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Closure of a duodenal stent-induced perforation by endoscopic stent removal and covered self-expandable metal stent placement (with video)
Closure of a duodenal stent-induced perforation by endoscopic stent removal and covered self-expandable metal stent placement (with video) Aaron J. Small, BS, Bret T. Petersen, MD, Todd H. Baron, MD, FASGE Rochester, Minnesota, USA
Duodenal perforations are rare but potentially fatal complications of self-expandable metal stent (SEMS) placement for gastric outlet obstruction.1,2 We report a 64-year-old man with duodenal perforation that occurred after SEMS insertion and palliative gastrojejunostomy. After endoscopic removal of the initial stent, a covered metallic stent was introduced into the duodenum and led to clinical improvement by sealing the perforation. To our knowledge, this is the first report describing successful treatment for bowel perforation by using a covered metallic stent. Placement of covered metallic stents may be an option for the treatment of patients with small-intestinal perforations, especially for those who are critically ill.
CASE REPORT A 64-year-old man presented with symptoms of biliary obstruction and gastric outlet obstruction. An unresectable pancreatic adenocarcinoma was identified. On endoscopy, the tumor was infiltrating the first and second portions of the duodenum and would not allow passage of an endoscope. The stricture measured 3 cm in length. A 20-mmdiameter by 60-mm-long Enteral Wallstent (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) was placed across the duodenal stricture. The proximal end of the stent was within the proximal duodenal bulb and the distal end was just above the papilla in the second part of the duodenum. Both stent edges were clear beyond the tumor margins. To palliate biliary obstruction, a percutaneous transhepatic cholangiogram (PTC) was performed and a 10-mm-diameter, 80-mm-long Wallstent was placed in the common bile duct. The patient subsequently developed severe right upper quadrant abdominal pain. An abdominal CTrevealed air between the duodenal stent and the duodenal wall that extended around the liver (Fig. 1). Despite a reduction in pain, the patient’s nausea and vomiting did not improve. He underwent surgical gastrojejunostomy to further palliate his gastric outlet obstructive symptoms. Several days after surgery, he was noted to have bilious material exiting from a surgical drain. Bilirubin and amylase levels in the fluid were elevated. A hepatobiliary iminodiacetic acid scan revealed a leak at the junction of the distal common bile duct and the duodenum. An endoscopy demonstrated several ulcers and perforations neighboring www.giejournal.org
Figure 1. CT, suggesting stent-induced duodenal perforation. The proximal edge of the stent appears out of the lumen and free air is present around the liver.
the proximal sharp wire ends of the Wallstent in the duodenal bulb (Fig. 2). Contrast was injected, which demonstrated extravasation outside of the duodenum toward the surgical drain. The duodenal stent was removed 16 days after its placement, by using a therapeutic channel upper endoscope and a rat-tooth forceps (Video 1; available online at www.giejournal.org). After grasping the interior of the stent near its mid portion, both endoscope and stent were withdrawn together without an overtube. Six metal endoclips (Hemoclips; Olympus America Corp, Melville, NY) were placed at the perforation sites in an attempt to close the duodenal leak. Initially, drainage from his surgical drain decreased. To fully close the fistula, a covered expandable metal stent was placed (Video 1). A therapeutic colonoscope was used to advance a stiff 0.035-inch guidewire beyond the ligament of Trietz; it provided sufficient mechanical advantage that could not be achieved by an upper endoscope for stent placement. A covered esophageal Ultraflex stent (28-mm proximal flange, 22-mm mid body, 9-cm central covered; Microvasive Endoscopy) was placed into the duodenum. The proximal end was left in the antrum, with the covered portion across Volume 66, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY 1063
Brief Reports
Figure 2. Endoscopic view of several overt ulcers and a perforation along the edges of the uncovered metallic stent barbs.
the known duodenal perforation. A 12F nasojejunal feeding tube was placed into the gastrostomy limb to provide nutrition and to avoid feeding into the duodenum. Drainage output nearly ceased over a 24-hour period. He resumed a general diet and continued without an increase in external drainage. Nine days later, a CTand a sinogram demonstrated resolution of the duodenal leak (Fig. 3). The patient was clinically well, without evidence of leakage up to 1 month after SEMS reinsertion. He died in a nursing home 10 months later.
DISCUSSION Intestinal perforation is a rare but serious complication of endoluminal SEMS placement.3,4 Gastroduodenal stent placement is an effective alternative to surgical bypass for malignant gastric outlet obstruction, with a clinical success (relief of symptoms or improved food intake) rate of up to 89%.3 Subsequent gastroenterostomy may be performed if final resolution of symptoms is not realized, as in our patient. Perforation can occur in 1% to 2% of patients after SEMS insertion for gastric outlet obstruction.5 Therapy of duodenal perforation conventionally requires immediate surgical closure or bypass. Known perforation is a contraindication to SEMS placement in the upper-GI tract.2 Fortunately, our patient did not have signs and symptoms of peritonitis, thus allowing us to attempt endoscopic management. Covered stents can successfully close malignant fistula in both the upperand lower-GI tract.6-8 Other investigators reported closure of both nonmalignant and malignant perforations of the esophagus with covered metallic stents.9-12 However, the use of metal stents to treat duodenal perforation is limited by the usual inability to remove the initial offending stent more than a few days after placement, if at all. In our case, 1064 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 5 : 2007
Figure 3. CT, demonstrating resolution of duodenal perforation 9 days after covered stent placement. The Ultraflex stent is visible in the stomach and the duodenum.
the uncovered stent responsible for the perforation was retrieved endoscopically 16 days after placement. The placement of endoscopic clips and reinsertion of a largediameter covered esophageal stent ensured sealing of the leak and allowed spontaneous closure. Successful closure of duodenal perforations by using endoscopic clips was previously described.13,14 Partially covered metal stents offer the advantages of preventing tumor ingrowth and migration while sealing off fistulous tracts or small perforations until resolution occurs, as demonstrated in our patient. Thus, the use of covered SEMS as therapy for intestinal perforations is feasible and may warrant further study in carefully selected patients. Perforation occurred in our patient where the sharp edge of the metal stent abutted the benign duodenal mucosa, probably as a result of shortening and straightening of the stent upon expansion. Since this event occurred, we have avoided leaving the proximal portion of the stent in the duodenum, instead preferring it to remain in the antrum. Newer expandable metal stents are available (eg, duodenal Wallflex; Microvasive) with rounded ends to minimize complications because of the sharp metal barbs of the Wallstent.
DISCLOSURE T. Baron receives grant support from Boston Scientific Corporation, though none of the authors have any financial interests in any products mentioned in this manuscript. Abbreviations: PTC, percutaneous transhepatic cholangiogram; SEMS, self-expandable metal stent.
www.giejournal.org
Brief Reports
REFERENCES 1. Laasch HU, Martin DF, Maetani I. Enteral stents in the gastric outlet and duodenum. Endoscopy 2005;37:74-81. 2. Baron TH, Harewood GC. Enteral self-expandable stents. Gastrointest Endosc 2003;58:421-33. 3. Simmons DT, Baron TH. Technology insight: enteral stenting and new technology. Nat Clin Pract Gastroenterol Hepatol 2005;2: 365-74. 4. Thumbe VK, Houghton AD, Smith MS. Duodenal perforation by a Wallstent. Endoscopy 2000;32:495-7. 5. Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004;36:543-50. 6. Repici A, Reggio D, Saracco G, et al. Self-expanding covered esophageal Ultraflex stent for palliation of malignant colorectal anastomotic obstruction complicated by multiple fistulas. Gastrointest Endosc 2000;51:346-8. 7. Saxon RR, Barton RE, Katon RM, et al. Treatment of malignant esophagorespiratory fistulas with silicone-covered metallic Z stents. J Vasc Interv Radiol 1995;6:237-42. 8. Kyoto Y, Iwasaki Y, Kaji T, et al. Gastrointestinal fistulas: treatment with covered stents. Abdom Imaging 2001;26:570-3. 9. Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356-61.
10. Morgan RA, Ellul JP, Denton ER, et al. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology 1997;204:527-32. 11. White RE, Mungatana C, Topazian M. Expandable stents for iatrogenic perforation of esophageal malignancies. J Gastrointest Surg 2003;7: 715-9. 12. Bethge N, Kleist DV, Vakil N. Treatment of esophageal perforation with a covered expandable metal stent. Gastrointest Endosc 1996;43:161-3. 13. Roses LL, Ramirez AG, Seco AL, et al. Clip closure of a duodenal perforation secondary to a biliary stent. Gastrointest Endosc 2000;51:487-9. 14. Seibert DG. Use of an endoscopic clipping device to repair a duodenal perforation. Endoscopy 2003;35:189.
Received January 4, 2007. Accepted March 29, 2007. Current affiliations: Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. Reprint requests: Todd H. Baron, MD, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St SW, Charlton 8, Rochester, MN 55905. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.03.1082
A landlubber with an ancient mariner’s leaky vessels Paul Berkram, MD, Pablo M. Bedano, MD, Charles J. Kahi, MD, Chamani Illamperuma, MD, David E. Matthews, MD, Asok C. Antony, MD, FACP Indianapolis, Indiana, USA
CASE REPORT A 56-year-old army veteran presented in late February 2006 with a 1-week history of pain in both ankles, with erythema and bruising (that he attributed to ill-fitting shoes and stumbling over an unpadded corner of his bed), associated with fatigue, weakness, and anorexia. Cellulitis was diagnosed at an emergency department, and he was treated with oral cephalosporin. Within 2 weeks, he was admitted after an episode of syncope and similar symptoms. In 2002, locally advanced head and neck cancer was treated with concurrent chemotherapy and local radiation, followed by radical neck dissection. He reported occasional epistaxis but no hematemesis, hematuria, rectal bleeding, or use of aspirin or anti-inflammatory drugs. The patient lived alone above a honky-tonk bar in a less reputable neighborhood of the city and indicated he ‘‘lived mainly on beer’’ (approximately 3-6 beers daily, by his estimate) and sipped 10 to 12 pints of water daily while socializing with the bar patrons. There was a long history of alcohol abuse and a 50 pack a year smoking history. He did not consume www.giejournal.org
fruits or vegetables and ate 1 meat sandwich daily. Examination revealed a man who was asthenic, bald, edentulous, with a petechial rash mainly on his scalp, upper arms, shoulders, and trunk, with a few perifollicular hyperkeratotic papules on his arms, and some bent and curved hair shafts. Both lower extremities revealed extensive ecchymoses with xerosis (Fig. 1A), with tenderness over the lower shins. Fecal occult blood was present. Laboratory values revealed Hb 10 g/dL (reference range 14-18 g/dL), normal white blood cell count, platelets 223,000/mL (150,000-450,000/mL), normal prothrombin time and partial thromboplastin time, sodium 121 mmol/L (135-145 mmol/L), potassium 4.6 mmol/L (3.5-5.5 mmol/L), chloride 89 mmol/L (95-105 mmol/L), and CO2 19 mmol/L (22-27 mmol/L). A head CT was normal. A presumptive diagnosis of hyponatremia because of low solute intake (attributed to beer potomania and malnutrition) and scurvy was treated with sodium replacement, thiamine, glucose, folate, multivitamins, and ascorbic acid. An upper endoscopy on hospital day 4 revealed petechial lesions in the distal gastric body and antrum. A colonoscopy Volume 66, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY 1065
Duodenal perforations are rare but potentially fatal complications of self-expandable metal stent (SEMS) placement for gastric outlet obstruction.1,2 We report a 64-year-old man with duodenal perforation that occurred after SEMS insertion and palliative gastrojejunostomy. After endoscopic removal of the initial stent, a covered metallic stent was introduced into the duodenum and led to clinical improvement by sealing the perforation. To our knowledge, this is the first report describing successful treatment for bowel perforation by using a covered metallic stent. Placement of covered metallic stents may be an option for the treatment of patients with small-intestinal perforations, especially for those who are critically ill.
CASE REPORT A 64-year-old man presented with symptoms of biliary obstruction and gastric outlet obstruction. An unresectable pancreatic adenocarcinoma was identified. On endoscopy, the tumor was infiltrating the first and second portions of the duodenum and would not allow passage of an endoscope. The stricture measured 3 cm in length. A 20-mmdiameter by 60-mm-long Enteral Wallstent (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) was placed across the duodenal stricture. The proximal end of the stent was within the proximal duodenal bulb and the distal end was just above the papilla in the second part of the duodenum. Both stent edges were clear beyond the tumor margins. To palliate biliary obstruction, a percutaneous transhepatic cholangiogram (PTC) was performed and a 10-mm-diameter, 80-mm-long Wallstent was placed in the common bile duct. The patient subsequently developed severe right upper quadrant abdominal pain. An abdominal CTrevealed air between the duodenal stent and the duodenal wall that extended around the liver (Fig. 1). Despite a reduction in pain, the patient’s nausea and vomiting did not improve. He underwent surgical gastrojejunostomy to further palliate his gastric outlet obstructive symptoms. Several days after surgery, he was noted to have bilious material exiting from a surgical drain. Bilirubin and amylase levels in the fluid were elevated. A hepatobiliary iminodiacetic acid scan revealed a leak at the junction of the distal common bile duct and the duodenum. An endoscopy demonstrated several ulcers and perforations neighboring www.giejournal.org
Figure 1. CT, suggesting stent-induced duodenal perforation. The proximal edge of the stent appears out of the lumen and free air is present around the liver.
the proximal sharp wire ends of the Wallstent in the duodenal bulb (Fig. 2). Contrast was injected, which demonstrated extravasation outside of the duodenum toward the surgical drain. The duodenal stent was removed 16 days after its placement, by using a therapeutic channel upper endoscope and a rat-tooth forceps (Video 1; available online at www.giejournal.org). After grasping the interior of the stent near its mid portion, both endoscope and stent were withdrawn together without an overtube. Six metal endoclips (Hemoclips; Olympus America Corp, Melville, NY) were placed at the perforation sites in an attempt to close the duodenal leak. Initially, drainage from his surgical drain decreased. To fully close the fistula, a covered expandable metal stent was placed (Video 1). A therapeutic colonoscope was used to advance a stiff 0.035-inch guidewire beyond the ligament of Trietz; it provided sufficient mechanical advantage that could not be achieved by an upper endoscope for stent placement. A covered esophageal Ultraflex stent (28-mm proximal flange, 22-mm mid body, 9-cm central covered; Microvasive Endoscopy) was placed into the duodenum. The proximal end was left in the antrum, with the covered portion across Volume 66, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY 1063
Brief Reports
Figure 2. Endoscopic view of several overt ulcers and a perforation along the edges of the uncovered metallic stent barbs.
the known duodenal perforation. A 12F nasojejunal feeding tube was placed into the gastrostomy limb to provide nutrition and to avoid feeding into the duodenum. Drainage output nearly ceased over a 24-hour period. He resumed a general diet and continued without an increase in external drainage. Nine days later, a CTand a sinogram demonstrated resolution of the duodenal leak (Fig. 3). The patient was clinically well, without evidence of leakage up to 1 month after SEMS reinsertion. He died in a nursing home 10 months later.
DISCUSSION Intestinal perforation is a rare but serious complication of endoluminal SEMS placement.3,4 Gastroduodenal stent placement is an effective alternative to surgical bypass for malignant gastric outlet obstruction, with a clinical success (relief of symptoms or improved food intake) rate of up to 89%.3 Subsequent gastroenterostomy may be performed if final resolution of symptoms is not realized, as in our patient. Perforation can occur in 1% to 2% of patients after SEMS insertion for gastric outlet obstruction.5 Therapy of duodenal perforation conventionally requires immediate surgical closure or bypass. Known perforation is a contraindication to SEMS placement in the upper-GI tract.2 Fortunately, our patient did not have signs and symptoms of peritonitis, thus allowing us to attempt endoscopic management. Covered stents can successfully close malignant fistula in both the upperand lower-GI tract.6-8 Other investigators reported closure of both nonmalignant and malignant perforations of the esophagus with covered metallic stents.9-12 However, the use of metal stents to treat duodenal perforation is limited by the usual inability to remove the initial offending stent more than a few days after placement, if at all. In our case, 1064 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 5 : 2007
Figure 3. CT, demonstrating resolution of duodenal perforation 9 days after covered stent placement. The Ultraflex stent is visible in the stomach and the duodenum.
the uncovered stent responsible for the perforation was retrieved endoscopically 16 days after placement. The placement of endoscopic clips and reinsertion of a largediameter covered esophageal stent ensured sealing of the leak and allowed spontaneous closure. Successful closure of duodenal perforations by using endoscopic clips was previously described.13,14 Partially covered metal stents offer the advantages of preventing tumor ingrowth and migration while sealing off fistulous tracts or small perforations until resolution occurs, as demonstrated in our patient. Thus, the use of covered SEMS as therapy for intestinal perforations is feasible and may warrant further study in carefully selected patients. Perforation occurred in our patient where the sharp edge of the metal stent abutted the benign duodenal mucosa, probably as a result of shortening and straightening of the stent upon expansion. Since this event occurred, we have avoided leaving the proximal portion of the stent in the duodenum, instead preferring it to remain in the antrum. Newer expandable metal stents are available (eg, duodenal Wallflex; Microvasive) with rounded ends to minimize complications because of the sharp metal barbs of the Wallstent.
DISCLOSURE T. Baron receives grant support from Boston Scientific Corporation, though none of the authors have any financial interests in any products mentioned in this manuscript. Abbreviations: PTC, percutaneous transhepatic cholangiogram; SEMS, self-expandable metal stent.
www.giejournal.org
Brief Reports
REFERENCES 1. Laasch HU, Martin DF, Maetani I. Enteral stents in the gastric outlet and duodenum. Endoscopy 2005;37:74-81. 2. Baron TH, Harewood GC. Enteral self-expandable stents. Gastrointest Endosc 2003;58:421-33. 3. Simmons DT, Baron TH. Technology insight: enteral stenting and new technology. Nat Clin Pract Gastroenterol Hepatol 2005;2: 365-74. 4. Thumbe VK, Houghton AD, Smith MS. Duodenal perforation by a Wallstent. Endoscopy 2000;32:495-7. 5. Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004;36:543-50. 6. Repici A, Reggio D, Saracco G, et al. Self-expanding covered esophageal Ultraflex stent for palliation of malignant colorectal anastomotic obstruction complicated by multiple fistulas. Gastrointest Endosc 2000;51:346-8. 7. Saxon RR, Barton RE, Katon RM, et al. Treatment of malignant esophagorespiratory fistulas with silicone-covered metallic Z stents. J Vasc Interv Radiol 1995;6:237-42. 8. Kyoto Y, Iwasaki Y, Kaji T, et al. Gastrointestinal fistulas: treatment with covered stents. Abdom Imaging 2001;26:570-3. 9. Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356-61.
10. Morgan RA, Ellul JP, Denton ER, et al. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology 1997;204:527-32. 11. White RE, Mungatana C, Topazian M. Expandable stents for iatrogenic perforation of esophageal malignancies. J Gastrointest Surg 2003;7: 715-9. 12. Bethge N, Kleist DV, Vakil N. Treatment of esophageal perforation with a covered expandable metal stent. Gastrointest Endosc 1996;43:161-3. 13. Roses LL, Ramirez AG, Seco AL, et al. Clip closure of a duodenal perforation secondary to a biliary stent. Gastrointest Endosc 2000;51:487-9. 14. Seibert DG. Use of an endoscopic clipping device to repair a duodenal perforation. Endoscopy 2003;35:189.
Received January 4, 2007. Accepted March 29, 2007. Current affiliations: Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. Reprint requests: Todd H. Baron, MD, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St SW, Charlton 8, Rochester, MN 55905. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.03.1082
A landlubber with an ancient mariner’s leaky vessels Paul Berkram, MD, Pablo M. Bedano, MD, Charles J. Kahi, MD, Chamani Illamperuma, MD, David E. Matthews, MD, Asok C. Antony, MD, FACP Indianapolis, Indiana, USA
CASE REPORT A 56-year-old army veteran presented in late February 2006 with a 1-week history of pain in both ankles, with erythema and bruising (that he attributed to ill-fitting shoes and stumbling over an unpadded corner of his bed), associated with fatigue, weakness, and anorexia. Cellulitis was diagnosed at an emergency department, and he was treated with oral cephalosporin. Within 2 weeks, he was admitted after an episode of syncope and similar symptoms. In 2002, locally advanced head and neck cancer was treated with concurrent chemotherapy and local radiation, followed by radical neck dissection. He reported occasional epistaxis but no hematemesis, hematuria, rectal bleeding, or use of aspirin or anti-inflammatory drugs. The patient lived alone above a honky-tonk bar in a less reputable neighborhood of the city and indicated he ‘‘lived mainly on beer’’ (approximately 3-6 beers daily, by his estimate) and sipped 10 to 12 pints of water daily while socializing with the bar patrons. There was a long history of alcohol abuse and a 50 pack a year smoking history. He did not consume www.giejournal.org
fruits or vegetables and ate 1 meat sandwich daily. Examination revealed a man who was asthenic, bald, edentulous, with a petechial rash mainly on his scalp, upper arms, shoulders, and trunk, with a few perifollicular hyperkeratotic papules on his arms, and some bent and curved hair shafts. Both lower extremities revealed extensive ecchymoses with xerosis (Fig. 1A), with tenderness over the lower shins. Fecal occult blood was present. Laboratory values revealed Hb 10 g/dL (reference range 14-18 g/dL), normal white blood cell count, platelets 223,000/mL (150,000-450,000/mL), normal prothrombin time and partial thromboplastin time, sodium 121 mmol/L (135-145 mmol/L), potassium 4.6 mmol/L (3.5-5.5 mmol/L), chloride 89 mmol/L (95-105 mmol/L), and CO2 19 mmol/L (22-27 mmol/L). A head CT was normal. A presumptive diagnosis of hyponatremia because of low solute intake (attributed to beer potomania and malnutrition) and scurvy was treated with sodium replacement, thiamine, glucose, folate, multivitamins, and ascorbic acid. An upper endoscopy on hospital day 4 revealed petechial lesions in the distal gastric body and antrum. A colonoscopy Volume 66, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY 1065