Fatal intestinal perforation secondary to fragmentation of a Celestin tube

Abstract

Background/aims: Oesophageal intubation remains one of the principal methods of palliation for an obstructing oesophageal carcinoma. We present a case which illustrates a rare but fatal complication of this procedure.

Methods: A 60-year-old female with oesophageal cancer presented with total dysphagia 9 months following insertion of a Celestin tube for palliation. Oesophagoscopy revealed a bolus obstruction which was successfully cleared. Two days later she developed generalised peritonitis and subsequently died.

Results: A post-mortem examination demonstrated fragmentation and displacement of the distal part of the Celestin tube resulting in perforation of the small bowel.

Conclusion: Celestin tube disintegration is a risk associated with long-term use, and routine replacement is indicated in patients with a prolonged survival to avoid this complication.