Plastic tube-assisted gastroscopic removal of embedded esophageal metal stents: A case report
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Abstract:
A patient with stent embedding after placement of an esophageal stent for an esophagobronchial fistula was treated with an ST-E plastic tube inserted into the esophagus to the upper end of the stent using gastroscopy.The gastroscope was guided into the esophagus through the ST-E tube,and an alligator forceps was inserted into the esophagus through the ST-E tube alongside the gastroscope.Under gastroscopy,the stent wire was grasped with the forceps and pulled into the ST-E tube.When resistance was met during withdrawal,the gastroscope was guided further to the esophageal section where the stent was embedded.Biopsy forceps were guided through a biopsy hole in the gastroscope to the embedded stent to remove silicone membranes and connection threads linking the Z-shaped wire mesh.While the lower section of the Z-shaped stent was fixed by the biopsy forceps,the alligator forceps were used to pull the upper section of the metal wire until the Z-shaped metal loops elongated.The wire mesh of the stent was then removed in stages through the ST-E tube.Care was taken to avoid bleeding and perforation.Under the assistance of an ST-E plastic tube,an embedded esophageal metal stent was successfully removed with no bleeding or perforation.The patient experienced an uneventful recovery after surgery.Plastic tube-assisted gastroscopic removal of embedded metal stents can be minimally invasive,safe,and effective.Keywords:
Esophageal stent
Perforation
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The incidence of caudal stent migration in high tracheal stenting is 13-21% and is common with silicone stents. This can lead to major problems, including emergency repeat procedures. Several antimigration methods are described, but have limitations in terms of their success rate, availability, cost or ease of the procedure.We describe an innovative method of stent migration prevention using a simple percutaneous anchoring "hitch stitch", validated in a large series.After tracheal stent placement, an Ethilon suture was passed into the stent lumen through an 18-G needle. To take this suture back to the exterior to complete the stitch, a retrieval loop was passed through another 14-G percutaneous cannula inserted into the stent lumen. Bronchoscopically, using a forceps the first suture was pulled inside the loop, the loop was retracted, the suture was exteriorized, and the knot was completed and embedded subcutaneously. While removing the stent, an endoscopic scissor was used to cut the stitch to free the stent.A total of 42 "hitch stitches" were done in 29 patients over 5 years, predominantly for silicone stents. Indications for stenting included postintubation tracheal stenosis (83.3%), malignancy (11.9%) and tracheoesophageal fistula (4.8%, metal stents). The procedure was successful in 41/42 (97.6%) patients. Stitch removal was uncomplicated.This is the largest series of an external stent anchoring procedure as a migration prevention strategy in high tracheal stenting, applicable to both silicone and metal stents. Stent migration prevention using this "hitch stitch" is simple, safe and successful, without any complications during stent removal.
Polydioxanone
Lumen (anatomy)
Tracheomalacia
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Hook
Cystostomy
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There is little experience regarding the use of argon plasma coagulation (APC) to trim malpositioned or migrated, endoscopic, metallic, self-expanding, colorectal stents. We report a case of a distally migrated, uncovered rectal stent complicated with several ulcerations because of impaction against the rectal wall and embedment within the healthy mucosa distal to the neoplasm. Endoscopic en bloc removal was not possible because of diffuse tumoral ingrowth. By using a second generation APC device (60 W, 0.6 L/min), the stent was trimmed allowing access to the back wall, which was tailored after digging up the embedded wires with gentle traction of the stent. Complete extraction of the protruding end of the stent by a 2.5 cm, fully covered pseudoepithelization tissue, was carried out through a flexible overtube. This is the first report of APC endoscopic transection of a long embedded segment from a distally migrated colorectal stent.
Impaction
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Recently, expandable metalic stents have been used to hold the lumen of large vessels, the bile duct, urinary tract, and so on. A rare case of tracheo-gastric tube fistula caused by an expandable metalic stent was reported. A 61-year-old male underwent an operation for thoracic esophageal cancer and his thoracic esophagus was reconstructed using a gastric tube. After the operation, a tracheo-gastric tube fistula was caused by a peptic ulcer of the gastric tube, followed by atelectasis of the left lung. Expandable metalic stents were inserted into his trachea and left main bronchus. Since a part of one of these stents penetrated the ulcer into the gastric tube lumen, the fistula did not close spontaneously. After cutting this part of the stent using a specially designed forceps through hard esophagoscopy, the fistula closed.
Lumen (anatomy)
Chylothorax
Fistulectomy
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Hook
Meatus
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Bronchopleural fistula
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Treating thoracic cavity fistula with covered esophageal stent through nasal esophagus drainage tube
Objective To explore the feasibility and value of treating esophageal thoracic fistula with covered esophageal stent through nasal esophagus drainage tube. Methods Seven patients with esophageal thoracic cavity fistula were enrolled and treated by 5F pigtail side-holes catheter inserting into thoracic cavity for drainage and then again through nasal esophagus and fistula, placing a covered stent in the esophagus to occlude the orifice of the fistula. The abscess cavities were washed and radiographied periodically through drainage tubes. Results The insertion of the drainage tube and the placement of covered stent were all successful. The drainage tubes were placed in abscess cavities for 12-22 days, average 15 days. The radiography through drainage tubes showed that the abscess cavities disappeared or shrank obviously with control of hydropneumothorax before the drainage tubes being pulled out. The esophagogram after withdrawal of the drainage tubes notified that the fistulae were occluded satisfactorily with stents expanded fully without displacement and stenosis. Conclusions Treating esophageal thoracic cavity fistula with covered esophageal stent through nasal esophagus drainage tube is feasible and safe with clinical efficiency.
Thoracic cavity
Esophageal stent
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An 84-year-old woman with history of carcinoma of the papilla of Vater, in which percutaneous transhepatic stent was placed, was admitted to our hospital with a complaint of fever. The patient was diagnosed as cholangitis. Immediate endoscopy examination revealed that the stent was projecting long and distal side of the stent had been embedded into the duodenal wall which located opposite to the papilla of Vater. Because of tumor in-growth, removal of the stent was impossible. In the literature, as well-known, endoscopic section of migrated stent using argon plasma coagulation (APC) is useful. However, the risk of the duodenal mucosa injury was the matter because the stent was embedded. We removed the distal side stent which is embedded to the duodenal wall using biopsy forceps without any complication. Afterwards we put covered stent into the original metallic stent with stent-in-stent manner. We conclude that biopsy forceps is safe and useful to dissect an embedded uncovered biliary stent.
Major duodenal papilla
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Objective To study how to prevent stent migration in patients with nonobstructive esophageal fistula treated by using modified covered self-expandable metal stent.Methods Twenty one cases of various types of esophageal fistula received unusual esophageal stenting.The structural and functional characteristics of this modified covered self-expandable metal stent with Shim's technique were as following: the uncovered proximal flange of the stent could be embedded into the esophageal mucosa in order to avoid delayed migration, before the growth of granulation tissue, the stent can be fixated by using a silk thread attached to the edge of the proximal end of the stent to the patient's ear via the nares.Results The fistulae in 19 cases were immediately sealed after the intervention, and the leakage in other 2 cases also disappeared after 1 week. Neither early nor delayed migration was found in 21 cases.Conclusion Compared to ordinary self-expandable covered stent, modified covered self-expandable stent can not only close esophageal fistula, but also solve migration problem.
Esophageal stent
Granulation tissue
Self-expandable metallic stent
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