Transpapillary Penetration of an Ampullary Tumor by a Migrated ERBD Tube

CASE REPORT A 94-year-old man presented with vomiting and loss of appetite. Contrast-enhanced computed tomography demonstrated dilation of the bile and pancreatic ducts, an enlarged major papilla (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) showed an irregularly enlarged papilla (Figure 1), and forceps biopsy revealed adenocarcinoma, establishing ampullary carcinoma. Because of biliary dilatation without jaundice, a 10-Fr straight endoscopic retrograde biliary drainage (ERBD) tube was placed (Figure 1).Figure 1.: (a) Contrast-enhanced computed tomography showing enlargement and enhancement of the major papilla (yellow arrow). (b) Endoscopic view demonstrating an irregularly enlarged papilla. (c) and (d) A 10-Fr straight endoscopic retrograde biliary drainage tube was placed for biliary obstruction caused by ampullary carcinoma (c: endoscopic view, d: fluoroscopic image).Several months later, he was readmitted with fever and abdominal discomfort consistent with acute cholangitis. Follow-up CT demonstrated distal migration of the ERBD tube with its tip penetrating the region of the papilla (Figure 2). Repeat ERCP confirmed transpapillary penetration through the ampullary tumor in a spear-like fashion (Figure 2). The transfixing tube was smoothly removed using grasping forceps (Figure 2) and replaced with a 7-Fr double-pigtail stent, with prompt clinical improvement. To minimize additional injury, stent removal should be performed under continuous endoscopic and fluoroscopic guidance, avoiding excessive torque or deviation from the stent axis. Regarding the mechanism of penetration, 1 possible explanation is that the distally migrated stent became caught at the side-flap portion against the papilla, eventually leading to perforation under repeated mechanical stress. This case illustrates a rare but important complication of migrated straight plastic biliary stents in ampullary carcinoma and underscores the need for careful stent selection and follow-up.1Figure 2.: (a) Contrast-enhanced computed tomography demonstrating the migrated ERBD tube penetrating through the major papilla. (b) and (c) Endoscopic views confirming transpapillary penetration of the ERBD tube. (d) The transfixing ERBD tube was smoothly removed using grasping forceps. ERBD, endoscopic retrograde biliary drainage.DISCLOSURES Author contributions: A.K. prepared the first draft of the manuscript. A.K. and M.H. managed the patient. M.H. and K.S. revised the manuscript. All authors approved the final version of the manuscript. Financial disclosure: None to report. Conflicts of interest: The authors have no potential conflicts of interest. Informed consent was obtained for this case report.