Endoloop application for the removal of a self-expandable metallic stent (SEMS) in an esophagocolonic anastomotic stricture

Anastomotic strictures occur in 3 % – 46.2 % of patients after colonic reconstruction of the esophagus [1]. Self-expanding metal stents (SEMS) are increasingly considered for refractory or complex benign strictures of the esophagus [2]. Migration is a common complication and the stent should be removed to avoid gastrointestinal complications.

A 54-year-old man was referred to our department for dysphagia following esophagectomy with colonic interposition to treat an esophageal adenocarcinoma. On esophagoscopy, a 5-mm wide and 3-cm long stricture, corresponding to the esophagocolonic anastomosis at 25 cm from the incisors, could not be traversed. After five dilation sessions at 2-week intervals the patient was still dysphagic and a fully covered stent (HanaroStent, 80 mm in length, 18 mm in diameter; MI Tech, Seoul, Korea) was positioned. The patient reported clinical improvement for 2 weeks but then the dysphagia recurred. Radiographic examination disclosed stent migration. Endoscopy confirmed its location at the distal part of the colonic segment, proximal to the cologastric anastomosis, and the persistence of the proximal anastomotic stenosis. We decided to re-dilate the stenosis up to 15 mm ([Video 1]), and mobilize the stent proximally and try to remove it using endoloops to reduce the stent diameter. With the stent positioned in the colonic segment, four detachable ligating devices (MAJ 254; Olympus, Tokyo, Japan) were applied. Because of the eversion of its distal edge and the risk of the stent getting caught in the tissue, it was rotated and then retrieved by utilizing the “lasso” stitch at the stent edge and pulling it against the endoscope. The whole assembly was subsequently removed under fluoroscopic control through the stricture without complications.

Removal of a migrated self-expandable metallic stent (SEMS) with endoloop application. The use of endoloops reduced the stent diameter and permitted its retrieval through an esophagocolonic anastomotic stricture.

The removal of migrated SEMS is technically challenging and different methods have been reported, including the use of endoloops [3] [4] [5]. To our knowledge this is the first video report of a stent retrieved from an esophagocolonic anastomosis.

Endoscopy_UCTN_Code_TTT_1AO_2AZ

Competing interests: None

• References

• 1 Yasuda T, Shiozaki H. Esophageal reconstruction with colon tissue. Surg Today 2011; 41: 745-753
• 2 Siersema PD. Stenting for benign esophageal strictures. Endoscopy 2009; 41: 363-373
• 3 Seitz U, Thonke F, Bohnacker S et al. Endoscopic extraction of a covered esophageal Z-stent with the aid of endoloops. Endoscopy 1998; 30: S91
• 4 Molina-Infante J, Fernandez-Bermejo M, Perez-Gallardo B. Removal of a migrated covered metallic stent through an esophageal stricture, with multiple endoloops. Endoscopy 2010; 42: E268-E269
• 5 An HJ, Lee HY, Kim BW et al. Endoscopic removal of a migrated esophageal self-expandable metal stent after compression with detachable snares through an intact esophageal stent. Gastrointest Endosc 2010; 71: 205-207