malignant duodenal stenosis sometimes occurs in patients with advanced periampullary carcinoma , and detrimentally affects the quality of life of patients because of unpleasant symptoms including insufficient oral intake , nausea , and vomiting . self - expandable metallic stents have been introduced to treat malignant duodenal stenosis , especially in patients with a short life expectancy , as a therapeutic alternative to surgical bypass , . duodenal stenting is reported to relieve symptoms associated with stenosis of the duodenum and to improve the patients quality of life . as duodenal stenosis usually follows biliary stenosis arising from periampullary carcinoma , double stenting of both duodenal and biliary stenosis should be performed for palliation , . complications associated with the placement of a self - expandable metallic stent for duodenal obstruction are reported in approximately 19.426.2% of cases . herein we report the successful treatment of duodenal perforation induced by a stent by means of surgical closure following intraoperative endoscopic additional stenting . an 80-year - old woman was referred to our hospital because of fever and anorexia . imaging and endoscopic examination revealed stenosis of not only the lower bile duct , but also the second portion of duodenum . she refused surgery and underwent placement of a wallflex duodenal stent ( 2.2    120  cm ; boston scientific , marlborough , ma , usa ) and a bile duct metallic stent for duodenal and biliary stenosis , respectively ( fig . we attempted biliary re - stenting , but found it difficult to stretch the endoscope ( tjf-260 ; olympus , tokyo , japan ) in the second portion of the duodenum because of the indwelling stent . ultimately the proximal end of the metallic stent migrated into the abdominal cavity as a result of compression of the exterior of the duodenal bulb ( fig . we decided to intervene surgically after confirmation of perforation of the first portion of the duodenum on computed tomography ( ct ) ( fig . we found a 4  cm perforation from the first to the second outside portion of the duodenum with prolapse of the duodenal stent ( fig . , intraoperative endoscopy was performed to place a total of three niti - s gastroduodenal stents ( 2.2    12  cm , 2.2    8  cm , and 2.2    10  cm ; century medical , tokyo , japan ) on the caudal and cranial sides of the prolapsed stent in a stent - in - stent fashion to reduce the axial force on the prolapsed stent . we confirmed the diminished expanding force on the perforated lesion , and closed the duodenal perforation by albert anastomosis ( fig . 4b ) . no leakage or poor passage was observed at the duodenum , and the patient was able to eat normally until her death 4 months after surgery . to our knowledge , this is the first report of surgical closure following intraoperative endoscopic additional stenting for duodenal perforation induced by a stent . double stenting for duodenal and biliary obstruction has been reported in patients with advanced periampullary carcinoma . endoscopic retrograde cholangiopancreatography ( ercp ) has been a safe procedure in patients with indwelling stents , with a low risk of stent prolapse and intestinal perforation . perforation of the digestive tract is one of the most life - threatening complications and must be avoided . to prevent duodenal perforation , clips and fibrin glue are used in ercp for patients with a suspicion of perforation , but no imaging evidence , . in this study , a surgical approach was required because the post - event ct revealed the stent to be apparently prolapsed from the duodenum with free air excised in the peritoneal cavity . at laparotomy , the prolapsed duodenal stent was linearized and moved to the perforation site of the duodenum by axial force . several strategies reported for intestinal perforation caused by a stent include removal or trimming of the stent followed by surgical closure , , . in the present case , the stent could not be removed because of its strong adherence to the mucosa due to the enlarged tumour . we therefore decided to use niti - s pyloric / duodenal stents with a small axial force for re - stenting up to the horizontal limb of the duodenum on the caudal side and up to the duodenal bulb on the cranial side of the existing stent . this reduced the force exerted on the injury site by the existing stent , making it possible to perform simple closure . additional intraoperative endoscopic stenting followed by surgical closure is a viable option for duodenal perforation induced by a stent . written informed consent has been already obtained from this patients and we describe about it in our manuscript .
highlightsperforation of duodenum rarely occurs after stenting , but it could be life threatening.reduced the force of the existing stent to the injury site , which could make it possible to perform simple closure.surgical closure following intraoperative endoscopic additional stenting could be one of the useful options for duodenal perforation by stent .