Bharathi Ramanathan Saranga, Rao Pankaj P, Ghosh Kunal
Department of Surgery, Armed Forces Medical College, Wanowrie, Pune, Maharashtra 411040, India.
Int J Surg. 2008 Dec;6(6):478-80. doi: 10.1016/j.ijsu.2006.06.012. Epub 2006 Aug 10.
Endoscopic biliary stenting is an accepted modality of palliation of malignant biliary obstructions. Delayed stent migration causing intra-peritoneal perforation of duodenum, is a rare life threatening complication. Proximal adhesion of stent to the tumor is believed to increase the intensity of distal trauma produced by the intra-duodenal segment, preventing its adaptation to intestinal peristalsis and causing perforation. Low bacterial load and containment of leak by gut and omentum blunts the clinical features. Unexplained abdominal discomfort in stented patients should alert the clinician to its possibility, irrespective of the delay between stent placement and onset of symptoms. Early diagnosis and treatment is desirable but aggressive surgical management with gastro-biliary diversion, tube duodenostomy, antibiotics, bowel rest and parenteral alimentation followed by distal alimentation, may make up for the delay in those presenting late. A case of 7 days old intra-peritoneal duodenal perforation following delayed migration (3 months) of endobiliary stent presenting with atypical features is reported. Stent's distal end was protruding through the duodenum with its proximal end in CBD. Mortality, fistulization, abscesses and sepsis are known complications but were not observed in our case. Much of the management can be done minimally invasively, if recognized early.
内镜下胆道支架置入术是缓解恶性胆道梗阻的一种公认的治疗方式。延迟性支架移位导致十二指肠腹腔内穿孔是一种罕见但危及生命的并发症。支架近端与肿瘤粘连被认为会增加十二指肠内段产生的远端创伤强度，阻碍其适应肠道蠕动并导致穿孔。低细菌负荷以及肠道和网膜对漏出物的包裹会使临床症状不明显。无论支架置入与症状出现之间的时间间隔如何，支架置入患者出现不明原因的腹部不适时，临床医生都应警惕这种可能性。早期诊断和治疗是可取的，但对于出现较晚的患者，积极的手术治疗，包括胃肠胆道分流、十二指肠造瘘术、使用抗生素、肠道休息和肠外营养，随后进行远端营养支持，可能弥补诊断延迟的影响。本文报告了一例在内镜下胆道支架延迟移位（3个月）后7天出现腹腔内十二指肠穿孔且伴有非典型特征的病例。支架远端经十二指肠突出，近端位于胆总管内。死亡率、瘘形成、脓肿和败血症是已知的并发症，但在我们的病例中未观察到。如果早期发现，大部分治疗可以通过微创方式进行。
