Commentary

Esophageal leaks can be effectively managed by self-expanding metal stent placement. However, safe stent removal may be complicated, especially in cases where the stent has become embedded in the esophageal wall. The authors in this E-Video were successful in removing an embedded stent that had also partially migrated into the mediastinum. The remaining leak was successfully closed with endoluminal vacuum therapy (EVT).

What are the take-home messages from this case? First, the risk of stent embedment has been reported to be higher with partially covered than with fully covered stents, especially when placed for a period longer than 3–4 weeks [1]; however, this case illustrates that stent embedment is also possible with fully covered stents. Second, what to do when stents are embedded and need to be removed? A decision can be made to leave the embedded stent in place, for example in elderly patients with severe comorbidity. One can also destroy the reactive tissue ingrowth with argon plasma coagulation or electrocoagulation and remove the stent when it is loose enough to be safely extracted. A third option is to insert a second, fully covered stent inside the embedded stent at the level of the reactive tissue, to induce pressure necrosis (the stent-in-stent technique) [2]. The fully covered stent inside the originally inserted stent will induce ischemia of the reactive tissue. Both the embedded and the second fully covered stent can then safely be removed after a stenting period of 7–14 days. Finally, this case nicely illustrates that EVT is increasingly becoming an effective strategy in patients with esophageal leaks and perforations, with a recent meta-analysis suggesting that the rate of successful closure may be even higher with EVT than with stent placement [3]. Appropriately designed studies are however required.

Publication History

Article published online:
24 February 2022

• References

• 1 Siersema PD, Homs MY, Haringsma J. et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003; 58: 356-561
• 2 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
• 3 Scognamiglio P, Reeh M, Karstens K. et al. Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis. Endoscopy 2020; 52: 632-642