Pallliative esophageal Stent Instent compressing the vertebrae causing severe refractory pain mandating its removal

Sameh Ibrahim Sersar MD©¥ and AbdulNassir O. Batouk MD¥ Mansoura University Hospitals; Mansoura: Egypt©¥ and King Abdullah Medical City: Makkah: Saudi Arabia¥.

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Abstract :

Local refractory pain just after insertion of a stent in stent as a palliation for cancer esophagus is very rare if any. We are reporting a case of locally advanced cancer esophagus with refractory pain just after stent instent insertion. The endoscopist felt that endoscopic removal of the stents will carry a very high risk of esophageal perforation. Palliative esophagectomy, Spitz fistula and feeding jejunostomy were carried after getting a very high risk consent. Its operative and postoperative courses were uneventifull.

Key Words:

Palliative esophagectomy, stent instent.

Introduction:

Stent placement carries a 5% to 10% risk of perforation, aspiration pneumonia, fever, hemorrhage, and severe pain. Minor complications are reported in 10% to 20% of patients, including mild retrosternal pain and or reflux esophagitis. Chest post stent placement increases after stent instent and may be related to the expansible force of the stent. It generally resolves within few days. (1-2-3)

Case Report:

A 32 years old female diagnosed as locally advanced squamous cell carcinoma upper third esophagus with fistula with the left main bronchus status post palliative radiochemotherapy 8 months ago. She had severe dysphagia hence a palliative stenting of the esophagus was performed. Stent had tissue in-growth was documented in 8 weeks so, a stent instent was inserted.(Fig.1).

During the insertion of the stent instent, there was no evidence of the tumor and multiple biopsies from the previous tumor site were negative. Few hours after the insertion of the new stent, she had severe pain in the back of the upper chest in the middle line which was refractory to the maximal dose of morphine either oral, parenteral and or patch. Palliative radiotherapy was recommended for possible help but in vain. The Pain persisted and even progressed for almost 3 months which necessitated continuous large doses of narcotics and hospitalization. Repeat CT chest showed severe compression on the upper thoracic vertebrae by the stent which was thought to have eroded through the vertebrae.(Fig.1) Our endoscopists were hesitant to remove the stents fearing to tear the esophagus. Follow up CT showed complete resolution of the tumor but persistence of the bronchoesophageal fistula. Severe progressive refractory pain urged the multidisciplinary team to decide high risk palliative esophagectomy and closure of the bronchoesophageal fistula through right thoracotomy with the stents plus Spitz fistula and feeding tube. The operation was surprisingly easy and its postoperative course was uneventifull. Pain was completely resolved and controlled on no analgesia.

Discussion:

Severe refractory Localized chest high back pain just behind the site of stent instent insertion mandating removal of the stents after failure of maximal doses of non steroidals, morphines and narcotics to control this pain in the long hospital stay just for pain control may not have been reported before at least to our knowledge. Also, very little is known about the best and safest way to remove such an impeded stent instent compressing the vertebral column. We decided to do some thing to help this patient after being rejected by our endoscopists. We decided to do right thoracotomy and removal of as much as we can from thoracic part of the esophagus and then proximal and distal control of the esophagus and repair of the fistula between the esophagus and the left main bronchus using an intercostals muscle flap, Spitz Fistula in the right side of the neck and feeding jejunostomy. Three months follow up was smooth and uneventifull. We are thinking and hoping in a year or so, we may try to do a conduot for her instead of the feeding tube.

Conclusion:

Palliative esophagectomy through the right chest can be an option for complicated stent instent compressing the vertebral column especially if associated with non malignant esophagobronchial fistula.

References:

1.Homs MY and Siersema PD. Stents in the GI tract. Expert Rev Med Devices. 2007;4:741–752.

2. Felix VN1, Caetano A, Cipullo JP, Almodova EC, Colaiacovo W and Zamboti AF. Mid-esophagus unresectable cancer treated with a low cost stent. First experience. BMC Res Notes. 2011: 10;4:486.

3. Aiolfi A, Bona D , Ceriani C , Porro M and Bonavina L . Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review. Endosc Int Open. 2015;3(4):E296-9.

Legend of Figures:

1 AB showing the compressed upper thoracic vertebra(blue arrow) by the Stent instent (yellow Arrow).

1CDE The fisulous tract(Red arrow).