Repeated enteral stent fracture in patient with benign duodenal stricture

Fracture of a Colonic Self-expandable Metallic Stent in Malignant Colonic Obstruction

Self-expandable metallic stents (SEMSs) are used for the management of malignant colorectal obstruction. A patient who underwent colonic uncovered SEMS insertion for extraluminal stenosis in the splenic flexure of the transverse colon due to advanced gastric cancer is herein reported. The patient presented with a fracture of the colonic SEMS 494 days after SEMS insertion. Although various complications of stenting have previously been reported, the details of fractures of colonic SEMSs have not yet been reported. Because the improvement in the prognosis for patients who undergo palliative SEMS insertion leads to long-term SEMS placement, diverse complications can thus be expected, and new events like stent fracture are expected to increase in the future.

Temporary placement of a covered duodenal stent can avoid riskier anterograde biliary drainage when ERCP for obstructive jaundice fails due to duodenal invasion

BACKGROUND

Duodenal stenosis is one of the most common causes of failed ERCP for obstructive jaundice. Alternative approaches include anterograde biliary drainage, with higher morbidity. We report in this study the efficacy and safety of temporary placement of a covered duodenal self-expandable metal stent (cSEMS) in order to access the papilla and achieve secondary retrograde biliary drainage in patients with obstructive jaundice and failed ERCP due to concomitant duodenal stenosis.

METHODS

From June 2006 to March 2014, a total of 26 consecutive patients presenting obstructive jaundice without severe sepsis with failed ERCP due to duodenal invasion were enrolled. A temporary 7-day duodenal cSEMS was placed during the failed ERCP, and a second ERCP was attempted at day 7 after duodenal stent removal.

RESULTS

Duodenal cSEMS placement and retrieval were technically successful in all cases. Access to the papilla at day 7 was possible in 25 cases (96 %, 95 % CI 80-99 %). Secondary successful ERCP was achieved in 19 cases (76 %, 95 % CI 55-91 %, i.e., 73 %, 95 % CI 73-86 %, in an intention-to-treat analysis). Mean bilirubin level was 102 ± 90 µmol/L at baseline rising to 164 ± 121 µmol/L at day 7. There were 6 stent migrations and no adverse events recorded between the two ERCPs.

CONCLUSIONS

When ERCP for obstructive jaundice fails due to duodenal invasion, temporary cSEMS placement offers a safe and effective way to achieve successful secondary ERCP while avoiding riskier endoscopic ultrasound or percutaneous transhepatic anterograde biliary drainage.

Esophageal stent fracture: Case report and review of the literature

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions. Self expanding metal stents (SEMS) are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions; however they have known complications of stent migration, stent occlusion, tumor ingrowth, stricture formation, reflux, bleeding and perforation amongst others. A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces. There have only been a handful of published case reports describing this problem. In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS, and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus. SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esophageal SEMS. It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment. Early recognition and prompt management may be able to prevent further problems.

An instant rare complication: a fractured metallic pyloric stent

Metallic pyloric stenting (also termed as metallic enteral stenting) performed endoscopically, stands as first-line treatment for malignant gastric outlet obstruction. With reported evidence, these self-expandable metallic stents (SEMS) re-enable oral food intake, preventing patients having to face invasive techniques such as surgical gastroenterostomy. We report a patient having received a covered pyloric SEMS insertion following a tumour growth causing stenosis in the gastric antropyloric region. After 3 weeks, the patient presented with a fracture of the pyloric SEMS, a rare complication, resulting in a second pyloric SEMS insertion.