MENDING THE
PROBLEM FOR GOOD

Experts at Nanavati Hospital successfully closed perforation
in a patient caused by unremoved stent from past surgery

A 22-year-old patient was rushed to the Emergency Department at Nanavati Super Speciality Hospital, Mumbai with pain in the periumbilical region which had gradually increased in the past 24 hours. The patient was in severe pain at the time of admission and had experienced multiple episodes of vomiting. Initial examination reported the patient's BP was 140/90 mm Hg, pulse rate was 102/min, and respiratory rate was 20/min. On further examination, the abdomen was found to be distended; guarding was present in epigastrium, left hypochondrium and periumbilical region. The patient's condition was a known case of hereditary Spherocytosis. The patient was earlier hospitalised in 2008 with chief complaints of Jaundice and abdominal pain in the right hypochondrium. The patient underwent an endoscopic procedure following which Laparoscopic Cholecystectomy and Splenectomy were done after a gap of 7-8 days.

Contrast-enhanced CT scan showed a sliver of pneumoperitoneum below the right crus of the diaphragm and extraluminal air in the vicinity of DJ flexure. A foreign body was protruding from the jejunum near the DJ flexure. In view of the above findings, an endoscopic retrieval was planned. An Upper Gastroscopy was done, but the foreign body could not be located. Subsequently, Diagnostic Laparoscopy was performed which revealed dense adhesions. Peritoneal fluid with pus contamination was also found. Adhesiolysis was done, yet, the site of the perforation could not be identified.

Finally, an Exploratory Laparotomy was then performed, and perforation with stent projecting out was located in the jejunum, just distal to the DJ flexure. The stent was removed, and the perforation was closed. Once peritoneal lavage was given, the drain was kept, and the abdominal wall was closed in layers. Postoperative period was uneventful, and the patient was discharged on the 7th post-operative day. Follow up showed good results and the patient is doing well now.

The rate of complications arising from endobiliary stents have been reported to be between 8 and 10%, mortality rate of 1%, and distal migrations up to 6%.

It is reported that these stents, which undergo migration, are often expelled through natural means or remain in the intestinal tract without causing symptoms. However, in this case, the patient did not follow up with the Gastroenterologist for stent removal and had approached the hospital after 10 years with perforation peritonitis due to a migrated biliary stent.