What is the management of stent migration after choledochoduodenostomy (surgical creation of a connection between the common bile duct and the duodenum)?

From the Guidelines

Stent migration after choledochoduodenostomy should be managed with prompt endoscopic retrieval as the first-line approach, using devices such as rat-tooth forceps, snares, or retrieval baskets during ERCP, as this method is associated with the best outcomes in terms of morbidity, mortality, and quality of life. When a stent migrates, an experienced endoscopist should attempt to retrieve it, and if the stent has migrated proximally into the biliary tree, balloon catheters can be used to pull it into a more accessible position 1. For distally migrated stents that have entered the small intestine, watchful waiting is often appropriate as most stents will pass spontaneously without complications. However, if the stent causes obstruction or perforation, surgical intervention becomes necessary. Some key points to consider in the management of stent migration include:

• Using stents with appropriate anchoring features like flaps or pigtails to prevent migration
• Selecting the proper stent length to minimize the risk of migration
• Scheduling timely follow-up appointments for stent removal before the expected migration timeframe
• Educating patients about potential migration symptoms, including abdominal pain, jaundice, or fever, which warrant immediate medical attention
• Regular imaging follow-up with ultrasound or CT scans to monitor stent position in high-risk cases. It is also important to note that covered SEMS, which are sometimes used in the treatment of benign biliary strictures, have a higher risk of stent migration due to their silicone coating, and this should be taken into consideration when choosing a stent type 1.

From the Research

Management of Stent Migration after Choledochoduodenostomy

• Stent migration is a known complication of biliary stent placement, including after choledochoduodenostomy 2, 3.
• The frequency of stent migration can vary, with reported rates ranging from 3% to 8.4% 3.
• Risk factors for stent migration include moderate to marked common bile duct dilation, complete sphincterotomy, the use of balloon dilation, and stent insertion for more than 1 month 3.
• Stent migration can lead to various complications, such as cholangitis, stent obstruction, bleeding, and duodenal perforation 3.
• Management of stent migration typically involves endoscopic retrieval of the migrated stent using techniques such as extraction balloon, Dormia basket, snares, and foreign body forceps 3.

Prevention of Stent Migration

• The use of lumen-apposing metal stents (LAMS) has been shown to have high technical and clinical success rates for EUS-guided choledochoduodenostomy, with low rates of migration 4, 5, 6.
• LAMS may be a suitable option for patients undergoing choledochoduodenostomy to reduce the risk of stent migration.
• However, the cost-effectiveness of LAMS compared to traditional tubular self-expandable metal stents (SEMS) remains to be proven 5.

Treatment of Stent Migration

• Endoscopic retrieval of the migrated stent is the preferred method of treatment 3.
• In some cases, surgical intervention may be necessary, such as in the case of small bowel obstruction caused by stent migration 2.
• The choice of treatment will depend on the individual patient's circumstances and the severity of the complications caused by the stent migration.