Anesthesia management of a rare case of esophageal ELLA stent migration causes intestinal obstruction

Anesthesia management of a rare case of esophageal ELLA stent migration causes intestinal obstruction: Shalendra Singh, Venigalla Sri Krishna, Deepak Dwivedi, Kaminder Bir Kaur



International Journal of Health & Allied Sciences 2020 9(1):94-95



Sir,

Acute variceal bleeding has devastating consequences if timely management is not done. Multiple pharmacological and mechanical modalities exist to control these active bleeding sites. Recently, a specially designed removable, self-expanding mesh-metal stent (SEMS) (SX-Ella stent, Danis; Ella-CS, Hradec Kralove, Czech Republic) is being used commonly for its treatment.^[1] It achieves hemostasis by direct compression of esophageal varices. It appears to be easier to insert, likely associated with a lower risk of complications compared to balloon tamponade and more effective in the treatment of patients with refractory variceal bleeding. Rare complications of stent placement include esophageal rupture, rebleeding, and stent migration.^[1] We present a case of SEMS migration following its placement, which presented as subacute intestinal obstruction.

A 43-year-old male, a known case of portal venous thrombosis for the past 4 years presented with a history of recurrent hematemesis and melena for which upper gastrointestinal endoscopy (UGIE) revealed actively bleeding esophageal varices. He underwent endoscopic bleeder ligation 1 year back. He presented now with fresh bouts of hematemesis (5 episodes with 150 ml blood loss per episode) for which SEMS stent was placed endoscopically. On the 3^rd day postplacement, he presented with fresh episode of hematemesis. He was started on injection terlipressin 1 mg intravenous (IV) eight hourly and injection pantoprazole infusion 8 mg/h. In view of hemoglobin (Hb)-4.9 g/dl, he was transfused two units of packed red blood cell (PRBC) following which Hb raised to 6.2 g/dl. He was under monitoring in the intensive care unit (ICU) and two units of PRBC were further transfused. On the 7^th day, he presented with the absence of flatus and abdominal distension along with fresh episode of hematemesis. A bedside UGIE was done which revealed ELLA stent was found to have migrated to the body of the stomach obstructing the pyloric opening [Figure 1]. He was taken up for exploratory laparoscopy the next day in ASA Grade III. Provision was made for intraoperative blood loss by demanding 4units PRBC, 8 units Fresh frozen plasma(FFP) and 1 Single donor platelet (SDP)/6 Random donor platelet (RDP) and for postoperative mechanical ventilation. Patient was administered injection fentanyl 100 mcg IV and then induced with injection etomidate 12 mg IV. Muscle relaxation was achieved with injection succinylcholine 130 mg IV and a cuffed polyvinylchloride endotracheal tube of 8.0 mm ID. The maintenance of anesthesia was done with injection sevoflurane admixed with oxygen. Central venous catheterization was performed through right internal jugular vein. Intraoperatively, patient was administered injection morphine 2 mg IV, injection fentanyl 100 mcg IV in divided doses and injection tramadol 100 mg IV over 10 min. Intraoperative IV fluid: 1000 ml of plasmalyte-A, 75 ml blood loss, urine output was 500 ml. No blood products were administered. A laparoscopic anterior gastrectomy and stent removal was performed. During procedure, 2 litre of ascitic fluid was drained and multiple collaterals were noted along greater curvature of the stomach. The patient was extubated on the next day in the ICU and was discharged on the 5^th postoperative day.

Figure 1: Left image (chest X-ray) showing ELLA stent lying inside stomach obstructing the pyloric opening and right image showing removed ELLA stent by laparotomy Click here to view

SEMS, in particular, have a 6%–7% chance of migration.^[1] Precautions that can be taken to prevent stent migration include the use of larger diameter stents (25–28 mm); however, this is associated with increased risk of stent-related complications, such as hemorrhage, perforation, and fistula.^[2] Patients can be monitored overnight in hospital following stent placement. As anesthesiologists, our management would predominantly be the same as any case taken up for laparotomy with additional focus on lung-protective ventilation strategies, serial lactate measurements, and a central venous catheterization to allow vasopressor administration if so needed. Antibiotic therapy must be initiated. Ryle tube must be placed, and position confirmed at laparotomy. A dreaded complication is esophageal stent perforation of tracheobronchial tree creating a fistula, especially in cases of malignancy. Cough, symptoms of choking, and respiratory distress in patients of esophageal stents are to be evaluated for stent migration. In addition, the presence of subacute intestinal obstruction has to be factored into our management plan. The message here is that esophageal stent migration is not as uncommon as one might assume and that it presents with a unique set of challenges which must be anticipated to deliver safe anesthesia and ensure speedy recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: A systematic review and meta-analysis. Dig Endosc 2016;28:539-47.
2.	Verschuur EM, Steyerberg EW, Kuipers EJ, Siersema PD. Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer. Gastrointest Endosc 2007;65:592-601.