Unexpected adverse event during endoscopy, retrieval of dislodged endoscopic suture material from the trachea. All authors have no financial disclosures. This is a case of a 75-year-old male with T3N1M0 esophageal adenocarcinoma who presented with worsening dysphagia. He was not deemed a good surgical candidate and was undergoing chemotherapy and radiation. He was referred for evaluation of esophageal stent placement for progressive dysphagia. Upper endoscopy was performed, which showed an esophageal mass leading to near complete obstruction of the esophageal lumen. Decision was made to proceed with an esophageal stent placement. A fully covered, self-expanding metal stent, 18 mm in diameter and 9.7 cm in length was placed. Here, the proximal and distal end of the esophageal stent can be seen post-placement. To prevent stent migration, decision was made to fix the stent using endoscopic suturing. An endoscopic suturing device was applied on a dual-channel upper endoscope. Two endoscopic sutures were placed in mucosa-stent-mucosa fashion. However, on deployment of the second suture, the stent malfunctioned and was unable to be deployed. The suture was cut. However, during this process, the suturing device got briefly stuck in the stent retrieval thread and the stent migrated proximally. Hence, the stent was removed. On request of the anesthesiologist and the patient's tenuous hemodynamic status, a decision was made to abort the procedure and reattempt the procedure in a few days. The patient had excessive airway secretions and a bedside bronchoscopy was performed by the anesthesiologist. Incidentally, a suture material was seen in the trachea. The disposable bronchoscope did not allow for the suture material to be removed. Menology was consulted. Given that the patient was already intubated in the endoscopy suite, a decision was made to remove the suture material by the GI endoscopist by using a pediatric upper endoscope under pulmonary supervision. A pediatric upper endoscope was inserted through the endotracheal tube. A pediatric biopsy forceps was used to grasp the suture material. The suture material was brought to the distal end of the endotracheal tube. Both the endotracheal tube and the endoscope were withdrawn at the same time. The patient was extubated the same day in the recovery suite. Unexpected adverse events can occur during gastrointestinal endoscopy. It is unclear how the suture material went into the trachea. Possible hypotheses include that the patient aspirated the previously cut suture material that was freely dislodged in the obstructed esophagus upon extubation attempt or it is also plausible that the suture material was stuck to the stent and upon stent removal, it fell off in the oropharynx and migrated into the trachea. This case highlights the importance of adapting to the situation and improvising with the available resources to allow for timely management of an adverse event. The patient might have been needed to be transferred to the operating room for bronchoscopy at our institution, but by working closely with pulmonary and anesthesia services, the suture material was successfully removed by gastrointestinal endoscopy. A key point is that when removing a foreign body from the airway, the endotracheal tube needs to be removed along with the foreign body with the anesthesiologist prepared at bedside to reintubate. It is important to remain calm and use a multidisciplinary approach to manage potential unexpected adverse events related to endoscopic suturing. While a pediatric endoscope is not commonly used to retrieve foreign material from the trachea, this case demonstrates that a team-based approach can allow for appropriate management as in our case.

adverse event

endoscopy

esophageal adenocarcinoma

esophageal stent placement

stent migration