iarjimphIARJIMPHIARJIMPH2709-331Xhttps://doi.org/10.47310/iarjimph.2022.v03i02.026Plastic Stent Migration and Duodenal Perforation: An Emergency Delayed Complication of Stent Placement during ERCPRizaSetyaAgrensaIdaBagus Budhi SuryaAdnyanaBackground: The procedure of endoscopic retrograde cholangiopancreatography (ERCP) is a challenging one with rare postoperative complications. Although biliary plastic stent-related duodenal perforations are uncommon, they can be fatal. Treatment options for perforations of this type are varied and controversial. Case presentation: A male patient, 48 years old, with severe pain in the abdomen was referred to Dr. Moewardi Hospital. For one day after endoscopic retrograd cholangiopancreatography (ERCP) five days ago. To hepatopancreatobiliary surgery department of Moewardi Hospital for malignant biliary obstruction due to advanced pancreatic cancer. Due to obstructed jaundice due to biliary stenosis, the patient underwent dilatation and stent placement of the bile duct. After perforation of duodenal due in to biliary peritonitis and biliary, the patients underwent duodenography, laparotomy, peritoneal lavage, and a biliodigest procedure. Conclusion: Despite the low risk of interference with complications, biliary obstruction such as pancreatitis, bleeding and fatigue may happen. Early detection or a high index of suspection lead to effective intervention. Stent migration can lead to duodenal perforation, which can lead to morbidity and mortality if treatment is delayed.‎