Journal of

Case Reports and Images in Surgery

 
     
Case Report
 
What is the treatment of esophageal stent migration in a schizophrenic patient?
Yucel Akkas1, Baris Dogu Yildiz2, Bulent Kocer3
1MD, Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey.
2Associate Professor, Department of General Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey.
3Associate Professor, Department of Thoracic Surgery, Ankara Numune Research and Training Hospital, Ankara, Turkey.

Article ID: 100037Z12YK2017
doi:10.5348/Z12-2017-37-CR-2

Address correspondence to:
Yucel Akkas
MD, Department of Thoracic Surgery
Ankara Numune Research and Training Hospital
Ankara
Turkey

Access full text article on other devices

  Access PDF of article on other devices

[HTML Abstract]   [PDF Full Text] [Print This Article]
[Similar article in Pumed] [Similar article in Google Scholar]

How to cite this article:
Akkas Y, Yildiz BD, Kocer B. What is the treatment of esophageal stent migration in a schizophrenic patient? J Case Rep Images Surg 2017;3:6–8.


Abstract
Introduction: In this case report, we describe surgical management of a schizophrenic patient who had a partially broken metallic stent which was placed for benign corrosive stricture.
Case Report: We describe surgical management of a 39-year-old male schizophrenic patient who had a partially broken metallic stent which was placed for benign corrosive stricture. An endoscopy revealed that the stent was partially broken and slipped below the strictured segment of the esophagus. Laparotomy and transhiatal esophagectomy with anastomosis on the neck were performed. In order to protect the anastomosis, wounds, and drains the patient was kept intubated.
Conclusion: Radical resection for benign strictures could prevent complications of repetitive stent placement in schizophrenic patients. Keeping the schizophrenic patient intubated under sedation could be a wise strategy to prevent inadvertent violation of the anastomosis.

Keywords: Benign stricture, Esophagus, Stent migration, Schizophrenia, Treatment


Introduction

Self-expandable metallic or plastic stents are more commonly used for the treatment of benign esophageal strictures as a minimally invasive technique. Unfortunately, this technique is not performed without morbidity or mortalities secondary to complications [1] [2].

In this case report, we describe surgical management of a schizophrenic patient who had a partially broken metallic stent which was placed for benign corrosive stricture.


Case Report

A 39-year-old male schizophrenic patient had a self-expandable temporary metallic stent placement nine months ago after esophageal stricture secondary to corrosive ingestion in another center. The patient presented to our hospital with dysphagia. The patient was cachectic and malnourished. His complete blood count showed mild anemia and blood biochemistry showed low albumin level. Computed tomography scan showed that the stent was migrated to upper stomach (Figure 1).

An upper endoscopy revealed that the stent was partially broken and slipped below the strictured segment of the esophagus. An attempt to remove the stent was undertaken but this was not possible because the broken parts of the stent were embedded inside the esophageal wall which posed the risk of perforation.

The patient was started with parenteral nutrition and when his nutritional status improved surgical intervention was decided with the consent of the family. Laparotomy and transhiatal esophagectomy with anastomosis on the neck were performed. This served both removals of the migrated stent and strictured, neoplasia prone esophagus. The stricture part of the esophagus was 6 cm (Figure 2).

In order to protect the anastomosis, wounds and drains the patient was kept intubated for one week in intensive care unit. On postoperative day-2, the patient had bilateral hemothorax and placement of chest tubes which were removed on postoperative day-5. The patient was extubated at the end of seventh day, started on oral feeds and drains removed. The patient was discharged on postoperative day-10 and after four months the patient has not any complications.


Cursor on image to zoom/Click text to open image
Figure 1: Computed tomography appearance of broken esophageal stent.



Cursor on image to zoom/Click text to open image
Figure 2: Surgical specimen showing the stent (white arrow) and strictured esophagus (black arrow).



Discussion

Esophageal stents (ES) are used for both malignant and benign conditions of the esophagus such as unresectable cancer, fistula, corrosive ingestion, iatrogenic perforation and anastomosis leaks [1] [3].

Esophageal stents can have early (chest pain, aspiration, bleeding perforation, or dysphagia) or late (obstruction, tumor ingrowth, tracheoesophageal fistula, etc.) complications [1] [3]. Fuccio et al. reported their rate of migration as 28.6% [4]. Esophageal stents mostly migrate to stomach or intestines causing perforation or obstruction and some are even passed out rectally. Our patient only had dysphagia. The patient was not aware of the symptoms due to the schizophrenia. In his history, we understand that the patient did not go to the hospital for esophageal stents controls because of this his esophageal stents was not removed on time.

Various techniques are available for removal of broken stents. In contrast to literature, the stent was partially broken in our patient which caused it to get embedded in the esophageal wall which necessitated surgical intervention. Our case is the 10th case in the review of literature [3].

Corrosive strictures were occurred 35.1% in healthy population after corrosive ingestion[5]. The diagnosis of psychotic disorders in all corrosive material ingestion rate is 3.7% [6]. Corrosive strictures of esophagus pose a 40% risk of malignancy after 20–50 years. This fact when added to the unease of endoscopic interventions in a schizophrenic patient made us decide on a radical surgical procedure [7] [8]. Keeping the patient intubated until patency of the anastomosis was verified could be considered as radical. But this was necessary as the patient could disrupt the anastomosis by inappropriate ingestion.


Conclusion

Radical resection for benign strictures could prevent complications of repetitive stent placement in schizophrenic patients. Keeping the schizophrenic patient intubated under sedation could be a wise strategy to prevent inadvertent violation of the anastomosis. This treatment method was our personal preference. Treatment approached should be multidisciplinary.


References
  1. Kim JH, Shin JH, Song HY. Benign strictures of the esophagus and gastric outlet: Interventional management. Korean J Radiol 2010 Sep-Oct;11(5):497–506.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Karagul S, Yagci MA, Ara C, et al. Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature. Int J Surg Case Rep 2015;11:113–6.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Khara HS, Diehl DL, Gross SA. Esophageal stent fracture: Case report and review of the literature. World J Gastroenterol 2014 Mar 14;20(10):2715–20.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Fuccio L, Hassan C, Frazzoni L, Miglio R, Repici A. Clinical outcomes following stent placement in refractory benign esophageal stricture: A systematic review and meta-analysis. Endoscopy 2016 Feb;48(2):141–8.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Pelclová D, Navrátil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicol Rev 2005;24(2):125–9.   [Pubmed]    Back to citation no. 5
  6. Ogunrombi AB, Mosaku KS, Onakpoya UU. The impact of psychological illness on outcome of corrosive esophageal injury. Niger J Clin Pract 2013 Jan-Mar;16(1):49–53.   [CrossRef]   [Pubmed]    Back to citation no. 6
  7. Genc O, Knight RK, Nicholson AG, Goldstraw P. Adenocarcinoma arising in a retained esophageal remnant. Ann Thorac Surg 2001 Dec;72(6):2117–9.   [CrossRef]   [Pubmed]    Back to citation no. 7
  8. Qureshi R, Norton R. Squamous cell carcinoma in esophageal remnant after 24 years: Lessons learnt from esophageal bypass surgery. Dis Esophagus 2000;13(3):245–7.   [CrossRef]   [Pubmed]    Back to citation no. 8

[HTML Abstract]   [PDF Full Text]

Author Contributions
Yucel Akkas – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Baris Dogu Yildiz – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Bulent Kocer – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2017 Yucel Akkas et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



  Home line About the Journal line Aim and Scope line Open Access line Archives
Apply as Editor line Apply as Reviewer line Submit Reviews - Editors line Submit Reviews - Reviewers
Instructions for Authors line Templates to Use line Copyright Form line Author Checklist
Online Submission line Email Submission line Submit Revision line Submit All Forms line Submit Page Proofs
Terms of Service line Privacy policy line Disclaimer line FAQ line Contact: Journal line Contact: Edorium Journals line Site Map
 
  Copyright © 2017. Edorium. All rights reserved.