BURIED LUMEN-APPOSING METAL STENT (LAMS) IN ESOPHAGO-GASTRIC ANASTOMOSIS: THE LAMS-IN-LAMS RESCUE TREATMENT

A 61-year-old man presented with progressive dysphagia and post prandial vomiting one year after undergoing esophago-gastric anastomosis for adenocarcinoma of the gastroesophageal junction. Upper endoscopy revealed a high grade, 1 cm long anastomotic stricture at 25 cm from incisors which failed to respond to multiple, serial 15 mm balloon dilation sessions. He subsequently underwent uneventful 15 mm diameter lumen apposing metal stent ((LAMS), Axios, Boston Scientific, Marlborough, MA) placement. This resulted in complete resolution of his symptoms. At six month follow up endoscopy, almost the entire LAMS was found to be embedded with significant tissue overgrowth. A second 15 mm LAMS was placed with “stent within stent” technique, completely overlapping the first LAMS. During three month follow up endoscopy, both LAMS were easily removed in an atraumatic fashion using a rat-tooth forceps. Post removal inspection of the first LAMS revealed complete disintegration of the coating which led to its embedding due to the prolonged in-dwell time.

Tissue overgrowth resulting in embedding of LAMS is a rare complication. It results from the foreign body reaction when used for the management of benign strictures. In the setting of benign tissue hyperplasia, forcible removal of the stent has been reported to cause luminal perforation. Thus, the "stent in stent" technique for removal of embedded covered metal stents has gained the best acceptance among the endoscopists. This technique involves placement of another stent covering in its entirety the inside of the trapped stent. This second stent should be of the same diameter, in order to achieve tissue necrosis of the hyperplasia resulting in easy, atraumatic removal of embedded stent. To our knowledge, this is the first report of successful removal of embedded LAMS using stent within stent technique.