Plastic biliary stent migration as a cause of ascending colon perforation.

A 65-year-old male with pancreatic cancer stage IV and history of endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placement 43 days earlier, arrived to the emergency department with 8-hour right upper quadrant pain, fever, and shivering. Contrast enhanced computed tomography showed migration of the biliary stent to the ascending colon, with signs of perforation on its antimesenteric edge. A surgical approach by laparotomy was decided. The biliary stent was found perforating the ascending colon and in contact with the abdominal wall. The stent contained the colonic perforation, avoiding leakage. Removal of migrated endoprosthesis and primary closure was made. The patient remained in observation and with IV antibiotics, a new was performed ERCP with placement of an 8 cm by 10 Fr Amsterdam-type plastic stent on the 7th day due to cholangitis, with subsequent complete recovery. Endoscopic placement of stents has become a well-established procedure for biliary disease. Stent migration may be present in up to 6-8% of the cases. In most cases, distal migration has an uncomplicated passage, but it may cause bowel injury in up to 1%. This life-threatening complication requires prompt evaluation and management either by endoscopic or surgical approach.

Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)