A case of small-bowel perforation caused by a migrated duodenal stent

Metal stents are used to palliate advanced malignant gastric outlet and duodenal obstruction [1] [2]. We present a rare complication due to a migrated duodenal stent, that highlights the need for a diagnosis of malignancy before deployment.

A 73-year-old man developed symptoms of gastric outlet obstruction following lumbar spine laminectomy at another institution. Computed tomography (CT) scanning revealed a mass lesion arising from the head of the pancreas compressing the second part of the duodenum. A presumptive diagnosis of carcinoma of the pancreas was made and an expanding metal stent was deployed without a histological diagnosis.

One month later he presented to our hospital with vague abdominal pain. A further CT scan showed free air and fluid within the peritoneal cavity and the pancreas looked normal. At laparotomy he was found to have a perforation where the metal stent had impacted in the distal ileum (Figure [1] and [2]). The pancreas felt normal. It was concluded that the pancreatic mass previously seen on CT scanning was inflammatory, and that as it resolved the stent had migrated. A small-bowel resection was performed. Following a good initial recovery the patient later developed cardiovascular instability from acute bacterial endocarditis (diagnosed on echocardiography) which was fatal. An autopsy was not performed as a cause of death had been identified.

Figure 1 Section of ileum showing perforation (stent removed).

Figure 2 Close up with stent in situ. The metallic stent had been placed endoscopically for gastric outlet obstruction secondary to a pancreatic lesion. The lesion was most probably inflammatory and when it resolved the stent migrated causing perforation of the distal ileum.

Duodenal perforation is a recognized complication associated with metal stents, both those in situ and migrated esophageal devices [3] [4] [5]. There have however been no reported cases of a duodenal stent migrating into the distal ileum and causing perforation. This case demonstrates the importance of a definitive diagnosis of malignancy before placing a stent for palliation.

Endoscopy_UCTN_Code_CPL_1AH_2AD

References

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• 2 Jung G, Song H, Kang S. et al . Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent - initial experience.  Radiology. 2000;  216 758-763
• 3 Bessoud B, De Baere T, Denys A. et al . Metallic stents for malignant gastroduodenal obstruction.  J Vasc Interv Radiol. 2005;  16 247-253
• 4 Thumbe V, Houghton A, Smith S. Duodenal perforation by a Wallstent.  Endoscopy. 2000;  32 495-497
• 5 Kim H, Han J, Kim T. et al . Duodenal perforation as a delayed complication of placement of an oesophageal stent.  J Vasc Interv Radiol. 2000;  11 902-904