Late Migration of Covered Metal Stent to the Stomach Through a Spontaneous Choledochoduodenal Fistula in a Patient With Malignant Biliary Obstruction

We report a case in which a spontaneous choledochoduodenal fistula occurred after biliary covered self-expanding metal stent (SEMS) placement and a late transfistula migration of the stent in a patient with malignant distal biliary obstruction. A partially covered WallFlex biliary stent (Boston Scientific) was appropriately implanted in the common bile duct. Subsequently the patient received chemotherapy with gemcitabine. After 7 months of the SEMS insertion, the patient presented with frequent vomiting. Abdominal computed tomography revealed the obstruction of the duodenal descending part and the migrated stent in the stomach. A choledochoduodenal fistula was observed endoscopically at the proximal point of the duodenal obstruction. These findings can cleanly account for the SEMS migration through the fistula. The mechanism of formation of the fistula is mostly associated with a mechanical contact between the bile duct wall and the SEMS edge, which is pushed up in the direction of the duodenum because of the enlargement of the primary tumor, finally penetrating through the duodenal wall. To our knowledge, this is an extreme unusual case, which has been unreported previously. Therefore, we emphasize the necessity of being alert to the potential for such complications in cases involving placement of SEMS for malignant biliary obstruction.