Cryotherapy for removal of an embedded, partially covered esophageal stent

Video

Video 1

Cryotherapy for removal of an embedded, partially covered esophageal stent.

Esophageal stents are used to relieve obstruction in diverse benign and malignant esophageal conditions. There are 3 types of esophageal stents (self-expanding metal stents [SEMS]): uncovered, fully covered, and partially covered. Partially covered SEMS (PC-SEMS) have a lower risk of migration because their bare metal ends allow better embedding in the esophageal wall.¹ This is a significant advantage considering that stent migration is the most common adverse event of esophageal stent placement.² However, excessive granulation tissue may make the removal of such stents challenging and thus increases the risk of adverse events such as bleeding and mucosal tear.³ Various methods to remove embedded PC-SEMS, such as stent-in-stent technique, argon plasma coagulation (APC), piecemeal extraction, and retrieval using rat-tooth forceps, have been described in literature.⁴ The role of cryotherapy in retrieval of embedded stents has not been studied well. A recent case report demonstrated the use of cryotherapy to assist the stent-in-stent technique in removal of an embedded stent.⁴ We report a case in which cryotherapy was used to remove an embedded PC-SEMS after failure of stent-in-stent technique, endo-loop cutter, and APC (Video 1, available online at www.giejournal.org).

A 40-year-old man was diagnosed with distal esophageal adenocarcinoma about 2 years prior to the procedure. He presented with epigastric pain and dysphagia 2 months after placement of a PC-SEMS (23 × 155 mm) (Fig. 1). His physical exam was notable for a tender mass in the epigastrium. Otherwise, the abdomen was soft and no rebound tenderness was appreciated. Labs were remarkable for iron deficiency anemia. A CT scan of the abdomen showed distal migration of the esophageal stent with possible perforation of the gastric wall (Fig. 2).

Figure 1.

Barium esophagram after initial stent placement confirmed appropriate position.

Figure 2.

A CT scan showing a migrated esophageal stent embedded in stomach wall.

An upper endoscopy showed distal migration of the stent along with embedding of the distal end in the gastric wall resulting in partial obstruction. On retroflexed view, the distal end was seen embedded in a granulomatous mass, but no perforation was seen (Fig. 3). The stent-in-stent technique was attempted first and a fully covered SEMS of the same width and length was deployed within the existing PC-SEMS. However, the FC-SEMS immediately migrated distally and had to be removed. An attempt to trim the embedded stent with an endoloop cutter was unsuccessful as well. APC was subsequently tried to cut the stent; however, it was limited by burning of the surrounding tissue. A decision was made to use cryotherapy to retrieve the stent after discussion in a multidisciplinary tumor board. Steris TruFreeze cryotherapy (Steris Healthcare, Dublin, Ireland) was applied to the proximal and distal ends of the embedded stent for 3 cycles of 20 seconds each (Fig. 4). Each cryotherapy cycle consisted of spraying for 20 seconds after frosting, then allowing for 30 to 60 seconds for thawing.

Figure 3.

Distal end of stent was seen embedded in a granulomatous mass in gastric mucosa.

Figure 4.

Frosting effect after application of cryotherapy to the embedded tissue.

At 3 weeks’ follow-up, the proximal end of the embedded stent appeared disimpacted (Fig. 5). However, the therapy could not successfully disimpact the distal end from gastric mucosa. Mechanical avulsion with biopsy forceps and rat tooth forceps was needed to manually dismantle the embedded stent from the gastric wall (Fig. 6). A repeat endoscopy confirmed an expected amount of oozing from the previously embedded tissue (Fig. 7). Healed gastric mucosa was noted on the endoscopy performed at 15 months follow-up (Fig. 8). The patient died 17 months after the procedure, while on hospice, because of postobstructive pneumonia secondary to pulmonary metastases.

Figure 5.

Proximal end of the stent found disimpacted after cryotherapy.

Figure 6.

Distal end of the stent disimpacted with mechanical avulsion.

Figure 7.

Expected amount of oozing seen from previously embedded tissue.

Figure 8.

Healed gastric mucosa at 15 months’ follow-up.

In conclusion, 3 cycles of cryotherapy for 20 seconds after frosting may be considered for embedded esophageal stent removal when other commonly used techniques are unsuccessful. However, larger studies are needed to investigate the efficacy and safety of cryotherapy for this indication.

Disclosure

All authors disclosed no financial relationships.

Supplementary data

Video 1

Cryotherapy for removal of an embedded, partially covered esophageal stent.