Esophageal Stent Migration Leading to Pneumothorax and Esophageal-Pleural Fistula: A Rare but Important Complication

Abstract

Purpose: Esophageal stents are used in the management of malignant dysphagia. Covered self-expanding stents are standard practice in esophageal cancer as either palliation or a bridge to surgical resection. Stent placement carries a risk of complications, including aspiration pneumonia, fistula formation, and stent migration. More severe complications such as stent fracture and jejunal perforations have been reported. Case Report: We report a case of a 63-year-old woman with a history of a malignant esophageal stricture who underwent placement of a fully covered esophageal stent. The procedure was well tolerated with symptom improvement. She was then treated with chemotherapy and radiation with ultimate plans for surgical resection. Over the next six weeks, she presented to the hospital twice for chest pain. Two upper endoscopies during this time revealed a patent esophageal stent in proper position. Eight weeks after initial stent placement, she represented with persistent nausea and dysphagia. An upper endoscopy revealed stent migration with mucosal ulceration in the mid-esophagus from previous stent placement. The stent was pulled back into proper position with a rat-toothed forceps. She returned two weeks later with acute dyspnea and chest pain. A CXR revealed a right-sided tension pneumothorax. A chest tube was placed and immediately drained bilious liquid. A chest CT demonstrated erosion of the proximal end of the stent through the esophagus into a contained posterior mediastinal space which communicated with the right pleural cavity. Emergent upper endoscopy revealed the proximal portion of the stent eroding through the esophagus with an area of visible pleura. Stent removal was attempted but unsuccessful. The stent was then grasped with a rat-toothed forceps and pulled back into the esophagus to seal the visible defect. Twelve hours later, a CXR again showed stent migration. A repeat endoscopy revealed the proximal end of the stent within the pleura. It was pulled back to cover the defect and a second partially covered esophageal self-expanding stent was placed within the previously placed stent. Unfortunately, the patient's respiratory status continued to deteriorate and she passed away a few days later. Discussion: This case describes a rare complication of esophageal stent placement: pneumothorax and esophageal-pleural fistula development. Although esophageal stents can be beneficial in select patients with malignant strictures, stent migration is a common complication. This case highlights the importance of not only recognizing these complications, but also the management dilemmas and endoscopic challenges they bring.