipop, dumbbell, or the stent shape. Bansal and his colleagues were the

first to term this complex ‘stentolith’ in 2009 [8]. The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases [10]. The management of CBD stones remains controversial - different surgical strategies are available as given below [11].

• ERCP 
  • with or without Spyglass cholangioscopy
• Laparoscopic CBD exploration 
  • Trans-cystic exploration
  • Transductal approach 
  • depends on the size of the duct and the size and location of the stone. 
• Open CBD exploration or Roux eny hepaticojejunostomy.

The management needs to be tailored to each case after careful history, investigations and clinical profile. In our case, the stent was placed 11 years ago and the patient didn’t come for follow-up. This was one of the longest durations of forgotten biliary stents as compared with the reported literature. Technical aspect wise what is different in our case was the use of gastroscopy as choledochoscopy.  Shunhui et al demonstrated that using gastroscopy as choledochoscopy was a safe and effective method for diagnosing and treating biliary diseases. The overall technical success rate of the procedure was 96.4%, indicating a high level of effectiveness in accessing the bile duct. [12]. Using gastroscopy as choledochoscopy through choledochotomy in a dilated biliary tree has several advantages namely easy availability and familiarity. Gastroscopy is a widely available procedure, and most hospitals and endoscopy centers have the necessary equipment and trained personnel to perform gastroscopy. Surgeons are often familiar with the technique of gastroscopy, and it is a relatively simple procedure to perform.  Using gastroscopy as choledochoscopy can be cost-effective, as it eliminates the need for specialized choledochoscopy equipment and training [12]. but it has a disadvantage of bile duct injury especially when used in narrow duct and patient who had previous bile duct surgery. 

Forgotten biliary stent is a medicolegal issue and the prevention of forgotten CBD stents requires a multifaceted approach. Patient education and awareness of the potential risks associated with CBD stents are essential. Patients should be informed of the importance of follow-up appointments and the potential consequences of a forgotten stent. In addition, healthcare providers should implement tracking systems to ensure that patients with CBD stents are followed up regularly.

To conclude, forgotten CBD stents are a significant cause of morbidity and mortality in patients with bile duct obstruction. Proper follow-up and monitoring of patients with CBD stents are essential to prevent complications such as obstructive jaundice. Patient education and awareness of the potential risks associated with CBD stents are also crucial.