A rare complication in a liver transplant patient: Meckel diverticulum perforation due to biliary stent.

INTRODUCTION: Meckel's diverticulum is the most common congenital lesion of the small intestine. The incidence varies between 0.5% and 2% Biliary stents can be used for the treatment of patients with bile duct complications. Intestinal perforation due migrated stents is a very rare and life threatening complication. "Perforation of the Meckel diverticulum due to stent", and no case was found in the literature. For this reason, our case has been identified as the first case seen in the literature. CASE
PRESENTATION: A 20 year old male patient liver transplantation was performed from a live donor. 3 years ago The patient presented at our clinic with abdominal pain, nausea and vomiting that has been present for 2 days. Abdominal computed tomography showed a foreign body in the small intestines Patient was operated in emergency conditions. Meckel Diverticulum 40 cm proximal to the ileocecal valve and a biliary drainage catheter perforating the diverticule was seen Meckel's diverticulum was excised, primary repair was performed, Postoperative recovery was uneventful. DISCUSSION: Complication rates due to a biliary stent range between 8-10% with a mortality below 1% (Konstantinidis et al. [1]). The most feared complication due to a biliary stent is stent migration. The perforation rate due to stent migration is below 1%. It most commonly occurs in the duodenum. Patients with stent related perforations are surgically managed as other GIS perforations.
CONCLUSIONS: Perforation due to stent migration should also be considered in differential diagnosis in patients with a biliary stent and Acute Abdomen.

Introduction

Biliary plastic stent placements are commonly performed to treat a variety of biliary disorders. This procedure presents short-term complications such as hemorrhage, pancreatitis, cholangitis, and perforation, in addition to long-term complications such as stent migration and late perforation [2]. Migration of biliary stent is an uncommon event and occurs in 5–10% of patients [3,4]. Most migrated stents are spontaneously expelled with passage. Serious complications such as intestinal perforation of migrated stents are very rare (<1%) and life threatening [5]. The diagnosis and the treatment were carried out at University Hospital of Cukurova This work is reported in line with the Surgical Case Report Guidelines (SCARE) criteria [6] The legal tutor agreed with the publication of the case and signed the informed consent

Case presentation

A 20-year-old Middle Eastern male patient, while being treated with ALL maintenance treatment 3 years ago, developed acute hepatic failure and underwent living donor liver transplantation utilizing a right hemi-liver graft from his mother. The patient walked into Emergency with abdominal pain, nausea and vomiting that has been present for 2 days. He had a history of liver transplant was taking medications including Tacrolimus 1 mg for these conditions The patient did not have any contributory family, or psychosocial history. He has no history of smoking or other metabolic diseases On physical examination, a sensitivity and rebound was detected in the lower right and upper right quadrant of the abdomen. Body temperature was 38 °C. BMI 20 other system examinations were normal. The following lab results were obtained; WBC: 10.2/mm [3], AST: 71U/L, ALT: 76U/L, ALP: 108U/L, (GGT): 226 U/L, total bilirubin: 2,9 mg/dl, direct bilirubin: 0.9 mg/dl. Hgb: 128 g/dl, Htc 39%, Plt 144.000 mm [3], BUN: 10 mg/dl, Creatinine: 081 mg/dl sodium: 144mEq/L; potassium: 4.4mEq/L, and albumine: 3.1 g/dl. Abdominal computed tomography showed changes secondary to liver transplantation, intrahepatic bile duct enlargement and air density, suspicious thickening on the cecum wall and plastering fluid adjacent to the cecum, and a foreign body in the small intestines (Fig. 1). Patient was admitted to intensive care unit intravenous fluid and antibiotherapy(piperacillin-tazobactam) were given before operation Patient was operated in emergency conditions. After anesthetic clearance, emergency laparotomy was performed under general anesthesia. The operation performed by experienced team of transplant surgeons In the exploration, purulent drainage in the pericecal area, Meckel Diverticulum 40 cm proximal to the ileocecal valve and a biliary drainage catheter perforating the diverticule was seen (Figs. 2, 3 ). Meckel’s diverticulum was excised, primary repair was performed, and the abdomen was irrigated with abundant warm SF. Operation time was 1 h 15 min and blood loss was 50 ml The patient was followed up in the postoperative intensive care unit Postoperative follow-up was followed by Antibiotic therapy (piperacillin-tazobactam), intravenous fluid,analgesics (paracetamol), anti-emetics were administered and the oral intake was started after the gastrointestinal passage was achieved Because our patient is immunosuppressed, infectious parameters should be followed closely The treatment of the patient who had no problems was planned and they were discharged on the 5th postoperative day. The patient had no specific postoperative complications any wound complication did not develop We do not need re-discovery / revision surgeons We have not experienced post-operative 30 day and long-term morbidity / mortality The patient was followed up as an outpatient 10 days after discharge and was well with no further complaints. Another follow-up was done at 6 months. The patient should be closely followed in terms of biliary complications

Fig. 1

Fluid adjacent to the cecum, and a foreign body in the small intestines.

Fig. 2

Intraoperative view of Meckel diverticulum perforation due to biliary stent.

Fig. 3

Intraoperative view of Meckel diverticulum perforation due to biliary stent.

Discussion

The most common complication of the Meckel diverticulum in adults is obstruction and has an incidence of 26.2%–53.4%. Other complications are bleeding (32%), diverticulitis (22%), umbilical fistula (10%) and diverticulum perforation [7]. The most frequently encountered complication after liver transplantation is biliary stenosis, and usually appears after 9–11 months after transplantation. Balloon dilatation and stenting with PTK or ERCP are often successful. Complication rates due to a biliary stent range between 8–10% with a mortality below 1% [1]. The most feared complication due to a biliary stent is stent migration. The risk of stent migration appears to be higher for benign as compared to malignant biliary strictures. The migration rate in plastic stents has been reported to be higher compared to metal stents, single stents have also been shown to have a higher rate of migration [8]. Distal (intestinal and colonic) migration is less common than proximal (duodenal) migration. Generally, in order to prevent migration after the diagnosis of stent migration has been made [1], patients with known risk factors such as adhesions, diverticular disease and hernias should be followed up carefully and stents retrieved if possible. The perforation rate due to stent migration is below 1%. It most commonly occurs in the duodenum. Apart from this, the right colon and the adhesion sites related to previous operations are places where perforation is frequently seen. Perforations due to stents have been reported in loops in parastomal or incarcerated hernias or in the presence of pathologies such as colonic diverticula [5,9,10].

Patients with stent related perforations are surgically managed as other GIS perforations. Pubmed, Google Academic and Ulakbim were screened with the “perforation of the Meckel diverticulum due to stent”, and no similar case was found in the literature. For this reason, our case has been identified as the first case seen in the literature.

Conclusion

When the intestinal lumen, was blocked caused by reasons such as diverticulitis a hernia, or luminal pathologies,created a resistance to this thrust, after which the stent,left between these two forces, perforated the intestinal wall.İn conlclusion perforation due to stent migration should also be considered in differential diagnosis in patients with a biliary stent and Acute Abdomen. Patients with comorbid abdominal pathologies, including diverticula or abdominal hernia, may be at increased risk of perforation from migrated stents.

Presentation information

21st National Congress of Surgery 2018 TURKEYReferences.

Conflicts of interest

No conflicts of interest were declared.

Sources of funding

We have no supportive funding.

Ethical approval

I certify that this kind of manuscript does not require ethical

approval.

Consent

Written informed consent for publication of his clinical details

and clinical images was obtained from the patient.

Author contribution

Uğut topal.-Ahmet gökhan sarıtaş study concept, writing the paper, final decision

to publish, data collection.

Abdullah ülkü. - study concept, data collection.

Atılgan tolga akçam. - data collection and analysis.

Guarantor

Ahmet Gökhan Sarıtaş, Abdullah Ülkü.

Provenance and peer review

Not commissioned, externally peer-reviewed.