complex removal of embedded partially covered self-expanding metal stent from the esophagus. In the management of selective esophageal diseases, careful consideration of the type of esophageal stents to be utilized is an important consideration especially in the treatment of esophageal leaks, fistulas, perforations, other benign esophageal strictures and malignant etiologies. Success is achieved when that indication for stent placement is accomplished without challenging complications, easy deployment and removal, stent migration, granulation tissue ingrowth and the need for reintervention is minimized. In order to reduce stent migration in the esophagus, partially covered self-expanding metal stent is considered when migration poses challenges in patient care. Partially covered self-expanding metal stent results in an embedded proximal bare portion of the stent in the esophageal wall to prevent migration. However, removal becomes challenging after a few weeks when needed. In inoperable esophageal malignancies, placement might be reasonable. However, in benign strictures or in cases of therapy for fistulas, consideration for fully covered stent with appropriate securing of proximal end is the mainstay of therapy. When partially covered self-expanding metal stent removal is required clinically after reactive mucosal tissue hypotrophy has occurred, the use of rat tooth forceps, APC, stent-in-stent technique and combination with cryoablation and endoscopic substance space dissection have been previously described for stent removal. We describe a case of removal of embedded partially covered self-expanding metal stent left in place for two years using APC, cap scraping and separation of stent off the tissue using the endoscope. A new invented method we call tornado twist method. Our case is a 61 year old man with history of hypertension, non-insulin dependent diabetes mellitus and stroke complicated by formation of tracheoesophageal fistula caused by inadvertent advancement of tracheostomy tube after the stroke. Patients struggled with recurrence of the tracheoesophageal fistula after several direct surgical repairs. Surgery was complex given the multi-level esophageal strictures, complex anatomy, multiple previous surgeries and the temporary esophageal stent was placed to revisit after a short period of time. However, patient's financial and insurance issues prevented his timely return for removal of stent and subsequent surgery. He presented to the emergency room with weakness and dysphagia after two years. Endoscopic evaluation revealed esophageal stenosis with stent embedded into tissue. Stenosis was dilated to 18 millimeters. Surgical team utilized flexible and then rigid endoscope to attempt stent removal and in the process broke some wire mesh. Endoscopic removal and reattempt was requested to facilitate patients undergoing appropriate surgery. Removal of the embedded metal stent in esophageal mucosa was challenging and required multiple attempts with repeated APC ablation of tissue combined with other methods of tissue removal. Repetitive scraping was performed after gentle APC ablation over the tissue until wires were seen. Because of the history of tracheoesophageal fistula, gentle and careful ablation was performed to avoid deep thermal injury and breakage of wire links. APC setting utilized 50 watts with short repetitive bursts. Anterior aspect was freed, however, some of the posterior aspects had broken wires and freeing the wire was met with some difficulty. Repeat APC was applied and desiccated tissue was removed using the cap. This desiccated tissue intermittently obscured the view and the stent wires were fragmented at several places. A rat tooth forcep was used to lift the stent off the esophageal wall to confirm detachment and further separation was promoted by inserting the endoscope in between the stent and the esophageal wall by gentle rotation of endoscope in a spiral method invented as the new tornado twist method. APC ablation was continued at areas of tissue overgrowth and this spiral twist method was used to encourage separation by further advancing the endoscope between them. After ablating the tissue over the stent and stent wire exposed, the rat tooth forceps was used to confirm separation. When separation was adequate to host the endoscope underneath, forceps were slid under the stent along the esophageal wall from the proximal end. Then rotation applied to lift the stent and forceps towards the center of the lumen with the endoscope again slid under the stent and forceps retracted. Further forward force was applied to gently separate the stent off the esophageal wall if not easily separated. Further ablation was repeated at a location with tissue scraping. On completion of separation of the stent of the esophageal wall, the stent was grasped on both sides using forceps and a double-channel endoscope, pulled back steadily into an overtube for added safety measures. A hot-snare polypectomy was intermittently used to remove excessive protruding granulation tissue. In conclusion, management of long-term, partially-covered, self-expanding metal stent placement is challenging, with possible significant tissue ingrowth and removal will be difficult if left after a period of time. Proper selection of stent for the patient's condition is paramount. Dipped tissue ingrowth may be managed with a multi-modal, stepwise approach. Maintaining the thermal energy is the key to reducing damage to surrounding tissue for stent removal and to prevent subsequent adverse events.

self-expanding metal stent

esophagus

APC

tornado twist method

tracheoesophageal fistula