Esophageal Avulsion Following Removal of a Partially Covered Esophageal Stent: Lessons Learned 10 Years Later

S esophageal stents are used for benign and malignant diseases, though no self-expandable metal stent (SEMS) is ood and Drug Administration (FDA)-approved for benign disease. ully covered SEMS and self-expandable plastic stents (SEPS) are emovable due to lack of tissue embedment.1 We describe a patient in whom a partially covered SEMS was placed for benign disease prior to the commercial availability of fully covered SEMS and SEPS. Subsequent removal was complicated by stent avulsion. A 60-year-old man underwent distal esophagectomy with proximal gastric resection of a T3N0M0 adenocarcinoma in early 2001. Two months after surgery, he developed an esophagogastric anastomotic stricture and tracheoesophageal fistula with severe aspiration pneumonia. Neither fully covered SEMS nor SEPS were commercially available then. A 23-mm diameter, partially covered SEMS (Ultraflex; Boston Scientific, Natick, MA) was placed across the esophagogastric anastomosis. He clinically improved with normal swallowing. Serial bronchoscopic examinations were performed (Figure A) until the stula could no longer be identified 6 months later. Endoscopic stent emoval was performed by grasping the proximal portion of the stent ith a rat-toothed forceps and was withdrawn, but the esophagus was till attached (Figure B). Pathology revealed squamous mucosa with ubmucosal fibrosis. The patient was emergently intubated, transerred to intensive care, and upper endoscopy showed completely enuded esophageal mucosa, but no perforation or disruption of the nastomosis was seen. Bronchoscopy showed a 1-mm tracheoesophgeal fistula. Repeat esophagoscopy and bronchoscopy 4 days later howed a hypopharyngeal tear at the upper esophageal sphincter. ollow-up examinations showed healing of the tear and fistula but he patient subsequently developed a refractory proximal cervical sophageal stricture necessitating hypopharyngeal colonic interposiion. Unfortunately, the patient developed chronic aspiration and ied of pneumonia 8.5 years after initial SEMS placement and withut recurrent adenocarcinoma. SEMS and SEPS were developed for palliation of malignant esophgeal disease. Over time they have been used for benign diseases. emoval of partially covered SEMS is feasible despite the fact that the ncovered portion becomes embedded into the esophageal wall. In ases where the distal end of a partially covered SEMS remains in the tomach embedding generally occurs only on the esophageal side. fter this present case and before SEPS and fully covered SEMS were ntroduced, we would remove partially covered SEMS using the inersion technique as described by Low and Kozarek.2 Nevertheless, there have been complications similar to this case.3,4 More recently, removal of partially covered SEMS using a stent-in-stent technique has been described.5 Using this method a fully covered SEMS or SEPS is placed inside the partially covered SEMS to induce tissue necrosis between the esophageal lumen and the embedded stent in order to bring the uncovered portion of the SEMS to the luminal surface. Both stents are then removed during the endoscopic session 7 to 14 days later (Supplementary Video 1). We continue to use partially covered SEMS in patients with benign esophageal disease who have experienced repeated SEMS and/or SEPS migration and have not resolved their underlying disease process with removal of the partially covered SEMS using the stent-in-stent technique as described. To date we have removed 5 partially covered SEMS using this method without technical difficulty or adverse event.