Linda I Yala, MD1, Rami Lutfi, MD, FACS, FASMBS2. 1UIC-MGH General Surgery Residency, 2Mercy Hospital, Chicago, IL
Introduction: In obstructing gastroesophageal junction tumors, self-expanding metal stents are often a means of palliation. Several studies have demonstrated that most common indication is for severe dysphagia and placement results in significant improvement therefore acting as a sufficient treatment option to restore swallowing function. However, complication rates associated with stenting ranges from 22% to 45% on various studies. A known complication of stent utilization is its migration for which an independent risk factor is adjuvant chemotherapy or radiation therapy. Much rarer but still prevalent are the cases of perforation.
Methods: We presented a 58-year-old male with a past medical history of alcohol and tobacco abuse and gastric adenocarcinoma who presented with substernal chest pain after eating. His CT scan at diagnosis demonstrated unresectable disease. At another facility, he underwent GEJ stenting to palliate, chemotherapy was initiated, and, one week prior to admission, he was noted to have stent migration due to his complete response to chemotherapy. An unsuccessful attempt to remove the stent at the facility prompted him to later present with findings of free air necessitating urgent operative intervention.
Surgery was performed by a trained laparoscopic surgeon with intent to convert to open if patient did not tolerate or needed more urgent damage control. He had purulent peritonitis and the greater curvature of the stomach had erosion of the stent with a large perforation below the hiatus. The decision was made to remove the stent as it was unlikely that the perforation would heal and the gastric erosion would progress.
Greater curvature was mobilized, lesser sac was entered, and a gastrotomy was created. With difficulty, the stent was freed. We then created a vascularized omental pedicle. The gastrotomy was closed and the pedicle was mobilized and loosely sutured into place. After drain placement and stent retrieval, the case concluded remaining entirely laparoscopic.
Conclusion: Self-expanding stents are increasingly being utilized in gastroesophageal junction tumors as palliation most often for severe dysphagia. All patients experience improvement in dysphagia after stenting however there are known risks associated including migration, perforation, fistulae, and bleeding. Stent migration is known to occur after chemotherapy and typically perforation is common immediately after placement, however, late complication of perforation is rare. We report a unique case where a patient had palliative stenting that was complicated by migration and the attempted retrieval of the stent in setting of friable tissue likely induced perforation and repair was completed laparoscopically.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94209
Program Number: V331
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop