Fracture of a Self-expandable Metallic Stent Inserted for Malignant Gastric Outlet Obstruction

Abstract

Duodenal stenting has gradually been established as the first-line treatment for malignant gastric outlet obstruction (GOO). We encountered a case of duodenal stent fracture in a 76-year-old woman with gastric cancer and GOO. She underwent self-expandable metallic stent (SEMS) placement. The SEMS was found to be fractured 4 weeks after its placement. We removed the broken part of the stent and placed a second SEMS. SEMS fracture is a rare and-to the best of our knowledge-unreported complication; hence, clinicians and their patients should be aware of this possibility.

Small Bowel Obstruction Caused by Migration of Fractured Metal Stent in Patients with Malignant Gastric Outlet Obstruction: A Report of Two Cases and Review of the Literature

“…According to previous reports, the incidence of stent fractures in patients with mGOO ranges from 0.0% to 4.8% (7). Stent fracture is an infrequent complication in patients with mGOO, and few case reports have described the management and outcomes of stent fracture (8)(9)(10). However, the mechanism underlying stent fracture remains unclear.…”

“…Some case reports have hypothesized that metal fatigue (e.g. the stress applied by the endoscopic procedure to the stent, gastric acid, removal of the stent coating material by re-interventions, and repeated and prolonged shearing forces caused by gastrointestinal motility), selection of stents with low axial force, and manufacturing defects can induce stent fracture (8)(9)(10). Kadokura et al (10) suggested that it may be useful to select a stent with a stronger axial force or to select a shorter stent to reduce the risk of fracture in cases of short stenosis in bending sites, such as at the gastric outlet (prepyloric region to the duodenum).…”

“…the stress applied by the endoscopic procedure to the stent, gastric acid, removal of the stent coating material by re-interventions, and repeated and prolonged shearing forces caused by gastrointestinal motility), selection of stents with low axial force, and manufacturing defects can induce stent fracture (8)(9)(10). Kadokura et al (10) suggested that it may be useful to select a stent with a stronger axial force or to select a shorter stent to reduce the risk of fracture in cases of short stenosis in bending sites, such as at the gastric outlet (prepyloric region to the duodenum). Takao et al (11) also presumed that prolonged friction between the stenotic and non-stenotic sections might have triggered stent fracture, and the inappropriate length and low axial force of the stent at the flexure led to stent fracture in a fracture case with colonic SEMS.…”

“…Javaid and Yusuf (9) and Kadokura et al (9,10) described a case of mGOO involving migration of the proximal stent segment into the stomach body, followed by restenting through the distal stent segment. Maetani et al ( 8) successfully repaired a damaged stent using a cutting wire filament and placing another duodenal stent coaxially with the first for stent fracture in a patient with mGOO.…”

Esophageal Self-Expandable Metal Stents Can Fracture in the Distal Third When Used for Post-Bariatric Surgery Complications: A Single Center Experience and Review of the Literature with Video

“…In contrast, SEMS with the highest axial forces were not found to be associated with any of the reported fracture cases. To that effect, Kadokura et al recommended the use of shorter stents with higher axial forces to avoid fractures in duodenal SEMS [ 39 ]. However, Hirdes et al express concern that stents with higher axial force can cause luminal wall injury [ 38 ].…”