Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review

Background: Endoscopic stenting is a widely used method for managing esophageal anastomotic leaks and perforations. Self-expanding metal stents (SEMSs) have proved effective in sealing these defects, with a lower rate of displacement than that of self-expanding plastic stents (SEPSs) as a result of tissue proliferation and granulation tissue ingrowth at the uncovered portion of the stent, which anchor the prosthesis to the esophageal wall. Removal of a fully embedded stent is challenging because of the risk of bleeding and tears.

Materials and methods: Temporary placement of a new stent within the first stent (stent-in-stent technique) may facilitate the mobilization and safe removal of both stents by inducing pressure ischemia of the granulation tissue. We report our own experience with the stent-in-stent technique in five consecutive patients in whom a partially covered Ultraflex stent had previously been implanted and compare our results with those in the current literature.

Results: The first SEMSs remained in place for a median of 40 days (range 18 – 68) without displacement. Placement of the new stent was technically successful in all patients. All stents were left in place for a median of 9 days. The overall stent-in-stent success rate was 100 % for the removal of embedded stents. No serious adverse events related to the procedure occurred.

Conclusion: The procedure was safe, well tolerated, and effective. The use of a partially covered Ultraflex stent of the same size as the old stent for a limited time (≤ 6 days) was consistently successful.

• References

• 1 Pross M, Manger T, Reinheckel T et al. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc 2000; 51: 73-76
• 2 Siersema PD, Homs MY, Haringsma J et al. Use of large-diameter metallic stents to seal traumatic non-malignant perforations of the esophagus. Gastrointest Endosc 2003; 58: 356-361
• 3 Evrard S, Le Moine O, Lazaraki G et al. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004; 60: 894-900
• 4 Eisendrath P, Cremer M, Himpens J et al. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy 2007; 39: 625-630
• 5 Siersema PD, Hirdes MM. What is the optimal duration of stent placement for refractory, benign esophageal strictures?. Nat Clin Pract Gastroenterol Hepatol 2009; 6: 146-147
• 6 Tunçözgür B, Savaş MC, Işik AF et al. Removal of metallic stent by using Polyflex stent in esophago-colic anastomotic stricture. Ann Thorac Surg 2006; 82: 1913-1914
• 7 Gelbmann CM, Ratiu NL, Rath HC et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 2004; 36: 695-699
• 8 Ott C, Ratiu N, Endlicher E et al. Self-expanding Polyflex plastic stent in esophageal disease: various indications, complications, and outcomes. Surg Endosc 2007; 21: 889-896
• 9 Radecke K, Gerken G, Treichel U. Impact of a self-expanding, plastic esophageal stent on various esophageal stenosis, fistulas, and leakages: a single-center experience in 39 patients. Gastrointest Endosc 2005; 61: 812-818
• 10 Freeman RK, Van Woerkom JM, Vyverberg A et al. Esophageal stent placement for the treatment of spontaneous esophageal perforations. Ann Thorac Surg 2009; 88: 194-198
• 11 Pennathur A, Chang AC, McGrath KM et al. Polyflex expandable stents in the treatment of esophageal disease: initial experience. Ann Thorac Surg 2008; 85: 1968-1972
• 12 Silva RA, Dinis-Ribeiro M, Brandao C et al. Should we consider endoscopic clipping for prevention of esophageal stent migration?. Endoscopy 2004; 36: 369-370
• 13 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
• 14 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
• 15 Vasilikostas G, Sanmugalingam N, Khan O et al. 'Stent in a stent' – an alternative technique for removing partially covered stents following sleeve gastrectomy complications. Obes Surg 2014; 24: 430-432