At the Focal Point

Commentary Migration of an uncovered enteral stent placed for palliation of malignant duodenal stenosis is an unusual delayed adverse event. Primary stent failure, whether because of in-growth, fracture, perforation, or migration, occurs infrequently. The gruesome outcome of the underlying diagnosis usually happens first. Uncovered stents are much less likely to migrate than are their partial or now, more commonly, fully covered metal counterparts. Antimigration struts, stronger intrinsic radial expansion forces, and simply the long, winding path make finding a current-generation stent in the mid-ileum a rare event indeed. Double-balloon endoscopy has revolutionized our endoscopic access to the entire playing field of the small bowel. The dramatic images that accompany this Focal Point reveal extensive mural in-growth, and I must confess amazement that the clever technique used here wasn’t accompanied by inadvertent endoscopic ileal resection. And I wonder whether the endoscopists treated themselves to a b-blocker during the time out! A plan B might have been placement of a fully covered stent within the migrated one, returning to tackle the retrieval in 2 weeks. The radial force of the second stent, which would not necessarily need to be of a larger diameter, could have freed up the uncovered stent by inducing pressure necrosis and sloughing of the entrapped mucosa. David Robbins, MD, MSc Assistant Editor for Focal Points

A rare case of inferior vena cava syndrome secondary to compression by a biliary stent A 48-year-old woman presented with right upper quadrant pain, elevated liver functional test (LFT) results, and imaging that revealed pancreatic and biliary ductal dilation. Several years earlier, she had undergone ERCP with sphincterotomy and stone extraction for choledocholithiasis, followed by cholecystectomy. ERCP at another institution was consistent with ampullary restenosis, and the previous sphincterotomy was extended. To maintain sphincter patency and treat possible microperforation, a fully covered self-expandable metal stent was placed in the bile duct. She presented to our center 1 month later with a right lower quadrant (RLQ) pain different from her biliary pain. She was afebrile, and her examination was notable for tachycardia, RLQ tenderness, and bilateral pedal edema. Blood work, including LFTs and lipase, was normal. A CT scan revealed pneumobilia, no biliary dilation, and significant compression of the inferior vena cava (IVC) by the biliary stent (AC). A diagnosis of IVC syndrome was made. Urgent ERCP was performed, and the metal stent was removed

successfully without complication. A cholangiogram revealed a normal biliary tree and no extravasation of contrast. Her pain improved, and a follow-up CT scan showed a patent IVC without compression (D-F). She was discharged home in stable condition. DISCLOSURE All authors disclosed no financial relationships relevant to this article. Saurabh Sethi, MD, MPH, Sumeet Tewani, MD, Jeffrey Mosko, MD, Ivana Dzeletovic, MD, Mandeep S. Sawhney, MD, MS, Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA http://dx.doi.org/10.1016/j.gie.2014.11.003

Commentary This is a terrific case of an exceptionally rare adverse event of a routine procedure, but what strikes me as most remarkable is that an advanced endoscopist looked at a patient’s feet! It’s almost too much to expect even a cursory abdominal exam these days. And who said the physical examination was a lost art? Tachycardia, RLQ pain, double-duct sign, and bilateral pedal edema might be an as-yet unnamed quatrad. The biliary stent in this case addressed a strictured ampulla from previous stone disease and instrumentation. This is, of course, a different scenario than the established use of a transsphincteric pancreatic stent to mitigate the risk of post-ERCP pancreatitis. The last thing on my mind initially here was the development of post-ERCP IVC syndrome, other reports of which I could not find. How she managed to stay home nearly a month after her acquired

1034 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015

www.giejournal.org

At the Focal Point

vasculopathy is equally remarkable. More common, although still exceptionally rare, is the almost mirror-image adverse event of a hepatobiliary malignancy causing compression of the IVC requiring intravascular stent placement. Resolution of the liver-associated blood tests after the second sphincterotomy confirmed that ampullary restenosis was indeed the initial dilemma, and follow-up imaging after stent removal for venous compression confirmed this as our first reported case in GIE. We are often reminded in the course of Focal Points that rare is the good deed that goes unpunished. Fortunately, it is not so rare that our endoscopic colleagues think quickly on their feet while keeping them planted squarely on the endoscopy unit floor. My tenure as an Assistant Editor for Focal Points has come to an end, and this is my last entry. I’d like to welcome aboard the new team of writers who will regale us with more strange tales and acts of endoscopic valor. I heard once that the Eskimo-Aleut language has dozens of words for snow, but not a single one for goodbye, and for good reason. So with that, I’m signing off and I’ll see you next time. David Robbins, MD, MSc Assistant Editor for Focal Points www.giejournal.org

Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1035

A rare case of inferior vena cava syndrome secondary to compression by a biliary stent.

A rare case of inferior vena cava syndrome secondary to compression by a biliary stent. - PDF Download Free
689KB Sizes 0 Downloads 9 Views