Forgotten metal stent (3 years) presenting with a high burden of intra- and extra-hepatic ducts stones and cholangitis

Forgotten stents may lead to serious complications. We present a case report of a forgotten common bile duct (CBD) fully covered metal stent presenting with recurrent cholangitis. A 79-years-old female patient presented with a history of recurrent cholangitis. Past surgical history was notable for open cholecystectomy for symptomatic cholelithiasis in 2016. Subsequently, she was found to have retained CBD stones in the same year. She had endoscopic retrograde cholangiopancreatography (ERCP), during which a complete clearance of the stone was not achieved and she was stented with a completely covered metal stent. She was lost to follow-up until 2019. A differential diagnosis of cholangitis secondary to a blocked stent was made. At ERCP, she had intra- and extra-hepatic stones, which could not be removed. A plastic stent was deployed. She later had an open bile duct exploration with Roux-en-Y hepaticojejunostomy. Forgotten stents can lead to serious complications. An electronic stent follow-up registry is recommended.