Kaci Sims, MD, Barry Ballard, MD, Isaac Payne, MD, Leander Grimm Jr, MD. University of South Alabama
Introduction: Esophageal perforations of benign origin or anastomotic leaks may be treated using temporary covered stents as a viable conservative treatment strategy. Typically, esophageal stents are removed after six to eight weeks. Well-described complications include tissue ingrowth, stent migration, ruptured stent, obstruction by food, severe pain and discomfort, esophageal rupture, hemorrhage or death.
Case: We present the case of a 67-year-old female evaluated in the emergency room for complaints of left flank pain. One month prior to presentation, she underwent placement of a covered esophageal stent for an anastomotic leak after resection of a benign distal esophageal stricture at another institution. She then failed to follow up after discharge for stent evaluation and possible removal. CT scan with PO and IV contrast on presentation to us demonstrated migration of the stent into the colon with impaction at splenic flexure. There was no evidence of a continued esophageal leak. The patient had mild left flank tenderness to palpation but normal bowel function, absence of laboratory abnormalities and no signs of peritonitis. A colonoscopy with intent for stent retrieval was performed after bowel preparation. During the colonoscopy, the distal edge of the stent was found impacted against an inflammatory mass at the splenic flexure. Another inflammatory mass was noted at the proximal end of the stent. The entirety of the stent was ultimately removed endoscopically with rat-toothed forceps without complication. Cold forceps biopsies and subsequent pathology confirmed the benign nature of both masses. After the procedure, the patient’s flank pain resolved, and she was discharged home tolerating a regular diet.
Discussion: Surgical repair of esophageal perforation or rupture is associated with a high level of morbidity and mortality. Esophageal stenting offers a minimally invasive alternative for indicated cases. Despite a minimally invasive approach, stent placements are not without complication. Sources describe migration of esophageal stents into the colon and various management options including: allowing stents to pass spontaneously in asymptomatic patients, observing and leaving asymptomatic impacted stents in the sigmoid, manual retrieval for stents in the rectum and colectomy for stents suspected of causing perforation. To our knowledge, this represents the first reported case of esophageal stent migration, impaction within the colon and successful retrieval via colonoscopy. We submit that endoscopic retrieval of migrated esophageal stents into the colon can be a safe, effective and efficient treatment modality for patients who are stable and without signs of peritonitis.