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Endoscopic retrograde biliary drainage (ERBD) usingmetal biliary stents is widely applied to biliary obstruction resulting from benign stricture or malignancy. The increased use of biliary stents has also been accompanied by an increasing number of cases of complications. Early complications occurring within 2 weeks of treatment by ERBD are not uncommon [1]. Delayed biliary perforation caused by metal stents is very rare [2]. Various methods have been suggested for the management of complications after placement of selfexpandable metal stents (SEMSs) including mechanical cleaning, use of a diathermic treatment to removemalignant tissue ingrowth, introduction of a second stent into the primary stent, use of percutaneous transhepatic biliary drainage, cutting the stent using argonplasma, or endoscopic removal of the stent [3,4]. A 74-year-old womanwas diagnosedwith pancreatic ductal adenocarcinoma with common bile duct (CBD) invasion and hepatic metastases. She underwent endoscopic insertion of an uncovered biliary SEMS (10mm×6cm) as palliative management. She was admitted again 4 months later with severe right upper quadrant pain, jaundice, and chills. An abdominal computed tomography (CT) scan revealed a mass in the head of the pancreas associated with the biliary stent, and fluid collections in the retroperitoneal space, right paracolic gutters, and pelvis (●" Fig.1). A percutaneous drainage catheter was inserted into the right-sided retroperitoneal space and bile-stained fluid was drained through the catheter. This was followed by a duodenoscopy, during which a portion of themetal stent was visible through a penetrating ulcer in the infundibulum of the duodenum (●" Fig.2). A balloon-occlusion cholangiogram was performed using an extraction balloon catheter and revealed a leak at the lateral side of the distal CBD (●" Fig.3a). A membrane-covered SEMS (10mm×6cm) was inserted endoscopically into the previously placed, uncovered SEMS. Immediately after the new stent was deployed, the cholangiogram indicated that the bile leak from the distal CBD had stopped (●" Fig.3b). A cholangiogram performed 7 days later showed no dye leakage from the CBD (●" Fig.3c). The patient was discharged in Fig.1 Abdominal computed tomography (CT) scan showing a mass in the head of the pancreas associated with a biliary metal stent and a fluid collection in the retroperitoneal space. Fig.2 Duodenoscopy image showing a penetrating ulcer in the infundibulum of the duodenum with a portion of the stent visible.

Bile duct perforation caused by an uncovered metal stent treated by placement of a covered metal stent in a patient with pancreatic cancer