Duodenal stents are frequently used for palliating malignant gastric outlet obstruction. Successful stent placement relieves obstructive symptoms, is cost effective, and has a relatively low complication rate. However, enteral stents have the potential of migrating distally and rarely, even lead to bowel perforation. We present a rare case of a duodenal stent placed as a palliative measure for gastric outlet obstruction due to unresectable pancreatic cancer that migrated distally after a gastrojejunostomy resulting in small bowel perforation.

Purpose: Duodenal stent placement is considered by some to be the procedure of choice for palliating malignant gastric outlet obstruction (GOO). Methods: A 55-year-old female presented with a 2-week history of a “viral illness” and recent onset of painless jaundice with dark colored urine. Her past medical history was significant for colon cancer resected 30 years prior. Physical exam was remarkable only for scleral icterus and jaundice. Laboratory studies were significant for a conjugated hyperbilirubinemia. A CT scan revealed a 1.5 cm mass in the head of the pancreas with biliary and pancreatic ductal dilatation. ERCP demonstrated a 2.5 cm stricture that was stented. Brushings revealed carcinoma. An EUS, biopsy, and staging laparoscopy revealed an unresectable pancreatic carcinoma that encased the superior mesenteric vessels. 15 months after initial presentation, the patient developed symptomatic gastric outlet obstruction and underwent endoscopic placement of two 20x60 mm enteral stent across the duodenal narrowing. Results: After failure of symptomatic resolution, a contrast study showed the stents in the duodenum (image on left). A loop gastrojejunostomy was performed without incident until postoperative day 5 when she developed an acute onset of abdominal pain, acidosis and leukocytosis. A CT scan at the time revealed a large amount of free fluid in the abdomen, a small amount of free air and a metallic stent in the distal small bowel (image on right). At exploration she was found to have a metallic stent 10 cm proximal to the ileocecal valve perforating the small bowel. The patient died three days later from multisystem organ failure secondary to overwhelming sepsis. Conclusion: Palliation with gastroenteric bypass in malignant GOO has been shown to carry significant morbidity and mortality. Enteral stent placement is cost effective and less morbid alternative to surgery with advantages of improved nutrition, decreased morbidity and hospital stay. A 17% complication rate including migration, duodenal perforation, biliary enteric fistulas, and reobstruction due to tumor growth and stent fracture has been reported. It is therefore imperative to recognize the potential risk of duodenal stent migration, particularly after manipulation of the stomach and/or duodenum during surgery.Figure