Enteral stents are increasingly utilized to palliate malignant gastrointestinal obstruction; however, they can be associated with significant complications. We describe an unusual case of a 67-year-old male with gastric adenocarcinoma who underwent placement of a WallFlex metallic enteral stent to relieve a malignant gastric outlet obstruction. Four months later, while actively undergoing chemotherapy, he developed acute abdominal pain and was found to have delayed stent migration and jejunal perforation. He required emergent surgical resection of the perforated segment of jejunum. Delayed migration of the WallFlex enteral stent with subsequent visceral perforation has yet to be reported in the literature. Chemotherapy after stent placement has been associated with an increase in maintenance of stent patency; however, shrinkage of the local tumor by chemoradiation may increase the risk of stent migration. Care should be taken in placing enteral stents in patients undergoing continued treatment of their malignancy, as delayed migration of even uncovered stents may occur. 1. Introduction Endoscopic enteral stent placement is commonly performed for palliative treatment of malignant gastric outlet obstruction [1]. This minimally invasive procedure, first described in 1992, involves the trans-endoscopic placement of a self-expandable uncovered metallic stent across a malignant obstruction [2, 3]. A number of studies have since demonstrated the safety and feasibility of this technique [4–9]. However, enteral stents can occasionally be associated with significant complications including perforation, bleeding, stent migration (immediate or delayed), stent malposition, and stent occlusion from tumor growth or food impaction [1]. The combination of delayed stent migration and perforation is extremely rare [9, 10]. Here we describe a case of delayed stent migration and jejunal perforation occurring four months after the insertion of a WallFlex metallic enteral stent to relieve malignant gastric outlet obstruction. 2. Case Report A 67-year-old male with stage IIIB gastric adenocarcinoma treated with Billroth-II gastrojejunostomy, adjuvant chemotherapy with oxaliplatin and 5-fluorouracil, and external beam radiation therapy presented one year following completion of adjuvant therapy with abdominal pain and inability to tolerate oral intake. Imaging studies including computed tomography (CT) of the abdomen and pelvis revealed a malignant gastric outlet obstruction at the gastrojejunal anastomosis (Figure 1(a)). Following nasogastric decompression, he underwent
References
[1]
T. H. Baron, “Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract,” New England Journal of Medicine, vol. 344, no. 22, pp. 1681–1687, 2001.
[2]
R. A. Kozarek, T. J. Ball, and D. J. Patterson, “Metallic self-expanding stent application in the upper gastrointestinal tract: caveats and concerns,” Gastrointestinal Endoscopy, vol. 38, no. 1, pp. 1–6, 1992.
[3]
S. Truong, V. Bohndorf, H. Geller, V. Schumpelick, and R. W. Gunther, “Self-Expanding metal stents for palliation of malignant gastric outlet obstruction,” Endoscopy, vol. 24, no. 5, pp. 433–435, 1992.
[4]
J. K. J. Gaidos and P. V. Draganov, “Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents,” World Journal of Gastroenterology, vol. 15, no. 35, pp. 4365–4371, 2009.
[5]
M. O. Baerlocher, M. R. Asch, A. Vellahottam, G. Puri, K. Andrews, and A. Myers, “Safety and efficacy of gastrointestinal stents in cancer patients at a community hospital,” Canadian Journal of Surgery, vol. 51, no. 2, pp. 130–134, 2008.
[6]
I. Maetani, H. Isayama, and Y. Mizumoto, “Palliation in patients with malignant gastric outlet obstruction with a newly designed enteral stent: a multicenter study,” Gastrointestinal Endoscopy, vol. 66, no. 2, pp. 355–360, 2007.
[7]
J. J. Telford, D. L. Carr-Locke, T. H. Baron et al., “Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study,” Gastrointestinal Endoscopy, vol. 60, no. 6, pp. 916–920, 2004.
[8]
A. J. Dormann, S. Meisner, N. Verin, and A. Wenk Lang, “Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness,” Endoscopy, vol. 36, no. 6, pp. 543–550, 2004.
[9]
B. Bessoud, T. de Baere, A. Denys et al., “Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents,” Journal of Vascular and Interventional Radiology, vol. 16, no. 2 I, pp. 247–253, 2005.
[10]
V. K. Thumbe, A. D. Houghton, and M. S. H. Smith, “Duodenal perforation by a wallstent,” Endoscopy, vol. 32, no. 6, pp. 495–497, 2000.
[11]
M. del Piano, M. Ballarè, F. Montino et al., “Endoscopy or surgery for malignant GI outlet obstruction?” Gastrointestinal Endoscopy, vol. 61, no. 3, pp. 421–426, 2005.
[12]
S. Mehta, A. Hindmarsh, E. Cheong et al., “Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction,” Surgical Endoscopy and Other Interventional Techniques, vol. 20, no. 2, pp. 239–242, 2006.
[13]
J. E. van Hooft, M. J. Uitdehaag, M. J. Bruno, et al., “Efficacy and safety of the new WallFlex enteral stent in palliative treatment of malignant gastric outlet obstruction (DUOFLEX study): a prospective multicenter study,” Gastrointestinal Endoscopy, vol. 69, pp. 1059–1066, 2009.
[14]
A. P. Holt, M. Patel, and M. M. Ahmed, “Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice?” Gastrointestinal Endoscopy, vol. 60, no. 6, pp. 1010–1017, 2004.
[15]
P. Mosler, K. D. Mergener, J. J. Brandabur, D. B. Schembre, and R. A. Kozarek, “Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series,” Journal of Clinical Gastroenterology, vol. 39, no. 2, pp. 124–128, 2005.
[16]
J. van Hooft, M. Mutignani, A. Repici, H. Messmann, H. Neuhaus, and P. Fockens, “First data on the palliative treatment of patients with malignant gastric outlet obstruction using th Wall-Flex enteral stent: a retrospective multicenter study,” Endoscopy, vol. 39, no. 5, pp. 434–439, 2007.
[17]
J. H. Kim, H. Y. Song, J. H. Shin et al., “Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients,” Gastrointestinal Endoscopy, vol. 66, no. 2, pp. 256–264, 2007.
[18]
K. Mergener and R. A. Kozarek, “Stenting of the gastrointestinal tract,” Digestive Diseases, vol. 20, no. 2, pp. 173–181, 2002.
