Endoscopy 2012; 44(S 02): E232
DOI: 10.1055/s-0032-1306795
Unusual cases and technical notes
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic removal of a broken self-expandable metal stent using the stent-in-stent technique

P. Didden
Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
,
E. J. Kuipers
Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
,
M. J. Bruno
Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
,
M. C. W. Spaander
Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
› Author Affiliations
Further Information

Corresponding author

M. C. W. Spaander
Department of Gastroenterology and Hepatology
Erasmus University Medical Center
’s Gravendijkwal 230
3015 CE Rotterdam
The Netherlands   
Fax: +31 10 7035172   

Publication History

Publication Date:
19 June 2012 (online)

 

A 55-year-old man with dysphagia due to an unresectable distal esophageal adenocarcinoma underwent placement of a 15-cm partially covered self-expandable metal stent (SEMS), diameter 18 mm (Ultraflex; Boston Scientific, Natick, Massachusetts, USA). After 3 months, he presented with recurrent dysphagia. At endoscopy, the meshes of the SEMS had broken, leading to collapse of the SEMS and obstruction of the lumen ([Fig. 1]). Because the patient’s clinical condition had improved and further treatment with chemotherapy or radiotherapy was considered, we decided to remove the SEMS using the stent-in-stent technique. A second SEMS, 17-cm long, fully covered, diameter 20 mm (Hanaro, M. I. Tech, Korea) was inserted, overlapping the full length of the first SEMS. After 2 weeks, on endoscopic examination, the loose struts of the disrupted SEMS had perforated the covering of the fully covered SEMS, and the radial pressure of the fully covered SEMS had succeeded in detaching the partially covered SEMS from the esophageal wall and tumor ([Fig. 2]). By pulling the proximal retrieval lasso of the fully covered SEMS, both SEMSs were extracted simultaneously without the need to exert much force.

Zoom Image
Fig. 1 Endoscopic image of one of the broken wires which resulted in collapse of the self-expandable metal stent (SEMS).
Zoom Image
Fig. 2 The broken wires of the first self-expandable metal stent (SEMS) have perforated the covering of the second SEMS.

Examination of the retrieved stents showed they were strongly attached to each other, indeed with loose struts of the first stent perforating the covering of the fully covered SEMS ([Fig. 3]). Immediately after removal of both stents, no esophageal stenosis was observed. The post-procedural course was uneventful, and the patient is currently without dysphagia.

Zoom Image
Fig. 3a Fully covered self-expandable metal stent (SEMS) strongly attached to the partially covered SEMS. b Close-up of the end of the partially covered SEMS with a loose wire.

Spontaneous fracture with collapse of an esophageal SEMS is a rare complication [1] [2]. However, if a SEMS is extracted by pulling its upper or lower end, and traction is forceful, as in the case of (partial) stent ingrowth, the struts may break causing the metal wire mesh to become disrupted. When the struts are already broken, it seems likely that by pulling on one end of the SEMS, the metal framework will be destroyed even further, making it impossible to remove the SEMS all in one. In such cases, the stent-in-stent technique is a simple and safe method to facilitate removal of embedded stents in benign disease [3]. This is the first report of removal of a broken SEMS using the stent-in-stent technique. It appears to be simple, safe and effective, also in malignant disease.

Endoscopy_UCTN_Code_TTT_1AO_2AZ


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Competing interests: None

  • References

  • 1 Homs MY, Steyerberg EW, Kuipers EJ et al. Causes and treatment of recurrent dysphagia after self-expanding metal stent placement for palliation of esophageal carcinoma. Endoscopy 2004; 36: 880-886
  • 2 Rana SS, Bhasin DK, Sidhu GS et al. Esophageal nitinol stent dysfunction because of fracture and collapse. Endoscopy 2009; 41: E170-E171
  • 3 Hirdes MM, Siersema PD, Houben MH et al. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol 2011; 106: 286-293

Corresponding author

M. C. W. Spaander
Department of Gastroenterology and Hepatology
Erasmus University Medical Center
’s Gravendijkwal 230
3015 CE Rotterdam
The Netherlands   
Fax: +31 10 7035172   

  • References

  • 1 Homs MY, Steyerberg EW, Kuipers EJ et al. Causes and treatment of recurrent dysphagia after self-expanding metal stent placement for palliation of esophageal carcinoma. Endoscopy 2004; 36: 880-886
  • 2 Rana SS, Bhasin DK, Sidhu GS et al. Esophageal nitinol stent dysfunction because of fracture and collapse. Endoscopy 2009; 41: E170-E171
  • 3 Hirdes MM, Siersema PD, Houben MH et al. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol 2011; 106: 286-293

Zoom Image
Fig. 1 Endoscopic image of one of the broken wires which resulted in collapse of the self-expandable metal stent (SEMS).
Zoom Image
Fig. 2 The broken wires of the first self-expandable metal stent (SEMS) have perforated the covering of the second SEMS.
Zoom Image
Fig. 3a Fully covered self-expandable metal stent (SEMS) strongly attached to the partially covered SEMS. b Close-up of the end of the partially covered SEMS with a loose wire.