Endovascular retrieval of a migrated covered stent from the pulmonary artery

Stent migration is a rare but significant complication following endovascular procedures. Techniques for managing dislodged stents have included surgical, endovascular, and conservative approaches. This case details a patient who had a covered stent placed within the left renal vein which later migrated to the pulmonary artery causing damage to the tricuspid valve. The migrated stent was successfully removed using a percutaneous endovascular approach utilizing fluoroscopy and transesophageal echocardiogram guidance.

A novel technique to remove migrated esophageal stent under fluoroscopy

PURPOSE

To evaluate the efficacy and safety of a novel technique for removal of migrated esophageal stent (MES) under fluoroscopy.

METHODS

From January 2009 to April 2023, 793 patients with a dysphagia score of 3-4 underwent esophageal stenting at our center, and 25 patients (mean age: 70.06 years old; male/female: 15/10) underwent stent removal using "loop method" under fluoroscopy. The primary outcomes were technical success and complications. The secondary outcomes were procedure time, radiation exposure, biochemical indicators [white blood cell (WBC), hemoglobin (Hb), platelet (PLT), albumin (ALB), alanine transaminase (ALT), total bilirubin (TB), urea nitrogen (UN) and C-reactive protein] of pre- and post-treatment at 2 weeks.

RESULTS

Technical success was 100% without major complications. The mean procedure time was (39.44 ± 9.28) minutes, which showed no statistical significance between benign (n = 5) and malignant (n = 20) group [(42.40 ± 8.85) vs (38.71 ± 9.46) mins, p > 0.05]. The mean radiation exposure was (332.88 ± 261.47) mGy, which showed no statistical significance between benign and malignant group [(360.74 ± 231.43) vs (325.92 ± 273.54) mGy, p > 0.05]. Pre- and post-procedure Hb [(114.46 ± 11.96) vs. (117.57 ± 13.12) g/L] and ALB [(42.26 ± 3.39) vs. (44.12 ± 3.77) g/L] showed significant difference (p < 0.05), while WBC, PLT, CRP, and ALT showed no significance (p > 0.05).

CONCLUSION

Fluoroscopy-guided "Loop method" for MES removal is an effective and safe alternative technique.

Iliac Stent Migration to the Right Atrium-Late Detection, a Complex Clinical Problem

•Stent migration is a rare but serious complication of venous stent placement. •No clear guidelines exist on the management of stent migration. •Multimodality imaging is vital in multidisciplinary management of venous stent migration.

Implications of aortic neck dilation following thoracic endovascular aortic repair

OBJECTIVE

This article reports on a retrospective observational study designed to evaluate the incidence, etiology, and clinical implications of aortic neck dilation following thoracic endovascular aortic repair (TEVAR) for aneurysms with landing zones II and III.

METHODS

The study included 37 patients who underwent TEVAR and had postoperative computed tomography angiography available within 30 days and at least one computed tomography angiography at 1 year postoperatively. The primary end point was proximal aortic dilation (defined as growth ≥5 mm or ≥10% of the original diameter), and secondary end points included annual growth of the aneurysmal sac, device migration, endoleak, and reintervention with additional neck-related adverse events. The measurements taken during follow-up included the maximum diameter of the aneurysm and aortic diameter at various locations relative to the stent graft.

RESULTS

During follow-up, a significant increase in aortic diameter was observed at the proximal edge of TEVAR. The estimated freedom from 5 mm or 10% proximal aortic neck growth at 1, 2, and 3 years was 81%, 70%, and 65%, respectively. At the proximal edge of TEVAR the type III aortic arch was significantly associated with 5 mm growth during follow-up (P = .047) and this growth (5 mm or 10%) as well as a 10% increase at +20 mm were significantly associated with more aortic-related reinterventions. Moreover, an aortic diameter at the start <36 mm was associated with a greater increase during follow-up (area under curve in receiver operating characteristic >80%; P < .05).

CONCLUSIONS

The study concludes that proximal aortic dilation after TEVAR is a common and progressive phenomenon, and the management strategies for aortic neck dilation, including surveillance, secondary interventions, and open conversion, should be considered carefully to optimize patient outcomes and improve the long-term success of the procedure.

Sems Sensibility: Biliary Stent Migration into the Oesophagus

Endoprostheses are commonly used in the treatment of biliary and pancreatic disorders. Fully-covered metal stents are intended for the palliation of malignant strictures in the biliary tree. We report a case of a patient affected by cancer of the pancreas who was treated with a proximal metallic biliary stent. The stent migrated to the oesophagus and was endoscopically removed. Proximal migration, although rare, should be kept in mind as a potential complication of the procedure.

Combined endoscopic stenting and laparoscopic stent fixation for benign gastric tube stricture after esophagectomy: a case report

BACKGROUND

There are several options for the treatment of gastrointestinal stricture, including endoscopic stent placement and bypass surgery. However, a benign stricture is difficult to manage in a reconstructed gastric tube in the thoracic cavity owing to the technical difficulty of bypass surgery, and the possibility of stent migration.

CASE PRESENTATION

A 78-year-old woman was admitted to our hospital for treatment for her inability to eat. She had undergone video-assisted subtotal esophagectomy with retromediastinal gastric tube reconstruction 7 years earlier. At the current admission, there was a severely dilated gastric tube in the thoracic cavity with a soft stricture immediately anterior to the spine. Conservative therapy was ineffective; therefore, endoscopic stenting was performed. However, the stent migrated to the upper side of the stricture because the stricture was mild, and the stent was not fixed in the gastric tube. Next, endoscopic stent placement followed by laparoscopic stent fixation was performed. The stent was patent and worked well, and the patient's body weight increased. However, the stent collapsed 2 years later, with recurrence of symptoms. Stent-in-stent placement with an over-the-scope clip was performed, and the second stent was also patent and worked well.

CONCLUSIONS

Laparoscopic stent fixation with endoscopic stent placement could be an effective option for patients with a benign stricture in the reconstructed gastric tube.

Self-expanding metallic stent for refractory pancreatic duct stricture in chronic pancreatitis: A prospective follow-up study

BACKGROUND AND AIMS

In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture.

METHODS

The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea).

RESULTS

During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98 years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture.

CONCLUSION

The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.

Mishaps with EUS-guided lumen-apposing metal stents in therapeutic pancreatic EUS: Management and prevention

EUS-guided interventions have become widely accepted therapeutic management options for drainage of peripancreatic fluid collections. Apart from endosonographic skills, EUS interventions require knowledge of the endoscopic stenting techniques and familiarity with the available stents and deployment systems. Although generally safe and effective, technical failure of correct stent positioning or serious adverse events can occur, even in experts' hands. In this article, we address common and rare adverse events in transmural EUS-guided stenting, ways to prevent them, and management options when they occur. Knowing the risks of what can go wrong combined with clinical expertise, high levels of technical skills, and adequate training allows for the safe performance of EUS-guided drainage procedures. Discussing the procedural risks and their likelihood with the patient is a fundamental part of the consenting process.

A novel fully covered metal stent for unresectable malignant distal biliary obstruction: results of a multicenter prospective study

Background/Aims

Endoscopic self-expandable metal stent (SEMS) placement is currently the standard technique for treating unresectable malignant distal biliary obstructions (MDBO). Therefore, covered SEMS with longer stent patency and fewer migrations are required. This study aimed to assess the clinical performance of a novel, fully covered SEMS for unresectable MDBO.

Methods

This was a multicenter single-arm prospective study. The primary outcome was a non-obstruction rate at 6 months. The secondary outcomes were overall survival (OS), recurrent biliary obstruction (RBO), time to RBO (TRBO), technical and clinical success, and adverse events.

Results

A total of 73 patients were enrolled in this study. The non-obstruction rate at 6 months was 61%. The median OS and TRBO were 233 and 216 days, respectively. The technical and clinical success rates were 100% and 97%, respectively. Furthermore, the rate of occurrence of RBO and adverse events was 49% and 21%, respectively. The length of bile duct stenosis (<2.2 cm) was the only significant risk factor for stent migration.

Conclusions

The non-obstruction rate of a novel fully covered SEMS for MDBO is comparable to that reported earlier but shorter than expected. Short bile duct stenosis is a significant risk factor for stent migration.

Endoscopic stent placement with laparoscopic stent fixation in a patient with obstruction at a gastrojejunostomy anastomosis site

BACKGROUND

Palliative endoscopic stent placement may be considered in patients with malignant gastrointestinal obstruction. Stent migration is a potential complication, particularly for those placed at a surgical anastomosis or across a stricture caused by extra-alimentary tract factors. We report a patient with left renal pelvis cancer and gastrojejunostomy obstruction who underwent endoscopic stent placement and laparoscopic stent fixation.

CASE PRESENTATION

A 60-year-old male with peritoneal dissemination of a left renal pelvis cancer was admitted for treatment of upper gastrointestinal obstruction. A laparoscopic gastrojejunostomy had been previously performed for cancer invasion of the duodenum. Imaging showed gastroduodenal dilation and impaired passage of contrast medium through the efferent loop of the gastrojejunostomy. Gastrojejunostomy anastomosis site obstruction due to dissemination of left renal pelvis cancer was diagnosed. Conservative treatment failed and endoscopic stent placement with laparoscopic stent fixation was performed. After surgery, the patient was able to tolerate oral intake and he was discharged without complications. The patient gained weight and was able to resume chemotherapy, indicating the procedure was effective.

CONCLUSIONS

Endoscopic stent placement with laparoscopic stent fixation for malignant upper gastrointestinal obstruction appears effective in patients with a high risk of stent migration.

Outcomes of colon self–expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature

BACKGROUND

Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement.

AIM

To review long- and short-term clinical success of SEMS use for colonic obstruction at our center.

METHODS

We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded.

RESULTS

Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS).

CONCLUSION

Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.

Proximal migration of a tapered open-cell stent after carotid artery stenting for restenosis following endarterectomy

OBJECTIVES

Stent migration is an uncommon but serious complication of carotid artery stenting. Shortening and migration of closed-cell stents after carotid artery stenting has been reported, but migration of open-cell stents is extremely rare.

MATERIALS AND METHODS

Herein, we report a case of proximal migration of a tapered-design open-cell stent after carotid artery stenting for restenosis following endarterectomy for radiation-induced stenosis.

RESULTS

A 70-year-old man with a history of radiation therapy for tongue cancer approximately 10 years earlier was diagnosed with transient ischemic attack owing to severe stenosis of the right cervical internal carotid artery and was referred to our hospital. We performed carotid endarterectomy with a patch graft; 6 months later, restenosis was observed. Therefore, we performed carotid artery stenting with a self-expandable tapered-design open-cell stent. On the second day after the procedure, asymptomatic downward migration of the stent was detected. During the 3-year follow-up period after stent placement, no restenosis or further stent migration was observed.

CONCLUSIONS

This report provides evidence that migration of implanted carotid stents can occur even with an open-cell stents. In particular, to our knowledge, there are no reports describing migration of tapered-design open-cell stents in the early postoperative period.

Endovascular Retrieval of a Dislocated Stent in the Right Ventricle of a Patient with Nutcracker Syndrome

Left renal vein stenting is a preferable therapeutic option for patients with nutcracker syndrome (NS). As a potential complication of stent implantation, stent migration from the original placement to the right ventricle is relatively rare but can seriously threaten the patient's life. Endovascular stent retrieval is the most beneficial procedure for coping with this fatal complication. In this report, we aimed to describe an effective but relatively feasible endovascular approach using the combination of a goose neck snare and a large bore sheath for the retrieval of a stent dislodged in the right ventricle.

Fracture of self-expandable metallic stent inserted for unresectable gastric cancer at the esophagogastric junction: successful retrieval of distal fragment by gastrotomy

Endoscopic stenting is useful for amelioration of gastrointestinal stenosis. This procedure benefits severely compromised patients who cannot afford surgery. Although the self-expandable metallic stent (SEMS) is safe, it is also associated with several complications such as perforation, migration, and fracture. Migration of a SEMS is not particularly rare; however, fracture of a SEMS is relatively rare. An 88-year-old man underwent stenting for dysphagia at another hospital. He was being treated for gastric cancer at the esophagogastric junction. After appropriate stenting, he regained his ability to eat and was discharged the hospital. Only 2 months later, however, he again lost his ability to eat and visited our hospital. Abdominal X-ray and computed tomography revealed a stent fracture. The proximal fragment was in the esophagus, and the distal fragment was in the stomach. An emergency operation involving gastrotomy and gastrostomy was performed. Open gastrotomy was performed to remove the fractured distal stent, and percutaneous tube gastrostomy was placed through the same gastric incision for nutrition support. The surgery was successful, and he was again able to eat. In this report, we discuss the occurrence of SEMS fracture within a short time periods after insertion.

Fishing line assisted endoscopic placement of multiple plastic biliary stents for unresectable malignant hilar biliary obstruction: a retrospective study

BACKGROUND AND AIMS

Stent migration is one of the most common complications during the placement of multiple plastic biliary stents (MPBS) under endoscopy. This study aims to evaluate the feasibility and efficiency of the fishing line assisted (FLA) method for preventing the complication.

METHODS

Patients with unresectable malignant hilar biliary obstruction (MHBO) who undergone endoscopic placement of MPBS using the FLA or conventional method from May 2018 to April 2021 in our center were enrolled in the study. The endpoints of this study were the stent migration rate, technical success rates, adverse events rates, times of stent migration, and the procedure time.

RESULTS

FLA group (N = 19) and conventional group (N = 22) had similar baseline characteristics of the patients. The technical success rates (100% vs. 95.5%; P > 0.05), ERCP-related adverse events rates (5.3% vs. 4.5%; P > 0.05), and the stent-related adverse events rates (0% vs. 4.5%; P > 0.05) were no significant differences between the FLA and conventional groups. MPBS inserted using the conventional method consumed more time (median, 33.9 min vs. 15.6 min; P < 0.05) method and increased the times of stent migration (median, 3 times vs. 0 times; P < 0.05) than using the FLA method. Even if no statistical difference was detected in the stent migration rate between groups, this rate was lower in the FLA group than the conventional group (0% vs. 13.6%; P > 0.05).

CONCLUSIONS

FLA method is an effective technique for MPBS implantation to prevent stent migration during endoscopic retrograde cholangiography (ERCP). The method should be applied to patients with unresectable MHBO who need to place MPBS.

Duodenal perforation secondary to stent migration after ERCP for hepatobiliary tuberculosis: Case report of a lethal complication in a young patient

INTRODUCTION

Interventional internal drainage of the biliary tract has become an established procedure for the temporary and definitive treatment of biliary obstruction due to malignant or benign disease. The complication rate is reported to be so low that when feasible, this technique is preferred over a surgical drainage procedure.

PRESENTATION OF A CASE

A 26-year old woman was referred to the hepatopancreaticobiliary surgery service due to severe abdominal pain for 3 days after undergoing endoscopic retrograde cholangiopancreatography (ERCP). She underwent biliary dilatation and stent insertion for obstructive jaundice secondary to biliary stricture from hepatobiliary tuberculosis. The patient underwent exploratory laparotomy, peritoneal lavage, duodenorrhaphy and tube jejunostomy for bilious peritonitis and duodenal perforation from biliary stent migration. The patient died one day post-operation due to septic shock from secondary bacterial peritonitis.

DISCUSSION

ERCP and other interventional endoscopic biliary interventions are increasingly being used for biliary obstruction. Despite the various complications which arise from these diagnostic and therapeutic modalities, complications are relatively uncommon. Duodenal perforation from biliary stent migration is a rare complication after undergoing ERCP and stenting. However, in patients presenting with severe pain and physical signs of acute abdomen after the procedure, it should always be a consideration.

CONCLUSIONS

Despite the relative safety of interventional techniques for biliary obstruction, complications like pancreatitis, hemorrhage and perforation may occur. Early recognition and high index of suspicion allows for early intervention with good outcomes. Duodenal perforation from stent migration can occur and when intervention is delayed may lead to morbidity and mortality.

Successful endoscopic closure with an over-the-scope clip for sigmoid colon perforation due to bile duct stent migration

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Intrathoracic ureteric stent migration through a reno-pleural fistula: a case report of rare antegrade ureteric stenting complication

BACKGROUND

Malignant obstruction and associated hydronephrosis is a common complication of advanced cervical cancer. Percutaneous nephrostomy (PCN) followed by antegrade stenting is often required to relieve obstruction as retrograde access fails in considerable proportion of such patients. Reno-pleural fistula is a rare complication of PCN which creates a patent connection between the renal collecting system and the thoracic cavity, and urine accumulation in the pleural space can cause pleural effusion (i.e., urinothorax). Upward or downward migration is a complication of indwelling ureteric stents. Further migration with extrusion outside of the urinary tract is uncommon. Herein we present an unprecedented case in adult of ureteric stent upward migration through a reno-pleural fistula into the thoracic cavity managed by thoracoscopy.

CASE PRESENTATION

A 66-year-old female was diagnosed of advanced stage cervical cancer with suspicious bladder invasion. Given her bilateral hydronephrosis with impaired renal function, she underwent bilateral PCN and subsequent antegrade ureteric stenting. However, she presented with dyspnea, right back pain, and oliguria four days after bilateral PCN catheter removal. Computed tomography reported massive right pleural effusion and an intrathoracic ureteric stent within reno-pleural fistula. Thoracoscopy with thoracostomy was performed to remove the ureteric stent and urine in right pleural space. A week later, urinothorax had resolved and right PCN was performed again. She was discharged after regaining normal renal function with right PCN and a left ureteric stent in place.

CONCLUSIONS

A reno-pleural fistula can serve as a route for ureteric stent migration and that continuous drainage of urine can cause urinothorax once the stent reaches the thoracic cavity. Anytime a supracostal approach is used for PCN, even when using small caliber catheters, clinicians should pay special attention given the risk of pleural injury and subsequent complications.

External fixation of airway stents for upper tracheal stenosis and tracheoesophageal fistula

OBJECTIVES

Stent migration is a common complication of airway stent placement for upper tracheal stenosis and tracheoesophageal fistula. Although several researchers have reported that external fixation is effective in preventing stent migration, the usefulness and safety of external fixation have not been proved because their cohorts were small. We therefore investigated the efficacy and safety of external fixation during upper tracheal stenting.

METHODS

Records of patients who underwent airway stent placement from May 2007 to August 2018 in a single centre were retrospectively reviewed. We included only patients whose stent had been placed in the upper trachea with external fixation to the tracheal wall. The primary endpoint of this study was the rate of stent migration.

RESULTS

Altogether, 51 procedures were performed in 45 patients (32 males, 13 females; median age 60 years, range 14-91 years). The median follow-up period was 9 months (range 0.3-90 months). Among the procedures, 15 were performed for benign disease and 36 for malignancy. Stents were composed of either silicone (n = 42) or metal (n = 9). Stent migration occurred in 3 (6%) patients. The stents with migration were all composed of silicone. Other sequelae were granulation tissue formation in 10 (20%) patients, sputum obstruction in 6 (12%), cellulitis in 3 (6%) and pneumonia in 1 (2%).

CONCLUSIONS

External fixation was an effective method for preventing migration of airway stents placed for upper tracheal stenosis and tracheoesophageal fistula. The complications were acceptable in terms of safety.

A successful endovascular repositioning of migrated transjugular intrahepatic portosystemic shunt (TIPS) stent

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed to create an intrahepatic tract between the hepatic and portal veins which helps to shunt blood away from the hepatic sinusoids. This shunt decreases the portal venous pressure and secondary morbidities, including variceal bleeding and recurrent ascites. However, stent migration is a known complication of TIPS stent placement which may occur both during the procedure or postprocedural. We present a case of a 58-year-old male with history of liver cirrhosis in the setting of alcohol abuse and chronic hepatitis C infection who presented with melena and hematemesis. Esophagogastroduodenoscopy showed 4 columns of large grade IV esophageal varices with stigmata of recent bleeding. Despite endoscopic variceal banding, the patient had persistent episodes of hematemesis and became hemodynamically unstable requiring pressor support. The decision was made to proceed with emergent transjugular intrahepatic portosystemic shunt placement. After obtaining transhepatic portal access and initial stent deployment, the stent migrated from the TIPS tract into the main portal vein. While maintaining through-and-through wire access, the stent was successfully mechanically retracted using an angioplasty balloon and it was appropriately repositioned within the original TIPS tract. The stent was then further secured in place with a slightly larger stent which was deployed within the hepatic portion of the initially migrated stent. This technique was successful and obviated complete removal of the stent and follow-up imaging demonstrated patent flow and adequate positioning several months after the procedure.

Delayed Proximal Flow Diverting Stent Migration in a Ruptured Intracranial Aneurysm: A Case Report

A flow diverter can be used to treat a ruptured aneurysm, especially during complicated cases for endovascular or open microsurgical procedures. However, some complications have been reported such as occlusion of side branches or perforating arteries, stent migration or improper stent position, re-rupture of the aneurysm, and in-stent thrombosis. A 38-year-old man diagnosed with a ruptured left supraclinoid aneurysm was treated with a Pipeline embolization device. Despite adequate stent coverage of the aneurysmal neck, delayed proximal migration was seen in follow-up imaging. To our knowledge, proximal migration of the stent mostly happens intraoperatively due to an undersized stent or excessive stretching. We report a case of delayed proximal flow diverter stent migration.

Aneurysm Growth After Endovascular Sealing of Abdominal Aortic Aneurysms (EVAS) with the Nellix Endoprosthesis

OBJECTIVE

The aim of this study was to measure the incidence of post endovascular aneurysm sealing (EVAS) abdominal aortic aneurysm (AAA) growth, and its association with stent migration, in a cohort of patients with differing compliance to old and new Instructions For Use (IFU).

METHODS

A retrospective single centre study was conducted to review the computed tomography (CT) and clinical data of elective, infrarenal EVAS cases, performed as a primary intervention, between December 2013 and March 2018. All included patients had a baseline post-operative CT scan at one month and at least one year follow up. The primary outcome measure was the incidence of AAA growth and its association with stent migration. AAA growth was defined as a ≥5% increase in aortic volume between the lowermost renal artery and the aortic bifurcation post EVAS at any time during follow up, in comparison to the baseline CT scan. Migration was defined according to the ESVS guidelines, as > 10 mm downward movement of either Nellix stent frame in the proximal zone.

RESULTS

Seventy-six patients were eligible for inclusion in the study (mean age 76 ± 7.4 years; 58 men). AAA growth was identified in 50 of 76 patients (66%); adherence to IFU did not affect its incidence (mean growth within IFU-2016 compliant cohort vs. non-compliant: 16% vs. 13%, p = .33). Over time, the incidence of AAA growth increased, from 32% at one year to 100% at four years. AAA growth by volume was progressive (p < .001), as its extent increased over time. Migration was detected in 16 patients and there was a statistically significant association with AAA growth (13 patients displayed migration and AAA growth, p = .036).

CONCLUSION

Patients treated with EVAS are prone to AAA growth, irrespective of whether their aortic anatomy is IFU compliant. AAA growth by volume is associated with stent migration. Clinicians should continue close surveillance post EVAS, regardless of whether patients are treated within IFU.

Impact of Compliance with Anatomical Guidelines of "Bell-Bottom" Iliac Stent Grafts for Ectatic or Aneurysmal Iliac Arteries

OBJECTIVE

To evaluate the impact of compliance with anatomical guidelines on outcomes of endovascular aortic aneurysm repair using "bell-bottom" stent grafts (BBSGs).

METHODS

This is a retrospective review from January 1999 to May 2012 of patients who underwent endovascular infrarenal abdominal aneurysm repair and whose iliac limbs were greater than 18 mm in diameter. Computed tomography angiography was utilized for compliance with anatomical guidelines as stated in manufacturer's instructions for use (IFU). The primary outcome observed was iliac limb events. The secondary outcome observed was the need for re-intervention due to BBSG failure.

RESULTS

Of the 376 BBSGs, 55 (15%) in 27 patients met IFU. Aneurysm exclusion was achieved in all patients. The mean follow-up was 44 ± 30 months. Twenty-eight patients (11%) had 29 iliac limb events (12 type 1b endoleaks, 4 aneurysm sac growth, 4 stenosis/kink, 4 retrograde migrations, 2 component separations, 2 ruptures and 1 limb occlusion); all among patients treated outside of IFU (p < 0.04). The rate of aneurysm sac enlargement was similar between both groups, at 56%, respectively, between those treated within and those treated outside of IFU. On multivariate regression analysis, larger common iliac artery (CIA) (HR 1.088, 95% CI 1.016-1.166, p = 0.016), greater CIA tortuosity (HR 2.352, 95% CI 1.004-5.509, p = 0.048) and limbs with more than two characteristics that did not meet IFU criteria (HR 3.84, 95% CI 1.15-12.83, p = 0.03) were associated with higher rates of BBSG events and re-interventions.

CONCLUSIONS

BBSGs effectively seal ectatic CIAs. But rates of iliac limb events and re-interventions are higher among patients who do not meet IFU criteria. The larger CIA diameter, the greater CIA tortuosity and more than two criteria not met by IFU were associated with BBSG failure and re-intervention.

Intraspinal Iliac Venous Stent Migration with Lumbar Nerve Root Compression

BACKGROUND

Venous stenting is a common treatment for chronic peripheral venous disease. The most frequent complications caused by this technique are stent misplacement and intracardiac or intravascular stent migration. In this publication, we will describe the first case of an intraspinal stent misplacement leading to lumbar nerve root compression.

CASE DESCRIPTION

Our patient was a 20-year-old woman with a bilateral pulmonary embolism caused by a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). She underwent an endovascular stenting of the left iliac vein. A few days later, she reported some pain in the right L5 radicular and showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography scan showed a stent misplacement into the spinal canal through the left L5 foramen with nerve root compression. She underwent a surgical removal of the stent through a unilateral L5-S1 laminarthrectomy. The postoperative follow-up showed a complete clinical recovery and a control lumbar computed tomography scan confirmed the L5 nerve root decompression.

CONCLUSIONS

The intraspinal misplacement of a venous stent is a rare complication that may cause nerve root injury. It requires a prompt treatment. Surgically removing the stent by a posterior approach seems to be a simple and safe therapeutic option.

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.

Suture fixation of tracheal stents for the treatment of upper trachea stenosis: a retrospective study

Background

Stent migration is a common complication in treating trachea stenosis. There is no report concerning suture fixation of tracheal stent. The aim of this study was to investigate whether suture fixation of tracheal stent could avoid stent migration in patients with upper trachea stenosis. The complications were further investigated.

Methods

The patients with upper trachea stenosis who underwent tracheal stent placement for benign/malignant conditions in our hospital between May 2016 and April 2018 were retrospectively reviewed. Clinical data were collected for each patient, including age, gender, co-morbid diseases, site of tracheal obstruction, degree of tracheal obstruction, success of stent placement, impact on patient’s symptoms, complications, etc.

Results

Eleven patients (8 males and 3 females; range of age: 17–85, and average age of 63) were enrolled into this study. Six silicone stents and five membrane-covered metal stents were used. The surgery was successfully performed in all the cases. The postoperative recovery was uneventful. All symptoms of the patients were relieved. No complications occurred. The average follow-up for patients was 5 months (range of 1–13 months). During the follow-up, no stent migration was observed according to CT and bronchoscope.

Conclusion

The results suggested that suture fixation of stents could avoid stent migration in treating upper trachea stenosis with metal stent or silicone stent. This method seemed to be effective without operation complications.

A case of pipeline migration in the cervical carotid

Since its emergence in 2011, the pipeline flow diversion (PFD) has gained recognition in the treatment of certain intracranial aneurysms. However, early or delayed pipeline migration (PM) and micro-catheter/guidewire retention have been infrequently reported. We report a case of PM and shortening in the treatment of a left cervical internal carotid artery (LICA) aneurysm. A middle-aged African-American patient presents for an off-label PFD treatment of an incidental 21 × 23 mm aneurysm at the sub-petrous segment of the left ICA. While the patient remained completely neuro-intact, a 6 months follow-up angiogram revealed a persisting filling of the cervical aneurysm with a foreshortening of the pipeline by 1/3 of its original 30 mm size and proximal migration into the aneurysmal sac. We opted to watch the aneurysm within 6 months especially that the aneurysm was extra-cranial and because of the potential risks involved in trying to re-access the device.

Laparoscopic extraction of gastric self-expandable metallic stent after migration in ileum: A case report

Revisional surgery in bariatric patients can sometimes lead to life-threatening complications that need a fast diagnosis and treatment as well as a multidisciplinary approach. If left undiagnosed or untreated, this may lead to sepsis, multiple organ failure, and death. In this case report, we describe the management of a gastric perforation which occurred after conversion of a gastric banding to a sleeve gastrectomy.

Clinical Impact of the Intra-scope Channel Stent Release Technique in Preventing Stent Migration During EUS-Guided Hepaticogastrostomy

BACKGROUNDS

Stent migration following endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) may sometimes be fatal because there are no adhesions between the biliary tract and stomach. To prevent stent migration and minimize the stent length in the abdominal cavity, we recently performed EUS-HGS using the technique of releasing the stent within the scope channel.

AIMS

To examine the technical feasibility of the intra-scope channel stent release technique.

METHODS

Forty-one consecutive patients who underwent EUS-HGS were enrolled. Between October 2015 and December 2015, EUS-HGS was performed using the extra-scope channel release technique, while the intra-scope channel release technique was performed between January 2016 and March 2016.

RESULTS

The distance between the hepatic parenchyma and the stomach wall after EUS-HGS in the intra-scope channel stent release group was significantly shorter than that in the extra-scope channel release group (0.66 ± 1.25 vs 2.52 ± 0.97, P < 0.05). Adverse events, such as biloma or stent migration, were seen in only the extra-scope channel release group.

CONCLUSION

In conclusion, although additional cases and randomized controlled studies using metal stents of various lengths are needed, our technique is likely to be clinically useful for the prevention of early and late stent migration.

Esophageal Stenting in Clinical Practice: an Overview

OPINION STATEMENT

PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice.

RECENT FINDINGS

Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.

The intra-conduit release method is useful for avoiding migration of metallic stents during EUS-guided hepaticogastrostomy (with video). J Med Ultrason (2001). 2018;45:399-403. [PMID: 29235065 DOI: 10.1007/s10396-017-0846-x]

PURPOSE

Although EUS-guided hepaticogastrostomy (EUS-HGS) with a covered self-expandable metal stent (SEMS) is a useful procedure, it is associated with severe adverse events, including stent migration. We, therefore, developed an intra-conduit release method, and investigated whether the technique yields a safer and more stable procedure.

METHODS

The intra-conduit release method is a procedure to release the SEMS in the working channel conduit of the scope for anchoring between the liver and stomach to avoid stent migration. Forty-three patients who underwent EUS-HGS at two high-volume centers in Japan were enrolled in this retrospective study, and the safety and usefulness of this method were evaluated retrospectively.

RESULTS

The intra-conduit release method was applied in 36 cases. The technical success rate of EUS-HGS with the intra-conduit release method was significantly higher in comparison with the conventional method. Additionally, the rate of early adverse events was significantly lower than that for the conventional method.

CONCLUSION

The intra-conduit release method during EUS-HGS is useful for a stable procedure that avoids early adverse events.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Partially covered metal stents have longer patency than uncovered and fully covered metal stents in the management of distal malignant biliary obstruction: a retrospective study

BACKGROUND

Self-expandable metal stents (SEMSs) are widely used for malignant biliary obstructions. Nitinol-covered SEMSs have been developed to improve stent patency. Currently, SEMSs may be uncovered, partially covered, or fully covered; however, there is no consensus on the best stent type for the management of malignant distal biliary obstruction (MDBO).

METHODS

Patients with unresectable MDBO receiving SEMS (Wallflex™) were retrospectively analyzed. Time to recurrent biliary obstruction (TRBO) and survival time were compared among the three types of SEMSs. Univariate and multivariate analyses were performed to identify risk factors for stent dysfunction.

RESULTS

In total, 101 patients received SEMSs for unresectable MDBO (44 uncovered, 28 partially covered, and 29 fully covered SEMSs). Median survival time was 200, 168, and 276 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. There were no differences in survival among the three groups. Median TRBO was 199, 444, and 194 days in the uncovered, partially covered, and fully covered SEMSs groups, respectively. Partially covered SEMSs had longer TRBO than uncovered (p = 0.013) and fully covered (p = 0.010) SEMSs. Tumor ingrowth occurred only with uncovered SEMSs and stent migration occurred only with fully covered SEMSs. Multivariate analyses confirmed that partially covered SEMSs have lower risk of dysfunction.

CONCLUSIONS

Partially covered SEMSs with a proximal uncovered flared end have longer patency than uncovered and fully covered SEMSs by preventing tumor ingrowth and stent migration.

Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis

BACKGROUND

Covered self-expandable metal stents (SEMS) are utilized for the management of benign and malignant esophageal conditions; however, covered SEMS are prone to migration. Endoscopic suture fixation may mitigate the migration risk of covered esophageal SEMS. Hence, we conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of endoscopic suture fixation for covered esophageal SEMS.

METHODS

Following PRISMA guidelines, we performed a systematic review from 2011 to 2016 to identify studies (case control/case series) reporting the technical success and migration rate of covered esophageal SEMS following endoscopic suture fixation. We searched multiple electronic databases and conference proceedings. We calculated pooled rates (and 95% confidence intervals [CI]) of technical success and stent migration using a random effects model.

RESULTS

We identified 14 studies (212 patients) describing covered esophageal SEMS placement with endoscopic suture fixation. When reported, SEMS indications included leak/fistula (n = 75), stricture (n = 65), perforation (n = 10), and achalasia (n = 4). The pooled technical success rate was 96.7% (95% CI 92.3-98.6), without heterogeneity (I ² = 0%). We identified 29 SEMS migrations at rate of 15.9% (95% CI 11.4-21.6), without heterogeneity (I ² = 0%). Publication bias was observed, and using the trim-and-fill method, a more conservative estimate for stent migration was 17.0%. Suture-related adverse events were estimated to occur in 3.7% (95% CI 1.6-8.2) of cases.

CONCLUSIONS

Endoscopic suture fixation of covered esophageal SEMS appears to reduce stent migration when compared to published rates of non-anchored SEMS. However, SEMS migration still occurs in approximately 1 out of 6 cases despite excellent immediate technical success and low risk of suture-related adverse events.

The Stent Patency and Migration Rate of Different Shaped Plastic Stents in Bile Flow Phantom Model and In Vivo Animal Bile Duct Dilation Model

BACKGROUND/AIM

In research and development of biliary plastic stents (PS), continuous efforts have been made to overcome short patency time and high rate of migration. The aim of this study was to evaluate the patency and migration rate of different PS shapes for a given period of time.

METHODS

Using an in vitro bile phantom model, we compared the patency among different shapes of PS (three straight PS, four double-pigtail PS, and a new screw-shaped PS). We performed an analysis of the degree of luminal narrowing by light microscopic examination. Using an in vivo swine model, we compared the patency and migration rate among the three different types of PS.

RESULTS

Eight weeks after the bile exposure in the bile flow phantom model, 80 PS were retrieved and analyzed. The straight PS showed less biofilm formation and luminal narrowing than other types of PS (p < 0.05). Forty-nine PS were inserted into the dilated bile ducts of 10 swine models, and 39 PS were successfully retrieved 8 weeks later. The stent migration occurred less frequently in the double-pigtail PS and the screw-shaped PS than it did in the straight PS (11.1, 10, and 27.3%, respectively). However, there was no statistical difference in stent patency among the different shapes.

CONCLUSIONS

Stent patency may not be significantly different depending on the shape of PS for 8 weeks. The screw-shaped PS showed similar patency and migration rate to the double-pigtail PS. These results may help guiding future PS development and clinical decisions.

Successful adjustment for self-expanding metallic stent migration using a flexible bronchoscope with two biopsy forceps technique

Although tracheobronchial stents are widely used for tracheal obstruction due to malignant or benign stenosis, stent migration has been reported as a major postoperative complication. A self-expandable metallic stent (SEMS) is more easily introduced compared with silicone stents. However, it is also difficult to remove or replace without complications. We report a new technique for successful SEMS adjustment using a flexible bronchoscope with two biopsy forceps.

Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial

Introduction

Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated.

Methods

Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter.

Results

There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083).

Conclusion

In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.

A rare cause for Hartmann's procedure due to biliary stent migration: A case report

•

Migration of a biliary stent can cause life-threatening complications.

•

When a stent migration occurs, in case of complications, surgical removal is the only treatment option.

•

Among the complications associated with stent migration, intestinal bleeding, obstruction and perforation are of outmost importance.

Introduction

Biliary stent migration (proximal or distal) occurs in 6% of all cases. The majority of these migrating stents are passing through the intestine, without causing any complications. Usually when a stent migration occurs, endoscopic retrieval is the proper treatment option, except in case of complications when surgical removal is the only treatment option. This report presents a case of a biliary stent which migrated and caused a sigmoid colon perforation.

Presentation of case

A 75 years old female patient presented to the emergency department with diffuse abdominal pain, nausea and vomiting. Clinical examination showed distended abdomen and signs of peritoneal irritation.

CT scan of the abdomen revealed free gas and fluid in the left iliac fossa, as well as a foreign body penetrating the sigmoid colon. Emergency laparotomy was performed. A plastic stent was found perforating the sigmoid colon through a diverticulum. The rest of the sigmoid colon was intact presenting only uncomplicated diverticula. Hartmann’s operation was performed, involving the diseased segment, together with part of the descending colon due to profound diverticulosis. Patient’s post-surgical course was uneventful and was discharged on postoperative day 10.

Discussion

Migration of a biliary stent can cause life-threatening complications such as perforation of the intestine and peritonitis. The migration of the stent from the biliary tree may be mostly asymptomatic except in cases of intestinal perforation that immediate surgery is the proper treatment option. On the other hand, even in cases of benign lesions of the bile duct, the stent should be removed immediately after dislocation in order to reduce the risk of secondary complications such as obstruction, infection or perforation.

Conclusion

In cases of non-complicated stent migration endoscopic retrieval is the indicated treatment. In patients who suffer serious complications due to stent dislocation, emergency surgery may be the proper treatment option.

Endoscopic suture fixation is associated with reduced migration of esophageal fully covered self-expandable metal stents (FCSEMS)

BACKGROUND

Esophageal fully covered self-expandable metal stents (FCSEMS) are indicated for the management of benign and malignant conditions of the esophagus including perforations, leaks, and strictures. FCSEMS are resistant to tissue ingrowth and are removable; however, stent migration occurs in 30-55% of cases. Endoscopic suture fixation of FCSEMS has been utilized to decrease the risk of stent migration though data supporting this practice remain limited. The primary aim of this study was to compare clinical outcomes and migration rate of patients who underwent placement of esophageal FCSEMS with and without endoscopic suture fixation.

METHODS

Our single-center, retrospective, cohort study includes patients who underwent esophageal FCSEMS placement with and without endoscopic suture fixation between January 1, 2012, and November 11, 2015. Baseline patient characteristics, procedural details, and clinical outcomes were abstracted. Logistic regression was performed to identify clinical and technical factors associated with outcomes and stent migration.

RESULTS

A total of 51 patients underwent 62 FCSEMS placements, including 21 procedures with endoscopic suture fixation and 41 without. Suture fixation was associated with reduced risk of stent migration (OR 0.13, 95% CI 0.03-0.47). Prior stent migration was associated with significantly higher risk of subsequent migration (OR 6.4, 95% CI 1.6-26.0). Stent migration was associated with lower likelihood of clinical success (OR 0.21, 95% CI 0.06-0.69). There was a trend toward higher clinical success among patients undergoing suture fixation (85.7 vs. 60.9%, p = 0.07).

CONCLUSIONS

Endoscopic suture fixation of FCSEMS was associated with a reduced stent migration rate. Appropriate patient selection for suture fixation of FCSEMS may lead to reduced migration in high-risk patients.

Efficacy of Retrievable Metallic Stent with Fixation String for Benign Stricture after Upper Gastrointestinal Surgery

Objective

To determine the efficacy of retrievable metallic stent with fixation string for benign anastomotic stricture after upper gastrointestinal (UGI) surgery.

Materials and Methods

From June 2009 to May 2015, a total of 56 retrievable metallic stents with fixation string were placed under fluoroscopy guidance in 42 patients who were diagnosed with benign anastomotic stricture after UGI surgery. Clinical success was defined as achieving normal regular diet (NRD).

Results

The clinical success rate after the first stent placement was 57.1% (24/42). After repeated stent placement and/or balloon dilation, the clinical success rate was increased to 83.3% (35/42). Six (14.3%) patients required surgical revision to achieve NRD. One (2.4%) patient failed to achieve NRD. Stent migration occurred in 60.7% (34/56) of patients. Successful rate of removing the stent using fixation string and angiocatheter was 94.6% (53/56). Distal migration occurred in 12 stents. Of the 12 stents, 10 (83.3%) were successfully removed whereas 2 could not be removed. No complication occurred regarding distal migration.

Conclusion

Using retrievable metallic stent with a fixation string is a feasible option for managing early benign anastomotic stricture after UGI surgery. It can reduce complications caused by distal migration of the stent.

Endoscopic management of internally migrated pancreatic duct stents (with video)

BACKGROUND AND AIMS

Spontaneous intestinal migration of pancreatic stents is a known phenomenon. However, retrieval of a proximally migrated pancreatic stent (PMPS) poses a therapeutic challenge. The primary aim of this study was to evaluate technical success of endoscopic retrograde of cholangiopancreatography (ERCP) for extraction of PMPS, including number of sessions, need of surgery for failures and intervention-induced adverse events. The secondary outcome was to evaluate long-term effects of PMPS on the ductal morphology.

METHODS

Data of patients undergoing pancreatic stenting since January 2007 was reviewed. Fourteen patients were found to have PMPS. The level of stent migration was divided into two categories: level 1: retropapillary migration of the stent, the distal end seen till the genu (n = 6). Level II: PMPS with distal end seen beyond genu (n = 8). The stents were placed due to following reasons, prophylactic pancreatic stenting after common bile duct stone extraction (n = 6), pancreatic endotherapy for chronic pancreatitis (n = 7), and recurrent acute pancreatitis with incomplete pancreas divisum (n = 1). ERCP was done using Olympus TJF 160/180 duodenoscope. Stent extraction was initially attempted using rat tooth forceps, snare with or without wire, wire-guided basket, and in case of failures, pancreatoscope was used (Boston Scientific, USA).

RESULTS

PMPS could successfully be retrieved in 13 out of 14 patients (92.8 %). Stents were retrieved using stone extraction balloon in two (14.2 %), modified angiography balloon in one (7 %), rat tooth in three patients (21.4 %), over-the-wire snare in three patients (21.4 %), lasso technique in one (7 %), and under pancreatoscope guidance in three patients (21.4 %). Adverse events encountered were mild pancreatitis (n = 2, 14 %) and self-limited bleeding (n = 2, 14 %).

CONCLUSIONS

Endotherapy of PMPS could be complex and associated with adverse events. Level II-migrated stents may require specialized methods like pancreatoscopy for stent retrieval.

Difficult removal of fully covered self expandable metal stents (SEMS) for benign biliary strictures: the "SEMS in SEMS" technique

BACKGROUND

Removal of biliary Fully Covered Self Expandable Metal Stents can fail due to stent migration and/or hyperplastic ingrowth/overgrowth.

METHODS

A case series of 5 patients with benign biliary strictures (2 post-cholecystectomy, 2 following liver transplantation and 1 related to chronic pancreatitis) is reported. The biliary stricture was treated by temporary insertion of Fully Covered Self Expandable Metal Stents. Stent removal failed due to proximal stent migration and/or overgrowth. Metal stent removal was attempted a few weeks after the insertion of another Fully Covered Metal Stent into the first one.

RESULTS

The inner Fully Covered Self Expandable Metal Stent compressed the hyperplastic tissue, leading to the extraction of both the stents in all cases. Two complications were reported as a result of the attempt to stents removal (mild pancreatitis and self-limited haemobilia).

CONCLUSION

In the present series, the "SEMS in SEMS" technique revealed to be effective when difficulties are encountered during Fully Covered Self Expandable Metal Stents removal.

Esophageal stent fracture: Case report and review of the literature

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions. Self expanding metal stents (SEMS) are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions; however they have known complications of stent migration, stent occlusion, tumor ingrowth, stricture formation, reflux, bleeding and perforation amongst others. A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces. There have only been a handful of published case reports describing this problem. In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS, and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus. SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esophageal SEMS. It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment. Early recognition and prompt management may be able to prevent further problems.