1715 Esophageal Stent Causing Osteomyelitis: An Emerging Complication

Abstract

INTRODUCTION: Esophageal stents are used to treat a wide variety of problems, most commonly malignant dysphagia as a form of palliation. Delayed complications include tumor ingrowth/overgrowth, stent migration, hemorrhage, and delayed perforation. We present a rare case of osteomyelitis secondary to a stent that was placed for the closure of a tracheoesophageal fistula. CASE DESCRIPTION/METHODS: A 55-year-old female presented with stage IV non-small-cell lung cancer with distant metastases. She was started on chemotherapy (gemcitabine and carboplatin) as well as immunotherapy (pembrolizumab). A bronchoscopy had revealed extensive cancer in the bronchial tree and detected a tracheoesophageal fistula, which required placement of an esophageal stent for closure. The stent had been repositioned twice for better location and patient comfort. Four months after the last stent, she presented with fevers, which was initially attributed to her malignancy. However, her symptoms eventually progressed to dysphagia, cough, chest and back pain. Serologic evaluation was notable for an elevated ESR at 112 and an elevated CRP of 105. Subsequent CT of the chest revealed erosive endplate changes at the T1-T2 vertebral level with soft tissue density adjacent to the proximal aspect of the stent. These findings were concerning for osteomyelitis in the setting of an esophageal stent erosion. The decision was made to reposition the stent endoscopically. EGD revealed that the proximal end of the stent was embedded into the esophageal wall without clear erosions or evidence of perforation. Attempt to reposition the esophageal stent was performed, but follow up CT revealed minimal change from endoscopic repositioning. No further endoscopic intervention was performed and she was treated for osteomyelitis with intravenous antibiotics. DISCUSSION: Few cases have reported osteomyelitis related to esophageal stent migration. Whether the stent-related osteomyelitis is potentiated by the effects of chemotherapy on the esophageal wall or related to pressure erosion caused by the stent is not entirely clear. With newer therapies for malignancies and increased life expectancies, new complications may emerge. The decision to perform endoscopic manipulation would largely depend on patients’ clinical status and a discussion of risks versus benefits in a case-based scenario. This case illustrates the importance of having a high index of clinical suspicion for osteomyelitis in a patient with previous esophageal intervention.