Iatrogenic duodenal perforation from palliative positioning of self-expandable metal stent

Clinical History

An elderly male patient with past history of cholecystectomy and positioning of plastic biliary stent for slow-growing carcinoma of the Vaterian ampulla two years earlier was hospitalized for recurrent obstructive jaundice, intermittent fever, vomiting and progressive weight loss. Physical findings and laboratory assays were interpreted as consistent with septic cholangitis.

Imaging Findings

Endoscopy and multidetector CT (Fig. 1a-e) depicted growing, stricturing Vaterian ampulla carcinoma causing upstream duodenal dilatation and distal common bile obstruction. The plastic biliary stent was removed, replaced with a metallic endoprosthesis (Fig. 1f, g).
Two weeks later, endoscopic positioning of an 11 cm long covered self-expanding metal stent (SEMS) was performed to palliate malignant duodenal luminal obstruction. During the procedure, the patient experienced severe abdominal pain with impending shock and physical findings of peritonitis. Emergency CT (Fig. 2) showed the distal SEMS end located outside the lumen of the third duodenum plus bilateral retroperitoneal air.
Repeated endoscopy (Fig. 3a) confirmed patent duodenal SEMS with its distal end protruding outside the duodenal lumen, causing extraluminal leak of injected contrast medium (CM) (Fig. 3b). Urgent laparotomic surgery included toilette of retroperitonal perforation, duodenotomy for SEMS removal, and duodeno-jejunostomy. The patient finally recovered after a prolonged intensive care hospitalization, during which persistent retroperitoneal leakage of water-soluble CM (Fig. 4) was observed.

Discussion

Usually representing a terminal complication of advanced malignancies, upper gastrointestinal obstruction (UGIO) leads to dysphagia, malnutrition, risk of aspiration pneumonia, and significantly decreased quality of life. Traditionally, UGIO was treated with bypass surgery (e.g. gastroenterostomy) with high perioperative complication rates (25-35%) and non-negligible mortality (2%) or by minimally invasive techniques (balloon dilatation, laser photo-ablation) with limited success [1-5].
To obviate surgery in patients with poor life expectancy, fluoroscopically-guided endoscopic positioning of self-expandable metal stents (SEMS) currently represents the preferred palliative treatment for gastroesphageal junction and gastroduodenal inoperable tumours. Nitinol or stainless steel reticular mesh SEMS effectively relieve UGIO in almost 90% of patients, allowing resumption of oral intake within 2-3 days, fast improvement of symptoms and quality of life [1-5].
However, short-term post-procedural complications occur in approximately 12% of patients, including improper SEMS placement, pancreatitis, haemorrhage, oesophageal or gastroduodenal perforation. Late complications include malfunction or blockage from stent migration or tumour ingrowth [1-3, 5-7].
Although uncommon (1-2% of patients), perforation represents one of the most feared SEMS-related complications, which may occur during placement or secondary to migration or fracture, particularly in presence of anatomic abnormalities (diverticula, hernias) or after chemoradiotherapy. While regurgitation, pyrosis and chest pain are common complaints after SEMS, perforation is usually heralded by severe pain, haemodynamic instability, respiratory distress, subcutaneous emphysema, progressive development of fever and increasing acute phase reactants [1-5, 7].
Early diagnosis of perforation prior to alimentation allows timely treatment, which is increasingly conservative (with nasogastric suction, nothing by mouth, hydration, broad-spectrum intravenous antibiotics) rather than surgical, even in presence of extensive retroperitoneal air. According to the World Society of Emergency Surgery guidelines, surgical drainage or repair are reserved for worsening clinical conditions (particularly with sepsis or shock) and imaging diagnosis of extraluminal fluid collections or extravasated contrast medium, especially in elderly or chronically ill patients [7, 8].
Therefore, as this case exemplifies, accurate depiction of site and features of SEMS-related perforation is crucial and should rely on multidetector CT. Sometimes complemented with oral contrast swallow in cooperative patients, CT has significant advantages over endoscopy and plain radiographs, particularly for retroperitoneal abnormalities such as those from injuries involving the oesophagogastric junction and second-through-fourth duodenal portions. CT is sensitive for even minimal intraperitoneal, mediastinal or retroperitoneal air, and provides comprehensive high-resolution display of the stent, gastrointestinal wall and surrounding structures, usually allowing clarification of the site and mechanism of injury and correct therapeutic choice [3, 6-10].

Differential Diagnosis List

Final Diagnosis

Iatrogenic retroperitoneal perforation during positioning of duodenal self-expanding metal stent

URL:	https://www.eurorad.org/case/12541
DOI:	10.1594/EURORAD/CASE.12541
ISSN:	1563-4086