Esophageal stent removal by stent cutting using the endoscopic submucosal dissection technique

The European Society of Gastrointestinal Endoscopy recommends temporary esophageal stenting for the treatment of benign esophageal leaks, but there is no consensus on the duration of stent placement [1]. Prolonged stenting can result in tissue hyperplasia that makes removal difficult, and forcible removal can cause esophageal perforation requiring surgery [2]. There are reports that a stent-in-stent approach enables stent removal [3], but it involves the cost of another stent. Argon plasma coagulation (APC) and an endoscopic submucosal dissection (ESD) knife are used to resect hyperplasia and reportedly allow stent removal [4] [5]. We unsuccessfully attempted to cut a stent using APC and completed the procedure by switching to an ESD knife. There are no reports of cutting gastrointestinal stents with an ESD knife and we report the procedure herein ([Video 1]).

Video 1 Stent cutting using endoscopic submucosal dissection technique.

A covered esophageal stent (Niti-S Esophageal ComVi Stent 18 × 100 mm; TaeWoong Medical, Gimpo-si, South Korea) was implanted in a 76-year-old woman for leakage at the esophageal jejunal anastomosis after proximal gastrectomy ([Fig. 1], [Fig. 2]). The leak improved after 4 months and stent removal was attempted, but the proximal and distal flared ends were embedded in the hyperplastic esophageal wall and could not be removed.

Fig. 1 Image of the leak. Contrast leakage is observed (arrow).

Fig. 2 Image of esophageal stenting: stent is implanted, and the leak area is covered (arrow).

We used a GIF-Q260 J (Olympus, Tokyo, Japan) scope with tip attachment and a VIO-300 D (Erbe Elektromedizin GmbH, Tübingen, Germany). APC was set at Forced APC flow rate of 2 L/min, 100 W. Effective stent cutting on the distal side was not possible because the working space was too narrow for selective discharge by APC. Therefore, we changed to a Dual Knife J (Olympus), setting it to Swift coagulation mode effect 4, 40 W. While cutting with the ESD knife, it was important to keep a small distance between the tip of the knife and the stent, and to be aware that the knife was cutting with a discharge. Using the ESD knife, the metal parts could be cut selectively and the cover parts easily. The stent was removed by cutting circumferentially.

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• References

• 1 Spaander MCW, van der Bogt RD, Baron TH. et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) guideline update 2021. Endoscopy 2021; 53: 751-762
• 2 Hirdes MM, Vleggaar FP, Van der Linde K. et al. Esophageal perforation due to removal of partially covered self-expanding metal stents placed for a benign perforation or leak. Endoscopy 2011; 43: 156-159
• 3 Aiolfi A, Bona D, Ceriani C. et al. Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review. Endoscopy Int Open 2015; 3: E296-299
• 4 Fiocca F, Cereatti F, Antypas P. et al. Argon plasma coagulation: a less-expensive alternative to the ‘stent-in-stent’ technique for removal of embedded partially covered esophageal stents. Gastrointest Endosc 2016; 83: 453
• 5 Chon SH, Ramadori E, Pinto Dos Santos D. et al. Endoscopic removal of a fractured esophageal stent from the mediastinum and leak closure with endoscopic vacuum therapy. Endoscopy 2022; 54: 334-335