Esophageal perforation due to removal of partially covered self-expanding metal stents placed for a benign perforation or leak

Abstract

Benign esophageal perforations and anastomotic leaks can be effectively managed by stent placement. However, when partially covered self-expanding metal stents (SEMS) are used, safe removal may be complicated. In this case series, we evaluated the complicated removal of SEMS placed for a benign esophageal perforation or leak in four patients. In all patients a partially covered SEMS was placed. After a median stent time of 29 days (range 21 - 30), the SEMS were found to have become embedded in the esophageal wall. Endoscopic removal resulted in perforation in all patients. All patients recovered uneventfully, although one patient underwent esophagectomy. If uncovered SEMS ends become embedded, removal of the stent may cause major damage to the esophageal wall. It is therefore recommended to remove embedded partially covered SEMS only after first placing a fully covered SEMS or self-expanding plastic stent inside this stent to necrotize the ingrown tissue at the uncovered stent ends.

Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents

“…Use of PCSEMS in the treatment of benign diseases is controversial due to the adverse events described during their removal [3,9,17,21,[26][27][28][29][30]. These adverse events may include: hemorrhage, granulation or hyperplasic tissue ingrowth, obstruction, stent fracture, penetration, perforation, avulsion, fistula formation (i.e., tracheoesophageal, esophagoaortic, pericardioesophageal), and epidural abscess formation [1,3,11,17,19,28,[31][32][33][34][35][36][37].…”

“…These adverse events may include: hemorrhage, granulation or hyperplasic tissue ingrowth, obstruction, stent fracture, penetration, perforation, avulsion, fistula formation (i.e., tracheoesophageal, esophagoaortic, pericardioesophageal), and epidural abscess formation [1,3,11,17,19,28,[31][32][33][34][35][36][37]. Despite these risks, PCSEMS have been used to treat benign esophageal diseases such as caustic strictures, leaks, fistulas and perforations, especially in patients with a prior history of stent migration [28,[38][39][40].…”

“…However, the uncovered portions of the stent act to anchor the stent in place, and also may act as a catalyst for granulation or hyperplastic tissue growth to ''seal off'' a leak or perforation [3,[14][15][16][17][18] (Fig. 1).…”

A new fully covered metal stent for the treatment of benign and malignant dysphagia: a prospective follow-up study

“…5,6,10 On the other hand, the use of PC SEMSs for benign indications must be avoided because of the risk of stent embedding and subsequent complications during removal. 1,4 A new stent design, which was reported to migrate less often and does not need to be removed, is the biodegradable ELLA stent. Recent data have shown migration rates of approximately 10%.…”

“…2,3 This hyperplastic reaction may even occur within a limited time period and could lead to the embedding of the uncovered metal wires in the esophageal wall, which may preclude safe stent removal. 4 The complete covering of newer FCSEMSs, such as the Alimaxx-E (Merit Medical Endotek, South Jordan, Utah), may prevent stent embedding and therefore has been suggested to be a safer treatment option for benign esophageal disorders. 5,6 In malignant diseases, the use of FCSEMSs may also have some benefits.…”