Scholarly article on topic 'Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature'

Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature Academic research paper on "Clinical medicine"

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{"Esophagus cancer" / Stent / Migration / Esophagectomy / "Endoscopic intervention"}

Abstract of research paper on Clinical medicine, author of scientific article — Servet Karagul, Mehmet Ali Yagci, Cengiz Ara, Ali Tardu, Ismail Ertugrul, et al.

Abstract Introduction Endoscopic esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although stent placement is safe and effective method, complications are increasing the morbidity and mortality rate. We aimed to present a patient with small bowel perforation as a consequence of migrated esophageal stent. Presentation of case A 77-years-old woman was admitted with complaints of abdominal pain, abdominal distension, and vomiting for two days. Her past medical history included a pancreaticoduodenectomy for pancreatic tumor 11 years ago, a partial esophagectomy for distal esophageal cancer 6 months ago and an esophageal stent placement for esophageal anastomotic stricture 2 months ago. On abdominal examination, there was generalized tenderness with rebound. Computed tomography showed the stent had migrated. Laparotomy revealed a perforation localized in the ileum due to the migrated esophageal stent. About 5cm perforated part of gut resected and anastomosis was done. The patient was exitus fifty-five days after operation due to sepsis. Discussion Small bowel perforation is a rare but serious complication of esophageal stent migration. Resection of the esophagogastric junction facilitates the migration of the stent. The lumen of stent is often allow to the passage in the gut, so it is troublesome to find out the dislocation in an early period to avoid undesired results. In our case, resection of the esophagogastric junction was facilitated the migration of the stent and late onset of the symptoms delayed the diagnosis. Conclusion Patients with esophageal stent have to follow up frequently to preclude delayed complications. Additional technical procedures are needed for the prevention of stent migration.

Academic research paper on topic "Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature"

International journal of Surgery Case Reports 11 (2015) 113-116

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International Journal of Surgery Case Reports

journal homepage: www.casereports.com

JOURNAL OF SURGERY

CASE REPORTS

Small bowel perforation due to a migrated esophageal stent: Report of oossMark a rare case and review of the literature

Servet Karagul *, Mehmet Ali Yagci, Cengiz Ara, Ali Tardu, Ismail Ertugrul, Serdar Kirmizi, Fatih Sumer

Department of Surgery, Faculty of Medicine, Inonu University, Malatya, Turkey

ARTICLE INFO

Article history:

Received 12 February 2015

Received in revised form 29 March 2015

Accepted 26 April 2015

Available online 29 April 2015

Keywords:

Esophagus cancer

Migration

Esophagectomy

Endoscopic intervention

ABSTRACT

INTRODUCTION: Endoscopic esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although stent placement is safe and effective method, complications are increasing the morbidity and mortality rate. We aimed to present a patient with small bowel perforation as a consequence of migrated esophageal stent. PRESENTATION OF CASE: A 77-years-old woman was admitted with complaints of abdominal pain, abdominal distension, and vomiting for two days. Her past medical history included a pancreaticoduodenectomy for pancreatic tumor 11 years ago, a partial esophagectomy for distal esophageal cancer 6 months ago and an esophageal stent placement for esophageal anastomotic stricture 2 months ago. On abdominal examination, there was generalized tenderness with rebound. Computed tomography showed the stent had migrated. Laparotomy revealed a perforation localized in the ileum due to the migrated esophageal stent. About 5 cm perforated part of gut resected and anastomosis was done. The patient was exitus fifty-five days after operation due to sepsis.

DISCUSSION: Small bowel perforation is a rare but serious complication of esophageal stent migration. Resection of the esophagogastric junction facilitates the migration of the stent. The lumen of stent is often allow to the passage in the gut, so it is troublesome to find out the dislocation in an early period to avoid undesired results. In our case, resection of the esophagogastric junction was facilitated the migration of the stent and late onset of the symptoms delayed the diagnosis.

CONCLUSION: Patients with esophageal stent have to follow up frequently to preclude delayed complications. Additional technical procedures are needed for the prevention of stent migration.

© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Endoscopic esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer [1-6]. Although stent placement is safe and effective method, complications are increasing the morbidity and mortality rate. Migration is one of the most common complication after stent placement [7]. The majority of migrations are often asymptomatic but they can cause hazardous issues like tracheoesophageal fistula formation, bleeding, obstruction and perforation. Nevertheless, migrated stents can exit via the rectum or remain in the body without complications.

* Corresponding author at: Inonu University, Turgut Ozal Medical Center, Department of Surgery, Malatya 44315, Turkey. Tel.: +90 422 341 0660/3706; fax: 90 422 341 0229.

E-mail addresses: servetkaragul@hotmail.com (S. Karagul), maliyagci@gmail.com (M.A. Yagci), aracengiz@yahoo.com (C. Ara), tarduali@gmail.com (A. Tardu), is_ertugrul@hotmail.com (I. Ertugrul), drserdarkirmizi@hotmail.com (S. Kirmizi), fatihsumer@outlook.com (F. Sumer).

Intestinal perforation is a rare and potentially lethal complication of stent migration. We presented a patient with small bowel perforation as a consequence of migrated esophageal stent and, to our knowledge, there was five cases previously reported [8-12] (Table 1).

2. Presentation of case

A 77-years-old woman was admitted to our hospital with complaints of abdominal pain, abdominal distension, and vomiting for two days. Her past medical history included a pancreati-coduodenectomy for pancreatic tumor 11 years ago, a partial esophagectomy for distal esophageal cancer 6 months ago and an esophageal stent placement (Niti-S fully covered self-expanding stent, Taewoong Medical, Seoul, Korea) by a gastroenterologist after an unsuccessful dilatation procedure for esophageal anastomotic stricture 2 months ago. The patient has not gone for follow-up appointments which was scheduled. On abdominal examination, there was generalized tenderness with rebound. Computed tomography showed the stent had migrated (Fig. 1). Surgery was

http://dx.doi.org/10.1016/j.ijscr.2015.04.030

2210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4X>/).

S. Karagul et al. / International Journal of Surgery Case Reports 11 (2015) 113-116

Table 1

Reported cases of small bowel perforation due to a migrated esophageal stent.

Reference

Age(year)/gender Diagnosis

Pre-stent surgical procedures

Perforation time after stent placement

Perforation site due to the stent

Management

Current case

Zhang et al. [12]

77/Female

17/Male

Bay and Penninga [11] 80/Male

Reddyet al. [10]

79/Female

Kim et al. [9]

Henne et al. [8]

86/Male 52/Female

Distal esophageal Esophagogastrectomy adenocarcinoma and

esophagojejunostony

Tracheoesophageal None fistula

inoperable distal None

esophageal

adenocarcinoma

Squamous cell carcinoma of the lower esophagus

Squamous cell carsinoma in the

distal esophagus

Squamous cell Esophagectomy and carcinoma colon interposition

2 Months

3 Weeks

3 Months

12 Months (6 month after insertion the stent had migrated to the stomach; six month after migration intestinal perforation was demonstrated.) 2 Months

Two perforations, at the antimesenteric border of the jejunum proximal to the Treitz ligament

Jejunal perforation located 50 cm from Treitz's ligament

Terminal ileum

Duodenal perforation

2 Weeks after insertion Anastomotic of second stent perforation of the

former side-to-side jejunostomy

Resection of the perforated small intestinal segment including the stent Perforations were closed. Stent was left in situ. At 6 days after the laparotomy, stent was expelled per rectum Resection of perforated small intestinal segment including the stent

Right hemicolectomy

Percutaneous drainage, no surgical intervention Resection and reconstruction

Gantry: 0" C: 40,0, W: 300,0

Time: 1000 ms WINDOW1 1/9

Kesit: 5 mm il Couch: -2,5 AbdRoutine 5.0 B31s

F:B31s 105 mA

130kV "IF, ,„

Image no: 54

Toplam 90 görüntüden 54.

28.02.2014, 10:32:32 P F

Fig. 1. Computed tomography revealed the stent in the left inferior ofthe abdomen.

performed and laparotomy revealed a perforation localized in the ileum due to the migrated esophageal stent (Fig. 2). The stent was taken out of the abdomen from the perforated area of the intestine. About 5 cm perforated part of gut resected and anastomosis was done. She was admitted to intensive care unit after surgery. Systemic inflammatory response syndrome was diagnosed in postoperative day 3. A multidisciplinary approach was carried out to overcome the progression clinical problems. The patient was exitus fifty-five days after operation due to sepsis.

3. Discussion

Esophageal strictures can be caused by malignant or benign disorders and esophageal stents are the most frequent method used fortreatment of esophageal strictures, regardless of etiologic conditions [5,13]. Also stenting is safe and effective procedure to provide continuance of oral nutrition [1]. Ability to swallow only liquids and complete obstruction or presence of tracheoesophageal fistula are indications for stent placement patients with dysphagia [4]. Rarely, esophageal tumors block the airway and result in breathing difficulties. Stent placement may be an option to improve breathing ability and to ease pain and discomfort.

Stent migration is a common strait after stent placement. Additionally, esophageal stent complications include gastroesophageal reflux, bleeding, stent occlusion, tracheoesophageal fistula formation, intestinal obstruction or perforation. There is no optimized

S. Karagul et al. / International Journal of Surgery Case Reports 11 (2015) 113-116

stent form or a stent placement technique. Fully covered stents, plastic stents, concurrent chemotherapy or radiotherapy increase the risk of migration [14,15]. An ideal stent should be easy to place, have low migration rates and also insertion and removal should be associated with minimal complications. Researchers are not only developing various types of stents to reduce complications but also exploring new stent fixation procedures to prevent the migration. In our hospital, gastroenterologists perform stent placement procedure and do not use any fixation technique to prevent stent migration.

In general, most stents migrate no further than stomach and remain in the stomach without complications. Thus, small bowel perforation is a rare complication of migrated esophageal stent. Six cases of small bowel perforation due to migrated esophageal stent, including our present case, have been reported in the literature [8-12] (Table 1). Henne et al. [8] reported a case of esophagectomy and colon interposition. Six month later, they revealed a stenosis in the cervical anastomosis and implanted a silicon-coated, wall stent. Six months later from the first stent, they noted a stenosis at the oral end of the stent and inserted a second one and two weeks later, they encountered the patient with small bowel perforation. Our patient had a history of total gastrectomy with esophagojejunos-tomy. These two cases suggest that resection of the esophagogastric juntion or pylorus may facilitate the migration of esophageal stents into the small bowel.

The other reported cases of small bowel perforation due to a migrated esophageal stent had no pre-stent surgical procedure. Kim et al. [9] described a patient who refused to undergo chemotherapy and radiation therapy. Eight months later, the patient underwent a palliative esophageal stent placement with a modified Gianturco stent (Song stent; Soho Medi-Tec). Because of the tumoral extention to cardia, lower end of stent was projected into fundus. Obligatory position of the stent rolled a potential effect to stent migration in their case. Reddy et al. [10] described a female patient who refused surgery for lower esophageal carcinoma and underwent chemoradiotherapy. She had a covered self-expanding metallic esophageal stent (Choostent; Solco Intermed, Seoul, Korea). Six months after insertion, stent fracture and migration to stomach was noted. Twelve months after insertion, perforation of the terminal ileum was demonstrated. Bay and Penninga [11] reported a case of inoperable distal esophageal ade-nocarcinoma and stented with a coated self-expanding esophageal stent. Their patient underwent chemoradiotherapy and revealed good response to the treatment. Unfortunately, it is clear that decreased size of the tumor by chemoradiotherapy allowed to stent migration. Zhang et al. [12] described a case with a history of a silicone-covered self expanding metallic esophageal stent (MTN-SE-G-20/80, Nanjing, China) 3 weeks previously for a tracheoesophageal fistula. Plain abdominal radiograph of their patient showed the stent lying in the inferior abdominal cavity and there was no evidence of intestinal obstruction or perforation. After two days of follow up, the patient failed to improve and experienced progressive abdominal pain. At laparotomy, two perforations were identified at the antimesenteric border of the jejunum proximal to the Treitz's ligament.

A point to be noted is that the lumen of stent is often allow to the passage in the gut, so it is troublesome to find out the dislocation in an early period to avoid undesired results. In our case, resection of the esophagogastricjunction was facilitated the migration of the stent and late onset of the symptoms up to mentioned passage delayed the diagnosis. Surgeons should be on the alert to the possibility of stent migration in patient with resection of esophagogastric junction.

If feasible, we prefer endoscopic removal of the stents in the stomach. Additionally, stents in the large bowel mostly move out via the rectum spontaneously. We suggest to observe such cases

with migrated stents in the colon. Patients with migrated stents in the small bowel should be observe closely. We have to keep in mind abdominal exploration according to clinical outcomes.

In our hospital, gastroenterologists carry out non-surgical treatment of the esophageal stenosis by balloon dilatation or stent placement. This team does not use a stent fixation method and we understood that further studies are necessary to develop safety techniques for stenting.

4. Conclusion

Patient with esophageal stent have to follow up frequently to preclude delayed complications. There were five cases previously reported in the literature. These cases reveal the importance of elective surgical removal of migrated stents and the necessity of additional technical procedures for the prevention of stent migration.

Conflict of interest

Authors declare that there is no conflict of interest.

Funding

Ethical approval

Not a research study.

Authors contribution

Ali Tardu, Mehmet Ali Yagci and Ismail Ertugrul participated in the care of the patient.

Servet Karagul performed the literature review and drafted the manuscript.

Serdar Kirmizi and Fatih Sumer assisted in the review of the literature and in revising the manuscript.

Cengiz Ara was involved in revising it critically for important intellectual content.

All authors read and approved the final manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this Journal.

Guarantor

Servet Karagul M.D., servetkaragul@hotmail.com. References

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