1. IntroductionEsophageal metallic stents are indicated in the palliative treatment of malignant dysphagia [1]. The ones usually used are covered or partially covered. They have a low mortality rate directly associated (0.5-2%) [2]. As with any endoscopic therapeutic procedure, it can get complicated. A distinction is then made between early complications (32% of patients) which are immediate after the procedure or at 2-4 weeks, and delayed complications (53-65% of patients) at more than 4 weeks after the procedure [3]. Hemorrhagic complications are most often early and not very important, related to the expansion of the prosthesis on the tumor. But late haemorrhages (haematemesis, haemoptysis) can also be observed, which can concern up to 7.3% of patients [4], and which can in some cases be massive.
2. Key wordsAorto-esophageal fistula; Metallic stent; Esophageal adenocarcinoma; Side effects; Massive hematemesis
3. CaseOur patient was 57 years old, with history of metastatic cardia adenocarcinoma. First, he received a chemotherapy and a radiochemotherapy. In February 2018, after failure of a balloon dilatation, he had a first covered metal stent (Boston Wallflex). A second stent was placed uppon of the first in June 2018, because of recurrence of dysphagia. The following months are marked by poor tolerance of the stents, with retrosternal pain. He had response of carcinologic treatment. He is admitted in February 2019 for an hemorrhagic shock with massive hematemesis after severe chest pain. A thoracic angioscanner revealed a fistulation of the anterior wall of the descending thoracic aorta within the esophagus, in contact with the upper end of the lower esophageal stent (Figures 1, 2).One similar case is described by Justin C. R. Wormald et al [5], the management differs with first-line gastroscopy instead of CT scan.
5. DiscussionWhen the indication for the esophageal metallic stent is malignant, the average survival observed in a palliative situation is 120 days, with a re-intervention rate of 25-35%. Complications related to metallic stents are more frequent when the patient has received prior radiochemotherapy [1, 2]. In the study by Wang MQ et al [4], they hypothesize that bleeding complications were more frequent when the upper end of the prosthesis was above or at the aortic arch. The 6 patients who presented with hematemesis all died, three died at home or during transport, and the other three died intra-hospital. Autopsy in one of the patients showed the presence of a perforation of the esophageal wall causing an aortoesophageal fistula at the proximal end. Five of the six patients had received radiation therapy prior to stenting. On the other hand, the exact cause of bleeding in these cases is controversial, it seems that the tumour itself is responsible and not the stent
Reference1. Lledo G, Mariette C, Raoul JL, Dahan L, Landi B, Conroy T, et al. «Cancer de l’œsophage». Thésaurus National de Cancérologie Digestive. 2016
2. Sharma P, Kozarek R. Practice Parameters Committee of American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol. 2010; 105(2): 258-274.
3. Hindy P, Hong J, Lam-Tsai Y et al. A comprehensive review of esophageal stents. Gastroenterol Hepatol 2012; 8: 526-34.
4. Wang MQ, Sze DY, Wang ZP, Wang ZQ, Gao YA, Dake MD. Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas. J Vasc Interv Radiol. 2001; 12(4): 465-474.
5. J. C. R. Wormald et al, Aorto-esophageal fistula: the multi-disciplinary team approach to management, Clinical Case Reports, 2016; 4(8): 800-802.
t .Aorto-Esophageal Fistula and Metallic Stent . Annals of Clinical and Medical Case Reports 2020