JRSM >
Volume 94, Number 5 >
Pp. 244-245
Department of Surgery, Addenbrooke's NHS Trust, Hills Road, Cambridge CB2
2QQ
1
Department of Surgery, Hinchingbrooke Hospital, Huntingdon, Cambridgeshire,
UK
Correspondence to: Dr K Hasan, 64 Settles Street, London E1 1JP, UK
Duodenal obstruction is present at diagnosis in about 5% of patients with adenocarcinoma of the head of the pancreas1. Surgical palliation was until recently the only means of improving their quality of life but duodenal stenting is now an option2,3.
CASE HISTORY
A man aged 55 with an irresectable adenocarcinoma of the pancreatic head had metallic Wallstents inserted in the bile duct and duodenum. Five months later he was admitted with acute right upper quadrant pain and right shoulder tip pain. He was apyrexial, anicteric and cardiovascularly stable. There was tenderness and guarding in the right upper quadrant but an erect chest X-ray showed no evidence of a pneumoperitoneum. Abdominal radiography revealed that the duodenal stent was now vertical (Figure 1), having previously been C-shaped in the second part of the duodenum. Next day a computed tomographic scan of the abdomen revealed free peritoneal air and a small amount of free fluid in the gallbladder fossa and around the duodenum. At laparotomy there was diffuse peritonitis together with a prepyloric perforation, approximately 3 mm in size, through which the edge of the stent could be felt. The perforation was closed with an omental patch. The patient died soon after the operation.
|
COMMENT
Metallic stents have an established place in the treatment of biliary and oesophageal obstruction but experience of their use in the duodenum is limited1. One reason is a perception that metallic stents placed in the bowel are prone to migration or liable to cause perforation2. Our suspicion that there might be a duodenal perforation in the present case was raised by the vertical position of the stent in the initial abdominal X-ray. After insertion, duodenal stents assume the C-shape of the duodenum. A vertical position might simply indicate straightening of the stent3. However, it could also represent migration or perforation; indeed, straightening-out might well be a risk factor for perforation.
In a patient with malignant duodenal obstruction, the expected survival is only a few months4. Therefore the aim of stenting is to provide good palliation with avoidance of surgery. In this short period the risk of stent occlusion is negligible, but the risk of duodenal perforation needs to be borne in mind.
REFERENCES
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
