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Endoscopic removal of a migrated duodenal stent into the ileum using double-balloon enteroscopy
At the Focal Point
chance of recurrence or residual disease is low because lymphatics do not penetrate much beyond the muscularis mucosae, and there is little risk of lymph node metastases. The worst to come may be benign stricturing of the distal ileum, and endoscopic dilatation may be in this patient’s future. The use of endoscopic dissection techniques to address a lesion like this may seem like an adverse event waiting to happen (and you would be right), but we tend not to publish the ordinary. To paraphrase from my medical school–era surgical textbook, “Surgical intervention provides the only hope of cure for patients with this disease.” That was the thinking not too long ago. We’ve come a long way, baby, indeed. David Robbins, MD, MSc Assistant Editor for Focal Points
Endoscopic removal of a migrated duodenal stent into the ileum using double-balloon enteroscopy
A 62-year-old man with pancreatic adenocarcinoma had undergone endoscopic placement of a selfexpanding metal stent (SEMS) to treat duodenal obstruction. Four months later he presented with ileus. CT scanning confirmed that the SEMS was located within the distal ileum. He refused surgery. Double-balloon enteroscopy (DBE) was performed. The SEMS was located 30 cm proximal to the ileocecal valve, embedded in the mucosa (A). The SEMS was carefully loosened from the mucosa by use of a forceps. The enteroscope was passed across the stent, the balloon of the endoscope was inflated within the stent, and the overtube was advanced to the distal part of the stent (B). The balloon of the overtube was further inflated to increase the diameter of the distal lumen, thus favoring the removal of the 22-mm diameter stent. A rat tooth forceps was used to grasp the nitinol branches of the stent. By application of a constant but gentle pulling force, the stent was slowly removed from its embedded location. Careful attention was paid to keep the overtube against the distal part of the stent
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(B). After several minutes, the entire stent could be removed (C). The patient recovered uneventfully. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Juan Pablo Gutierrez, MD, Department of Gastroenterology, Hospital de Clinicas, Montevideo, Uruguay, Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA, C. Mel Wilcox, MD, MSPH, FASGE, Klaus Mönkemüller, MD, PhD, FASGE, Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA http://dx.doi.org/10.1016/j.gie.2014.10.004
Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1033
At the Focal Point
Commentary Migration of an uncovered enteral stent placed for palliation of malignant duodenal stenosis is an unusual delayed adverse event. Primary stent failure, whether because of in-growth, fracture, perforation, or migration, occurs infrequently. The gruesome outcome of the underlying diagnosis usually happens first. Uncovered stents are much less likely to migrate than are their partial or now, more commonly, fully covered metal counterparts. Antimigration struts, stronger intrinsic radial expansion forces, and simply the long, winding path make finding a current-generation stent in the mid-ileum a rare event indeed. Double-balloon endoscopy has revolutionized our endoscopic access to the entire playing field of the small bowel. The dramatic images that accompany this Focal Point reveal extensive mural in-growth, and I must confess amazement that the clever technique used here wasn’t accompanied by inadvertent endoscopic ileal resection. And I wonder whether the endoscopists treated themselves to a b-blocker during the time out! A plan B might have been placement of a fully covered stent within the migrated one, returning to tackle the retrieval in 2 weeks. The radial force of the second stent, which would not necessarily need to be of a larger diameter, could have freed up the uncovered stent by inducing pressure necrosis and sloughing of the entrapped mucosa. David Robbins, MD, MSc Assistant Editor for Focal Points
A rare case of inferior vena cava syndrome secondary to compression by a biliary stent A 48-year-old woman presented with right upper quadrant pain, elevated liver functional test (LFT) results, and imaging that revealed pancreatic and biliary ductal dilation. Several years earlier, she had undergone ERCP with sphincterotomy and stone extraction for choledocholithiasis, followed by cholecystectomy. ERCP at another institution was consistent with ampullary restenosis, and the previous sphincterotomy was extended. To maintain sphincter patency and treat possible microperforation, a fully covered self-expandable metal stent was placed in the bile duct. She presented to our center 1 month later with a right lower quadrant (RLQ) pain different from her biliary pain. She was afebrile, and her examination was notable for tachycardia, RLQ tenderness, and bilateral pedal edema. Blood work, including LFTs and lipase, was normal. A CT scan revealed pneumobilia, no biliary dilation, and significant compression of the inferior vena cava (IVC) by the biliary stent (AC). A diagnosis of IVC syndrome was made. Urgent ERCP was performed, and the metal stent was removed
successfully without complication. A cholangiogram revealed a normal biliary tree and no extravasation of contrast. Her pain improved, and a follow-up CT scan showed a patent IVC without compression (D-F). She was discharged home in stable condition. DISCLOSURE All authors disclosed no financial relationships relevant to this article. Saurabh Sethi, MD, MPH, Sumeet Tewani, MD, Jeffrey Mosko, MD, Ivana Dzeletovic, MD, Mandeep S. Sawhney, MD, MS, Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA http://dx.doi.org/10.1016/j.gie.2014.11.003
Commentary This is a terrific case of an exceptionally rare adverse event of a routine procedure, but what strikes me as most remarkable is that an advanced endoscopist looked at a patient’s feet! It’s almost too much to expect even a cursory abdominal exam these days. And who said the physical examination was a lost art? Tachycardia, RLQ pain, double-duct sign, and bilateral pedal edema might be an as-yet unnamed quatrad. The biliary stent in this case addressed a strictured ampulla from previous stone disease and instrumentation. This is, of course, a different scenario than the established use of a transsphincteric pancreatic stent to mitigate the risk of post-ERCP pancreatitis. The last thing on my mind initially here was the development of post-ERCP IVC syndrome, other reports of which I could not find. How she managed to stay home nearly a month after her acquired
1034 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org
chance of recurrence or residual disease is low because lymphatics do not penetrate much beyond the muscularis mucosae, and there is little risk of lymph node metastases. The worst to come may be benign stricturing of the distal ileum, and endoscopic dilatation may be in this patient’s future. The use of endoscopic dissection techniques to address a lesion like this may seem like an adverse event waiting to happen (and you would be right), but we tend not to publish the ordinary. To paraphrase from my medical school–era surgical textbook, “Surgical intervention provides the only hope of cure for patients with this disease.” That was the thinking not too long ago. We’ve come a long way, baby, indeed. David Robbins, MD, MSc Assistant Editor for Focal Points
Endoscopic removal of a migrated duodenal stent into the ileum using double-balloon enteroscopy
A 62-year-old man with pancreatic adenocarcinoma had undergone endoscopic placement of a selfexpanding metal stent (SEMS) to treat duodenal obstruction. Four months later he presented with ileus. CT scanning confirmed that the SEMS was located within the distal ileum. He refused surgery. Double-balloon enteroscopy (DBE) was performed. The SEMS was located 30 cm proximal to the ileocecal valve, embedded in the mucosa (A). The SEMS was carefully loosened from the mucosa by use of a forceps. The enteroscope was passed across the stent, the balloon of the endoscope was inflated within the stent, and the overtube was advanced to the distal part of the stent (B). The balloon of the overtube was further inflated to increase the diameter of the distal lumen, thus favoring the removal of the 22-mm diameter stent. A rat tooth forceps was used to grasp the nitinol branches of the stent. By application of a constant but gentle pulling force, the stent was slowly removed from its embedded location. Careful attention was paid to keep the overtube against the distal part of the stent
www.giejournal.org
(B). After several minutes, the entire stent could be removed (C). The patient recovered uneventfully. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Juan Pablo Gutierrez, MD, Department of Gastroenterology, Hospital de Clinicas, Montevideo, Uruguay, Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA, C. Mel Wilcox, MD, MSPH, FASGE, Klaus Mönkemüller, MD, PhD, FASGE, Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA http://dx.doi.org/10.1016/j.gie.2014.10.004
Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1033
At the Focal Point
Commentary Migration of an uncovered enteral stent placed for palliation of malignant duodenal stenosis is an unusual delayed adverse event. Primary stent failure, whether because of in-growth, fracture, perforation, or migration, occurs infrequently. The gruesome outcome of the underlying diagnosis usually happens first. Uncovered stents are much less likely to migrate than are their partial or now, more commonly, fully covered metal counterparts. Antimigration struts, stronger intrinsic radial expansion forces, and simply the long, winding path make finding a current-generation stent in the mid-ileum a rare event indeed. Double-balloon endoscopy has revolutionized our endoscopic access to the entire playing field of the small bowel. The dramatic images that accompany this Focal Point reveal extensive mural in-growth, and I must confess amazement that the clever technique used here wasn’t accompanied by inadvertent endoscopic ileal resection. And I wonder whether the endoscopists treated themselves to a b-blocker during the time out! A plan B might have been placement of a fully covered stent within the migrated one, returning to tackle the retrieval in 2 weeks. The radial force of the second stent, which would not necessarily need to be of a larger diameter, could have freed up the uncovered stent by inducing pressure necrosis and sloughing of the entrapped mucosa. David Robbins, MD, MSc Assistant Editor for Focal Points
A rare case of inferior vena cava syndrome secondary to compression by a biliary stent A 48-year-old woman presented with right upper quadrant pain, elevated liver functional test (LFT) results, and imaging that revealed pancreatic and biliary ductal dilation. Several years earlier, she had undergone ERCP with sphincterotomy and stone extraction for choledocholithiasis, followed by cholecystectomy. ERCP at another institution was consistent with ampullary restenosis, and the previous sphincterotomy was extended. To maintain sphincter patency and treat possible microperforation, a fully covered self-expandable metal stent was placed in the bile duct. She presented to our center 1 month later with a right lower quadrant (RLQ) pain different from her biliary pain. She was afebrile, and her examination was notable for tachycardia, RLQ tenderness, and bilateral pedal edema. Blood work, including LFTs and lipase, was normal. A CT scan revealed pneumobilia, no biliary dilation, and significant compression of the inferior vena cava (IVC) by the biliary stent (AC). A diagnosis of IVC syndrome was made. Urgent ERCP was performed, and the metal stent was removed
successfully without complication. A cholangiogram revealed a normal biliary tree and no extravasation of contrast. Her pain improved, and a follow-up CT scan showed a patent IVC without compression (D-F). She was discharged home in stable condition. DISCLOSURE All authors disclosed no financial relationships relevant to this article. Saurabh Sethi, MD, MPH, Sumeet Tewani, MD, Jeffrey Mosko, MD, Ivana Dzeletovic, MD, Mandeep S. Sawhney, MD, MS, Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA http://dx.doi.org/10.1016/j.gie.2014.11.003
Commentary This is a terrific case of an exceptionally rare adverse event of a routine procedure, but what strikes me as most remarkable is that an advanced endoscopist looked at a patient’s feet! It’s almost too much to expect even a cursory abdominal exam these days. And who said the physical examination was a lost art? Tachycardia, RLQ pain, double-duct sign, and bilateral pedal edema might be an as-yet unnamed quatrad. The biliary stent in this case addressed a strictured ampulla from previous stone disease and instrumentation. This is, of course, a different scenario than the established use of a transsphincteric pancreatic stent to mitigate the risk of post-ERCP pancreatitis. The last thing on my mind initially here was the development of post-ERCP IVC syndrome, other reports of which I could not find. How she managed to stay home nearly a month after her acquired
1034 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
www.giejournal.org