A 17-year-old man presented to our emergency department with a 5-day
history of persistent lower abdominal pain and nausea. His medical history was
significant for a silicone-covered self-expanding metallic esophageal stent
(MTN-SE-G-20/80, Nanjing, China) placed 3 weeks previously for a
tracheoesophageal fistula. Plain abdominal and chest radiographs showed the
stent lying in the inferior abdominal cavity ([Fig. 1]).
Fig. 1 Plain abdominal
radiograph showing the stent in the inferior abdominal cavity.
There was no evidence of small-intestinal obstruction or
perforation. Over the next 2 days the patient failed to improve and experienced
progressive lower abdominal pain. A laparotomy revealed a roughly 10-cm long
stent lying within the ascending colon. There were no signs of impaction and
obstruction. Two perforations, approximately 0.2 cm, with feces and pus
were identified at the antimesenteric border of the jejunum proximal to the
Treitz ligament. The perforations were closed in two layers following
debridement and the stent was left in situ. At 6 days after the laparotomy, the
stent was expelled per rectum ([Fig. 2]). The
patient made an uneventful postoperative recovery.
Fig. 2 The stent eliminated per
rectum.
A rare but serious complication of endoscopic stent placement is
stent migration with resultant intestinal perforation [1]
[2]
[3].
Congenital anatomical abnormalities and fixation of the bowel because of
previous postoperative eventration or adherence are common risk factors for
bowel perforation because these conditions impede progression of the stent
through the bowel [4].
In our case, fixation of the proximal jejunum to the Treitz ligament
may have led to decreased mobility of the migrated stent, and the mechanical
force exerted by the uncovered flared ends of the metallic stent against
intestinal mucosa may have led to pressure necrosis and delayed perforation of
the wall over a long period of time. We suggest that patients with a removable
esophageal stent should be carefully evaluated and followed up. In addition, we
advocate elective surgical removal of migrated metallic stents.
Endoscopy_UCTN_Code_CPL_1AH_2AD
