title: Fatal intestinal perforation secondary to fragmentation of a Celestin tube.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Southport District General Hospital, Southport, Merseyside, UK.
authors.forename: J D
authors.initials: JD
authors.lastname: Evans
authors.forename: C M
authors.initials: CM
authors.lastname: Halloran
authors.forename: P
authors.initials: P
authors.lastname: Mansour
authors.forename: M R
authors.initials: MR
authors.lastname: Zeiderman
mesh_terms: D004868:Equipment Failure; D004938:Esophageal Neoplasms / Q000628:therapy; D004940:Esophageal Stenosis / Q000209:etiology / Q000628:therapy*; D004947:Esophagus; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology*; D007421:Intestine, Small / Q000293:injuries; D007440:Intubation / Q000009:adverse effects / Q000295:instrumentation*; D008875:Middle Aged; D010166:Palliative Care; D010538:Peritonitis / Q000209:etiology