Biodegradable stents are increasingly used to treat benign gastrointestinal strictures
[1]
[2]. Here, we report on two patients who developed persistent vomiting after thoraco-abdominal
esophageal resection for cancer and perforation. Assessments by endoscopy and imaging
studies demonstrated a severe stricture of the distal gastric conduit in both patients
([Fig. 1]), which were thought likely to be due to low-flow ischemia of the gastric conduit.
Fig. 1 Radiographic images showing: a complete stenosis within the distal gastric conduit in patient 1 (black arrow) with
no further flow of the contrast agent delivered through a nasogastric tube apparent;
b a long stenosis of the distal gastric conduit in patient 2 (white arrowheads).
The treatment of both patients was identical. Because balloon dilation (20-mm CRE
Wireguided Balloon Dilator; Boston Scientific, Galway, Ireland) had not produced an
improvement in symptoms, a 10-cm long biodegradable stent (BD Ella; Ella-CS, s.r.o.,
Hradec Králové, Czech Republic) was placed.
Patient 1 became immediately symptom-free and remained so 12 months later. The stent
was fully resorbed after 16 weeks.
In contrast, patient 2 experienced persistent grade 4 dysphagia due to insufficient
stent expansion ([Fig. 2 a]) as the stenosis was too rigid for the maximal expansive capacity of the stent.
Follow-up imaging and endoscopy revealed progressive stenosis due to stent-induced
hypergranulation ([Fig. 2 b] and [Fig. 3]), a rare complication after the use of biodegradable stents that was also observed
in some earlier studies [1]
[3]
[4]. Despite repeated balloon dilation to 20 mm, the grade 4 dysphagia persisted. After
13 weeks, the stent was fully resorbed. The stenotic area was slightly enlarged compared
with the situation before placement of the stent, but was still considerably smaller
than the original lumen of the gastric conduit. A small, 1 to 2-cm long segment with
a high-grade stenosis remained in the middle of the conduit, probably a remnant of
the hypergranulation ([Fig. 4]). Repeated balloon dilation to 20 mm at monthly intervals resulted in a progressive
improvement over the course of 6 months ([Fig. 5]). Thereafter, the patient was able to eat semisolid foods, consistent with grade
2 dysphagia.
Fig. 2 Images from contrast swallow studies performed in patient 2 showing: a partial stent expansion 1 day after stent placement due to the rigidity of the stenosis
(white asterisks indicate radiopaque markers); b hypergranulation-induced progressive stenosis in the stent area 3 weeks after stent
placement (white arrows).
Fig. 3 Views during endoscopic examinations performed in patient 2 showing: a hypergranulation with the mesh in the middle of the stent still visible (black arrow)
3 weeks after its placement; b hypergranulation that completely covers the mesh in the middle of the stent 5 weeks
after placement. The whole stent is still present.
Fig. 4 Image from a contrast swallow performed before balloon dilation to 20 mm, which reveals
a long relatively mild stenosis (black arrowheads) with a short (2-cm long) markedly
stenotic section (black arrow). The gastric wall contains lipiodol, which had been
previously injected to mark the stenosis (*).
Fig. 5 View during an endoscopy performed in patient 2 some months later showing hypergranulation-induced
stenosis prior to balloon dilation. Proximal to the stenosis, a raised area of granulation
tissue is visible (black arrow), which was formed by the mesh of the now degraded
stent.
Placement of biodegradable stents is an emerging and promising treatment alternative
for benign esophageal strictures, but if stenosis due to stent-induced hypergranulation
occurs, significant morbidity ensues.
Endoscopy_UCTN_Code_CPL_1AH_2AD
