Successful Salvages of Partially Covered Esophageal Metal Stent Using Repeated Sessions of Argon Plasma Coagulation

Abstract

Esophageal stents have utility in temporizing esophageal leaks and benign or malignant strictures, but their removal can be complicated by tissue embedment. Special methods for removal include argon plasma coagulation (APC) induction of tissue necrosis and stent-in-stent technique (SIS). APC is a non-contact thermal technology that uses argon gas to deliver plasma of thermal energy to an area adjacent to the probe, and it is widely used as a method to control bleeding. APC can be set at a precise setting to limit necrosis to the superficial layer of the esophageal mucosa. On the other hand, SIS utilizes a second esophageal stent that is placed within the first stent to induce necrosis of embedded tissue, enabling removal of both stents. We present two cases with successful removal of embedded, partially-covered self-expandable esophageal metal stents (SEMS) using APC at a precise setting of 50W. One case showed the flexibility of APC in removal of a migrated SEMS in a 75-year-old female patient with metastatic esophageal cancer. The stent had migrated into the stomach with the distal tip eroding into gastric mucosa with embedment of proximal stent into distal esophagus. Given the positioning, SIS was not possible. APC was used to induce necrosis of embedded tissue. Two days later, repeat APC treatment was performed with removal of the stent with grasping forceps<./p> The second case demonstrated the efficacy of APC in removal of a SEMS placed for an esophageal leak after sleeve gastrectomy in a 44-year-old female patient. A partially-covered SEMS was chosen to minimize migration. After esophageal leak resolution one month later, APC was used to induce tissue necrosis of areas of stent embedment. On repeat endoscopy, the esophageal stent was easily dislodged using blunt dissection with a plastic cap with minimal bleeding. We propose that APC is a superior technique for esophageal stent removal compared to the SIS. APC is more readily available with decreased cost compared to the SIS which requires a second stent. Placing a stent within another can be complicated by incomplete induction of necrosis, severe pain and tracheal compression. APC and SIS both require at least two separate days of endoscopy, but APC in our study has only needed an interval time of 2-4 days versus median time of 9-14 days for SIS. Given the small sample sizes, further investigation is needed to determine the optimal technique for esophageal stent removal.2115_A Figure 1. CT Scan of Abdomen showing esophageal stent migration with erosion into gastric fundus.2115_B Figure 2. #1 shows the migrated esophageal stent. #2 Induction of tissue necrosis with APC.