Oesophageal stent migration into the liver capsule causing liver abscess

A 47-year-old female patient was referred to a tertiary Liver Centre after presenting with symptoms of severe chest and abdominal pain with raised inflammatory markers.

 She had a complex Upper GI surgical history which included a previous fundoplication, partial then total gastrectomy, followed by a revision of the oesophageal anastomosis, followed by a repair of para-oesophageal hiatus hernia. She later developed an anastomotic stricture which was dilated on numerous occasions and had an oesophageal stent inserted 3 years prior to her presentation.

Her CT chest and abdomen on admission (Figure 1) showed that the oesophageal stent had migrated and lay horizontally within the stomach. The proximal part of the stent had eroded through the gastric wall and into the liver capsule to cause a 6.6x5cm size liver abscess (Figure 2).

The patient was initially treated with IV antibiotics. Three weeks later, a repeat CT abdomen (Figure 3) showed a mild reduction in the size of the abscess.

Further contrast swallow imaging (Figure 4) confirmed the horizontal position of the stent within the stomach and the proximal end eroding the liver capsule.

Major surgery was performed to excise the stent, no action was taken against the abscess intraoperatively. Postoperatively she developed an oesophageal leak (Figure 5). A repeated contrast swallow showed the oesophageal leak draining into the left chest drain (Figure 6). The patient died 8 months post-surgery as a result of these complications.

Oesophageal stents have proven to be important therapeutic interventions for the management of benign and malignant oesophageal diseases. In the past, rigid plastic prosthesis was used in the palliative management of inoperable oesophageal malignancy and was associated with higher morbidity rates [1]. The evolution stents, which are now made from durable polymers and hard metal alloy compounds, have increased their use in benign conditions including refractory strictures (such as those induced by peptic ulcers, anastomoses, and radiation), tracheoesophageal fistulae, iatrogenic perforations, and leaks [2].

Common early complications, within 4 weeks post-procedure, include chest pain, bleeding, perforation, and aspiration[3]. One of the most common delayed complications, which has been reported in up to 32% of patients in one study[4], is stent migration.  As in this case, stent migration is more common in stents positioned over the gastroesophageal junction. Other factors that can contribute to migration are overdilation of the stricture/lesion prior to stent insertion, mal-positioning of the stent and in the case of malignant strictures, shrinkage of the tumour due to chemo/radiotherapies [5,3].  The pressure necrosis caused by the continuing radial force of the stent on the oesophageal wall can cause bleeding if erosion occurs into the vessels within the oesophageal wall [3]. Perforation of the wall itself and surrounding structures can also occur and should be included as differentials in patients presenting with abdominal or chest pain with oesophageal stents in situ. These structures can be delineated through the use of contrast swallow imaging. Only in symptomatic patients is stent removal indicated (either via surgery or endoscopy) after complete migration[5].

No explicit written consent was obtained from patient before she passed away. All patient identifiable information has been removed.