A fractured duodenal self-expanding metal stent in a patient with pancreatic cancer

A 65-year-old man with biliary and duodenal obstruction due to metastatic adenocarcinoma of the pancreas underwent placement of an uncovered biliary self-expanding metal stent (SEMS). Subsequently, palliative chemotherapy with gemcitabine and nab-paclitaxel was initiated. Because the patient developed worsening symptoms of gastric outlet obstruction, an uncovered, 12-cm duodenal SEMS (Niti S-enteral D type, diameter 20 smm; TaeWoong Medical, Seoul, South Korea) was placed 4 weeks later.

After 2 months a partial tumor response was documented; however, 6 weeks later he presented again with recurrent symptoms of gastric outlet obstruction. Computed tomography (CT) demonstrated fracture of the duodenal SEMS, which had partially migrated into the distended stomach ([Fig. 1]). A remnant of the SEMS was still in place but was not patent ([Fig. 2]). After the migrated piece of the SEMS had been removed with a snare, an additional uncovered 8-cm SEMS (same type, diameter 22 mm) was placed in the remnant duodenal SEMS ([Fig. 3]). Examination of the removed piece of SEMS showed that the wire mesh was broken ([Fig. 4]). The biliary stent remained patent. After this procedure, the patient was able to eat soft food again.

Fig. 1 Computed tomography (CT) scan showing the fractured duodenal self-expanding metal stent (SEMS), which had partially migrated into the distended stomach.

Fig. 2 Endoscopic view of the remnant part of the duodenal self-expanding metal stent (SEMS), which was no longer patent.

Fig. 3 Radiographic images following the extraction of the migrated part of the self-expanding metal stent (SEMS) showing a second duodenal SEMS positioned in the remnant of the original SEMS. The patent biliary SEMS, which remains in place, is also shown.

Fig. 4 The removed piece of self-expanding metal stent (SEMS) showing a broken wire mesh (arrow).

Placement of a duodenal SEMS is the standard palliative treatment for malignant gastric outlet obstruction and results in prompt relief of symptoms. Distal stent migration can occur in up to 56 % of patients who have covered SEMSs placed [1] [2]. In contrast, stent migration is rare in patients who have had uncovered duodenal SEMSs placed, being reported in less than 2 % of patients in a recently published prospective multicenter study [3]. An extremely rare adverse event of such SEMSs is complete stent fracture and subsequent migration of the broken part. To date, 12 cases of complete fracture of a SEMS, mostly esophageal SEMSs, have been reported [4].

In cases where symptoms of gastric outlet obstruction recur after initially successful placement of a duodenal SEMS, tumor ingrowth, stent migration, and stent fracture, as reported in the present case, should all be considered.

Endoscopy_UCTN_Code_CPL_1AH_2AD

Competing interests: None

• References

• 1 Woo SM, Kim DH, Lee WJ et al. Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer. Surg Endosc 2013; 27: 2031-2039
• 2 Waidmann O, Trojan J, Friedrich-Rust M et al. SEMS vs cSEMS in duodenal and small bowel obstruction: high risk of migration in the covered stent group. World J Gastroenterol 2013; 19: 6199-6206
• 3 Tringali A, Didden P, Repici A et al. Endoscopic treatment of malignant gastric and duodenal strictures: a prospective, multicenter study. Gastrointest Endosc 2014; 79: 66-75
• 4 Khara HS, Diehl DL, Gross SA. Esophageal stent fracture: case report and review of the literature. World J Gastroenterol 2014; 20: 2715-2720