A 50-year-old woman underwent endoscopic placement of a biliary
self-expandable metallic stent (SEMS) and a
22 × 90 mm WallFlex™ duodenal stent (Boston
Scientific, Natick, Massachusetts, USA) across an inoperable periampullary
adenocarcinoma. Eighteen months later, the patient presented with nonbilious
vomiting. A clinical diagnosis of gastric outlet obstruction due to disease
progression was made. Endoscopy revealed a normal esophagus, dilated stomach,
and narrowing between the first and second parts of the duodenum, but the stent
was not clearly visualized.
One week later, the patient underwent a water-soluble contrast study
for assessment of the gastric outlet obstruction. Preliminary fluoroscopy
revealed a radiopaque foreign body in the cervical esophagus, which was
presumed to be the displaced fragment of the stent ([Fig. 1 a]).
Fig. 1 a Preliminary
fluoroscopy revealed a fractured stent fragment with partially disrupted mesh
in the cervical esophagus (arrow). b Contrast was
entrapped in the interstices of the mesh in the empty phase (arrow). There was
no mediastinal leak.
There was free flow of contrast across the fragment ([Fig. 1 b]). Luminal obstruction was apparent
at the proximal end of the fractured stent in the second part of the duodenum
with abrupt cutoff and prestenotic dilatation of the proximal duodenum and
stomach ([Fig. 2]).
Fig. 2 The fractured enteral
stent (arrows) with duodenal obstruction and prestenotic dilatation.
At endoscopy, the stent fragment, with a partially disrupted mesh,
was seen just below the cricopharynx ([Fig. 3 a]).
Fig. 3 a On endoscopy, the
fractured fragment was visualized just below the cricopharynx. There was no
evidence of deep esophageal injury. b Post-retrieval
specimen.
It was retrieved by grasping it by its sides with two forceps, using
a double-channel endoscope (Fujinon, Tokyo, Japan) ([Fig. 3 b]).
Migration is a known complication of enteral SEMS with reported
rates of up to 5 % [1]. Distal migration is
the norm and proximal migration is an exceptional event. The incidence of SEMS
fracture and the exact reasons for this complication are elusive. Acid
corrosion, thermal overstrain induced by laser application, and defective
material at the time of deployment are some of the proposed explanations
[2]
[3]. However, there was no
obvious reason for the cervical esophageal migration of the fractured segment
in our patient, and we hypothesize that the reverse peristalsis accompanying
the frequent episodes of vomiting was responsible for this unusual
presentation.
Endoscopic removal of stents that have migrated into the esophagus
should be considered after ruling out potential complications with a
water-soluble contrast study.
Endoscopy_UCTN_Code_CPL_1AH_2AD
