Self-expanding metal stents (SEMS) are relatively easy to deploy,
with a high technical success rate, and provide rapid relief of dysphagia
[1], which is the major factor affecting quality of life
in patients not suitable for resection. Since Domschke et al. first reported the use of SEMS in 1990
[2], the technique has been widely used for malignant
esophageal stenosis [3], although there have been many
reports of complications associated with the combination of SEMS and
chemoradiation therapy (CRT) [4]
[5].
A 56-year-old man was diagnosed as having carcinoma of the lower
esophagus in July 2008. After CRT, he was admitted to our hospital for
second-line chemotherapy in October 2008. The patient had developed
uncontrollable salivation in the month prior to admission. A SEMS was placed
successfully, but he developed fever and low blood pressure on November 28,
2008. Computed tomography (CT) examination revealed a fistula between the
esophagus at the oral end of the SEMS and the mediastinum, and mediastinitis
was suspected. Despite the administration of antibiotics, and steroid pulse and
γ-globulin combination therapy, an abscess with liquefaction was confirmed
in the mediastinum 7 days later ([Fig. 1]).
Fig. 1 CT examination after
first SEMS insertion. a There is an infiltrative shadow
between the mediastinum and the esophagus. Consolidation on the dorsal side
suggests air inclusion. Formation of a fistula between the esophagus and the
mediastinum was suspected. Septic shock caused by mediastinitis was diagnosed.
b An abscess with liquefaction in the mediastinum, noted
7 days later despite the administration of antibiotics, and steroid pulse and
γ-globulin combination therapy.
An endoscopic nasobiliary drainage (ENBD) tube was placed in the
mediastinal abscess along a guide wire to allow drainage ([Fig. 2]).
Fig. 2 Upper gastrointestinal
endoscopy. a Partial granulation accompanied by white
necrotic tissue at the oral edge of the stent. b Removal
of the granulation tissue revealing the fistula between the esophagus and the
mediastinum. An endoscopic retrograde cholangiopancreatography (ERCP) catheter
was inserted into the fistula. c A 6-Fr endoscopic
nasobiliary drainage (ENBD) tube was placed in the mediastinal abscess along
the guide wire.
A CT scan demonstrated improvement in the abscess 12 days after
insertion of the ENBD tube ([Fig. 3]).
Fig. 3 Radiological follow-up
after endoscopic nasobiliary drainage (ENBD) tube drainage. Computed tomography
(CT) examination confirmed adequate drainage of the mediastinal abscess, and
revealed improvement of the abscess 12 days after tube insertion.
The risks and benefits of SEMS insertion must be weighed in light of
the existing illness and the patient’s quality of life. We report the
case of a patient with esophageal carcinoma treated with CRT who developed
mediastinitis after SEMS insertion. Mediastinitis was treated by
esophago-mediastinal drainage of the mediastinal abscess via the insertion of
an ENBD tube. This technique has not been previously reported, but appears to
represent a useful method for management of mediastinitis after SEMS
insertion.
Endoscopy_UCTN_Code_TTT_1AO_2AI
