The Traction that Broke the Anti-reflux Stentʼs Back - A Rare but Important Complication

Abstract

Purpose: The Cook Dua Esophageal Stent with Anti-Reflux Valve was developed to reduce reflux of stomach contents in patients with cancers of the esophagus. We report a case of a spontaneously torn anti-reflux flap previously noted to be in working order. Methods: The patient was a 55-year-old male with metastatic distal esophageal adenocarcinoma with progressive dysphagia. Previous placement of a partially covered esophageal Wallflex stent had allowed oral intake, but resulted in significant reflux symptoms secondary to the stent traversing the gastroesophageal junction. Decision to attempt placement of a Dua Anti Reflux Stent within the previously placed stent in order to curb the reflux of gastric contents. A gastroscope was advanced to the stomach traversing the previously placed Wallstent, retroflexion revealed the stent to be well situated beneath the lower esopohageal sphincter. A 12 cm Cook esophageal Z-stent with Dua anti-reflux valve was then passed over a Savory guide-wire with the distal most radio-opaue marker positioned over the distal margin of the previous stent. The stent was deployed into excellent position under fluroscopic guidance. The gastroscope was then advanced with no resistance and verification of positioning of both stents was confirmed. Post placement x-ray showed no evidence of perforation or migration and the patient was discharged with symptomatic improvement in reflux related discomfort. Results: Two weeks post placement, the patient returned with unbearable chest pain secondary to progressive reflux symptoms. The patient had severe dysphagia to both liquids and solids and had no chest wall tenderness and crepitis. Repeat Esophagogastroduodenoscopy (EGD) with fluroscopy revealed the two stents to be in good position. The scope was passed through the center of the stents into the stomach. The anti-reflux flaps of the Dua stent appeared to be partially torn along the distal edge of the stent with prolapse into the esophagus. A rat tooth forceps was used to grasp the proximal edge of the Z- stent and under fluroscopic guidance the stent was removed. The endoscope was passed again through the previous Wallflex stent which remained in good position without migration and tissue in-growth. The patient was medically managed for reflux and will be considered for repeat stent placement. Conclusion: Previous reports have noted overstrain or defective materials as the reason for the rupture. We believe the etiology of the tear of the anti-reflux valve in this instance to be from direct contact injury from the distal edge of the previously placed Wallflex esophageal stent. We recommend that post-placement tear with consequent dysphagia and recurrent reflux symptoms be cited as a potential complication.