PERFORATION AFTER BALLOON DILATION OF ACHALASIA TREATED WITH SELF-EXPANDING METAL STENT: MY AWFUL DAY!

A 72-year old man with achalasia underwent balloon dilation. Following dilation there was a huge and deep laceration. No contrast extravasation was seen. However, the laceration was deep and there was concern for microperforation. Therefore, we decided insert a fully-covered self expanding metal stent (fcSEMS). The fcSEMS was placed in correct position and the patient was admitted to the hospital, where he remained stable for 24 hours, after which he was discharged home in stable condition. The plan was to electively remove the stent in 2 weeks. The patient, however, returned after one week with massive vomiting. Upon EGD the stent had slipped and migrated distally, embedding into the stomach, blocking the transit of the food bolus or liquids. The stent was deeply embedded, and various efforts to remove it proximally were futile. These efforts included grasping the stent with snares and various types of forceps. Finally, after tightly grasping the proximal part of the fcSEMS with a rat tooth forceps and constant, but gentle pulling using a torque-like movement and rotation, it was possible to disengage the stent from the stomach and esophageal attachments. Upon visualization of the proximal part of the fcSEMS coming out of the hypopharynx, victory was declared, but suddenly the forceps lost the stent, the stent slid back into the hypopharynx and esophagus. Nevertheless, the quick reaction of the nurse assistant saved the situation, as her quick fingers grabbed the stent. Evidently, the game was not over, as once the proximal third of the stent was out of the mouth of the patient, the patient started to wake up from sedation and his strong teeth closed tightly around the stent. Gentle action by the entire team finally convinced the patient to release the stent and put an end to this awful day.