Esophageal Stent Migration Research Articles

Prevention of Migration of Esophageal Self-Expandable Metallic Stents Using Endoscopic Clips.

Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications.

Pleural migration of esophageal stent

Pleural migration of esophageal stent

Success rates of fixation techniques on prevention of esophageal stent migration: a systematic review and meta-analysis.

Esophageal stenting is an important intervention for managing malignant and benign dysphagia, with stent migration representing a common drawback. This systematic review with meta-analysis aimed to assess the benefit of stent fixation over nonfixation. A systematic search was performed in MEDLINE, Cochrane, Scopus, and ClinicalTrials.gov databases until January 2023 for comparative studies evaluating the migration rates of esophageal stents with versus without (control) fixation. The primary outcome was migration rate. Secondary outcomes included adverse event rate. A subgroup analysis stratified the results based on different fixation techniques: suturing, over-the-scope (OTS) clipping, and through-the-scope (TTS) clipping. Meta-analysis was based on a random effects model and the results were reported as odds ratios (ORs) with 95 %CIs. 10 studies (1014 patients) were included. The rate of stent migration was significantly lower after fixation (OR 0.20, 95 %CI 0.11-0.37; I2 = 59 %, P = 0.01). The adverse event rate was similar between fixation and control groups (OR 0.65, 95 %CI 0.28-1.52; I2 = 55 %, P = 0.06). In the subgroup analysis, all fixation techniques remained superior to nonfixation of stents (suturing OR 0.23, 95 %CI 0.10-0.53; OTS clips OR 0.31, 95 %CI 0.17-0.58; TTS clips OR 0.10, 95 %CI 0.03-0.38); however, only the OTS and TTS clip groups achieved nonsignificant heterogeneity (I2 = 0 %, P = 0.67 and P = 0.73, respectively). No difference between techniques was recorded for migration rates. Esophageal stent fixation was associated with significantly lower migration rates compared with nonfixation of stents, regardless of fixation technique and stenting indication.

Abstract 15622: Hydro-Pneumopericardium Due to Esophageal-Pericardial Fistula: A Rare Complication of Esophageal Stent Migration

Introduction: Esophageal-pericardial fistulas are rare complications of a variety of conditions ranging from benign esophageal disorders to iatrogenic etiologies such as radiofrequency catheter ablation. Here, we present a unique case of esophageal-pericardial fistula formation following esophageal stent migration in the setting of ulcerative esophagitis and benign esophageal stricture. Case Presentation: A 53-year-old woman with a history of ulcerative esophagitis and associated esophageal stricture was managed with esophageal stenting. Following stenting, her course was complicated by esophageal stent migration, resulting in severe dysphagia and multiple gastrointestinal bleeds requiring percutaneous endoscopic gastrostomy (PEG) tube placement. She presented with fatigue, melena, and dark output from her PEG tube and was hypotensive, tachycardic, and tachypneic. An echocardiogram (Figure 1A) showed hydro-pneumopericardium with cardiac tamponade physiology requiring emergent pericardiocentesis and aspirated fluid shown in Figure 1B. A subsequent computed tomography (CT) scan of the chest demonstrated a large complex pericardial effusion with air in the anterior pericardium, a large esophageal-pericardial fistula, and a moderate left hydropneumothorax (Figure 1C). Given the extent of her esophageal defect, the patient was taken for an esophagectomy with esophagostomy formation. Discussion: On review, we found only a few cases of hydro-pneumopericardium in the context of spontaneous pericardial herniation due to subcutaneous emphysema, radiofrequency ablation for atrial arrhythmias and esophagectomy for esophageal adenocarcinoma. However, there has been no report of esophageal-pericardial fistula due to esophageal stent migration. Conclusion: In an appropriate setting, clinicians should maintain a high index of suspicion for esophageal-pericardial fistulas, as delay in the management of these conditions could be fatal.

S2878 When One Stent Fails, Another One to the Rescue: A Novel Approach to Managing Small Post-Op Gastric Leaks Following Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a commonly used procedure in the surgical management of Obesity. However, post-op complications such as gastric leaks and their sequelae pose challenges. We present a case of a novel alternative in managing a small contained post-op gastric leak, which was difficult to define radiographically but was visible endoscopically causing the patient symptoms. Case Description/Methods: A 47 year old female with history of prior LSG, hiatal hernia, pernicious anemia presented for revision of her LSG for continued weight gain and hernia repair for dyspepsia. Surgery was uneventful but on post-op day 25 she developed fever (101.5 F), tachycardia (HR125), BP 131/74, RR 18, Sat 96%. Suspecting gastric leak, CT scan was performed which showed only extraluminal bubbles (Panel 1). Despite a negative upper GI series she was placed on prophylactic antibiotics and 3 days later an EGD performed confirmed the presence of pus 3-4 cm below GE junction consistent with an anastomotic leak. (Panel 2). A therapeutic 23 x 150 mm fully covered esophageal metal stent was placed , however 6 days later she developed nausea, vomiting and left upper quadrant pain. Abdominal x-ray showed distal migration of the esophageal stent confirmed by subsequent EGD (Panel 3). At that point, the stent was removed and a 7 Fr x 7 cm plastic double pigtail stent was placed into the abscess cavity for drainage of purulent fluid (Panel 4) into the stomach. Successful drainage of the abscess was achieved and confirmed by repeat EGD on post-op day 83 indicating normal gastric mucosa. The pigtail stent was subsequently removed. The patient has since been asymptomatic. Discussion: Endoscopic stenting has been widely used to manage post-op LSG gastric leak by closing off the cavity and draining extra-luminally. However, its migration causes significant patient discomfort, allows persistent fluid collection and abscess formation, delays healing and prolongs hospital stay. We propose a novel technique of mimicking a transgastric pseudocyst drain using a double pigtail plastic stent as an effective method of treating a small post-op LSG gastric leak after esophageal stent migration. In our patient, this technique hastened recovery, and decreased morbidity- related outcomes and hence this technique can be considered as future first line treatment.Figure 1.: (1) CT Ab/Pelvis arrowhead notes extraluminal bubbles near the GE Junction (arrowhead) (2) EGD showing white fluid (pus) 3 – 4 cms below the EG junction consistent with post-op LSG gastric leak (3) EGD showing increased pus anterior to tip of migrated stent (arrowhead) (4) Placement of double pigtail for successful drainage of purulent material.

Reduction of esophageal stent migration rate with a novel over-the-scope fixation device (with video)

Self-expandable metal stent (SEMS) placement is routinely performed in a variety of benign and malignant GI diseases. One of the most frequent adverse events after esophageal SEMS placement is stent migration. We evaluated a novel over-the-scope clip device (stentfix OTSC; Ovesco Endoscopy, Tuebingen, Germany) designed and approved for SEMS fixation. This single-center retrospective observational cohort study was performed to analyze stent migration ratesbefore and after availability of the stentfix OTSC device. A cohort of patients who consecutively underwent SEMS fixation with the stentfix OTSC system (SF cohort) was compared with an historical cohort of patients who did not receive stentfix OTSC fixation or any other stent fixation method (NF cohort) before the stentfix OTSC system became available. Outcome variables including technical success, adverse events and clinical success were analyzed. Seventy-seven patients (SF cohort, 26; NF cohort, 51) underwent esophageal SEMS implantation for malignant (69%) and benign (31%) conditions. The technical success rate of stent fixation was 100%, and no procedure-related adverse events were observed. The stent migration rate was significantly lower in the SF cohort compared with the NF cohort (8.3% vs 35.4%, P< .001), indicating a relative risk reduction of 76.5% associated with stentfix OTSC application. Stent implantation across the gastroesophageal junction was identified as a predictor of stent migration. In patients with benign or malignant gastroesophageal diseases, there was a significantly lower stent migration rate in patients managed with the stentfix OTSC system compared with those without stent fixation. The application was technically successful in all cases, and no adverse events related to clip application or removal were observed.

Use of loop and clips to prevent migration of esophageal stent.

Use of loop and clips to prevent migration of esophageal stent.

Esophageal stent migration to the transverse colon, entrapped within a hiatal hernia status post esophagectomy

Abstract Self-expandable metal stents are used in both benign and malignant esophageal conditions for the treatment of strictures, leaks and perforations. With this intervention, the most common complication is stent migration. Those in whom migration occurs are subject to additional procedures with significant risk. We present a unique case of stent migration in a 61-year-old male who underwent transhiatal esophagectomy secondary to esophageal adenocarcinoma. Postoperatively, two covered stents were applied to relieve anastomotic stricture and proximal esophageal occluding web. Several months thereafter, the initial stent was found to have migrated to the transverse colon subsequently entrapped in a hiatal hernia defect. Fortunately, the migrated stent was amenable to colonoscopic retrieval. As endoscopic stent use grows, it is important to recognize that covered stents may migrate through anatomic narrowing’s such as pylorus and ileocecal valve, but can also become entrapped in nonanatomic narrowing’s such as a hernia leading to further complications.

Fishing technique: A novel way to prevent oesophageal stent migration

AbstractSelf‐expandable metallic stent (SEMS) is commonly used in treating oesophageal disorders but migration is not uncommon. A special method, the Fishing technique, is introduced in this article to show how it works in a complicated oesophageal perforation case.

A novel technique to prevent migration of esophageal stent.

A novel technique to prevent migration of esophageal stent.

Anesthesia management of a rare case of esophageal ELLA stent migration causes intestinal obstruction

Anesthesia management of a rare case of esophageal ELLA stent migration causes intestinal obstruction

Esophageal Perforations: An Endoscopic Approach to Management.

Esophageal perforations are associated with high morbidity and mortality. As opposed to surgical repair, endoscopic closure techniques have emerged over the years as a more minimally invasive approach for management. Our goal is to discuss different modalities for closure. Through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), and esophageal stent placement are well known options for closure. We will also discuss the more recent technique of endoscopic suturing for closure of larger defects as well as prevention of esophageal stent migration. For mediastinal collections associated with perforations, a more novel endoluminal vacuum therapy (EVT) for drainage may be an option. Overall, there are several different endoscopic options that can tailored to the specific features of an esophageal perforation. This review will discuss various techniques with which a gastroenterologist or thoracic surgeon should be familiar.

1715 Esophageal Stent Causing Osteomyelitis: An Emerging Complication

INTRODUCTION: Esophageal stents are used to treat a wide variety of problems, most commonly malignant dysphagia as a form of palliation. Delayed complications include tumor ingrowth/overgrowth, stent migration, hemorrhage, and delayed perforation. We present a rare case of osteomyelitis secondary to a stent that was placed for the closure of a tracheoesophageal fistula. CASE DESCRIPTION/METHODS: A 55-year-old female presented with stage IV non-small-cell lung cancer with distant metastases. She was started on chemotherapy (gemcitabine and carboplatin) as well as immunotherapy (pembrolizumab). A bronchoscopy had revealed extensive cancer in the bronchial tree and detected a tracheoesophageal fistula, which required placement of an esophageal stent for closure. The stent had been repositioned twice for better location and patient comfort. Four months after the last stent, she presented with fevers, which was initially attributed to her malignancy. However, her symptoms eventually progressed to dysphagia, cough, chest and back pain. Serologic evaluation was notable for an elevated ESR at 112 and an elevated CRP of 105. Subsequent CT of the chest revealed erosive endplate changes at the T1-T2 vertebral level with soft tissue density adjacent to the proximal aspect of the stent. These findings were concerning for osteomyelitis in the setting of an esophageal stent erosion. The decision was made to reposition the stent endoscopically. EGD revealed that the proximal end of the stent was embedded into the esophageal wall without clear erosions or evidence of perforation. Attempt to reposition the esophageal stent was performed, but follow up CT revealed minimal change from endoscopic repositioning. No further endoscopic intervention was performed and she was treated for osteomyelitis with intravenous antibiotics. DISCUSSION: Few cases have reported osteomyelitis related to esophageal stent migration. Whether the stent-related osteomyelitis is potentiated by the effects of chemotherapy on the esophageal wall or related to pressure erosion caused by the stent is not entirely clear. With newer therapies for malignancies and increased life expectancies, new complications may emerge. The decision to perform endoscopic manipulation would largely depend on patients’ clinical status and a discussion of risks versus benefits in a case-based scenario. This case illustrates the importance of having a high index of clinical suspicion for osteomyelitis in a patient with previous esophageal intervention.

Valuing innovative endoscopic techniques: endoscopic suturing to prevent stent migration for benign esophageal disease

Reimbursement often presents a significant barrier to widespread adoption of innovative endoscopic devices. We aimed to determine the value (defined as cost savings to a payer) of endoscopic suturing devices in preventing the migration of esophageal stents placed for benign esophageal diseases. A decision-analytic model was constructed from a payer perspective evaluating fully covered metal stent placement for benign esophageal diseases (fistula, leak, perforation, or stricture) in a hospital outpatient setting. The model compared 2 strategies: endoscopic suturing to anchor the stent or no suture. Health care outcomes and costs were derived from published systematic reviews and national databases (U.S. Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] for safety data; 2018 Medicare Physician Fee Schedule and Provider Utilization and Payment Data databases for reimbursement data). From a payer perspective, reimbursement for care increased by US$1487.98 without endoscopic suturing per patient, compared with US$621.06 with endoscopic suturing, to cover the risk of stent migration in addition to usual professional and facility reimbursement for stent placement. Thus, an average cost saving of US$866.92 per patient was achieved with endoscopic suturing to reduce stent migration risks. Cost savings associated with suturing ranged from US$147.48 to US$1586.36 per patient, based on the indication for the procedure in sensitivity analysis. Cost savings increased with higher rates of technical success in suture placement. Creating a defined reimbursement pathway for endoscopic suture fixation of a stent for the treatment of benign esophageal diseases appears to be justified from a payer perspective.

DOZ047.14: Endoscopic incisional therapy and other novel strategies for treatment of congenital esophageal stenosis

Abstract Summary Management of congenital esophageal stenosis (CES) often involves dilation with reversion to myotomy or stricture resection in refractory cases.1,2 However, surgery often fails to produce durable response, with anastomotic strictures requiring ongoing dilation and stenotic symptoms plaguing more than half of the patients in published series.3 Methods In this study, the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and October 2018 were retrospectively reviewed. Success was defined as full when the diet included all age-appropriate textures with dysphagia once per month or less, or partial when the diet included most textures with dysphagia at most 1–2 times per week. Results Thirty patients with CES had at least one endoscopic intervention. All patients had balloon dilation(s) and at least one other therapy such as endoscopic incisional therapy (EIT), steroid injection, or stenting. Esophageal vacuum-assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Of patients who had EIT at their CES (N = 18), 14 (77.8%) achieved full (N = 13) or partial (N = 1) success with endoscopic therapy alone; 3 (16.7%) required surgery to achieve full (N = 3) success; 1 nonsurgical patient does not yet eat by mouth due to oral aversion. Of patients who did not undergo EIT at their CES (N = 12), 5 (41.7%) achieved full success with endoscopic therapy alone; 7 (58.3%) required surgery (2 full success, 4 partial success, and 1 does not eat by mouth due to airway comorbidities). The rate of surgical intervention was significantly lower in the group that received EIT (Fisher's exact test, P = 0.045). Twenty-five endoscopies (8.9%) were associated with complications, including esophageal leak (N = 21) or stent migration (N = 4). Of endoscopies with a complication, 16 (64%) involved EIT. Odds of complications after therapeutic endoscopies involving EIT were significantly higher than those without EIT (odds ratio 6.15; 95% CI (2.44, 15.52); P &lt; 0.001). The rates of esophageal leak significantly decreased over time as the use of EVAC increased (P = 0.003). Conclusion EIT shows promise as an alternative to surgery in CES; however, further study is needed. Complementary endoscopic techniques such as injection, stenting, and EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES.

Fully-covered esophageal stent migration rates in benign and malignant disease: a multicenter retrospective study.

Background and study aims Stent migration is a common complication of fully-covered self-expanding metal stents (FCSEMS), but the rate of clinically relevant migration as defined by stent migration followed by reintervention via endoscopy for stent replacement is unknown. The goal of this study is to gain insight into the total migration rate and clinically relevant migration rate of different types of FCSEMS placed within benign and malignant strictures with specific attention paid to stent manufacturer, diameter, and length. Patients and methods Multicenter retrospective analysis of endoscopic data from patients with FCSEMS placed within benign or malignant strictures. FCSEMS used included a variety of sizes and manufacturers. Results A total of 369 patients were included, 161 of whom had benign strictures and 208 of whom had malignant strictures. The total migration rate and clinically relevant migration rate in benign strictures were 30 % and 17 %, respectively. For benign strictures, Wallflex stents had a clinically relevant migration rate of 15 %, compared to Endomaxx stents with 19 %, and Evolution stents with 25 % ( P = 0.52). The total migration rate and clinically relevant migration rates in malignant strictures were 23 % and 14 %, respectively. Evolution stents had a significantly higher clinically relevant migration rate (29 %) than the Wallflex stents (7 %) and the endomaxx stents (12 %), P = 0.003. Conclusion This study is the largest to investigate migration rates for FCSEMS in benign and malignant strictures. Clinically relevant migration is a relatively common occurrence with all stent types studied and better anti-migration features are needed.

식도 스텐트 이동 및 내구성 시험을 위한 디자인과 실험적 분석

식도 스텐트 이동 및 내구성 시험을 위한 디자인과 실험적 분석

Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

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

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.

Esophageal Metallic-Stent Migration: a Rare Cause of Anal Pain in a Patient with Gastric Cancer.

Stents are a great development for esophageal fistula treatment; however, stent migration is a frequent complication. A stent migration that caused anal pain is presented. A 79-year-old man with poorly differentiated gastric carcinoma was submitted to a total gastrectomy with a Roux-en-Y esophagojejunostomy. The patient developed an anastomosis leakage 3 months after surgery; a fixed metallic stent was used as treatment with good evolution. Five months after the stent (and 8 months after gastrectomy), the patient returned to the emergency department with acute incapacitating anal pain; the pain was caused by the migrated stent. Esophageal stent migration is frequent; however, rarely, metallic stent migration may cause anal pain.