Impalement of a fractured esophageal fully covered metal stent. Removal with the assistance of an overtube. Primary author Yazan Abboud. Overtube-assisted removal of an impaled fractured esophageal stent. Co-authors Srinivas Kadam, Shahaf Mehdizadeh, Simon K. Lowe. These are our disclosures. A 65-year-old morbidly obese female underwent an operation for hiatal hernia repair, removal of a laparoscopic restriction band, and laparoscopic sleeve gastrectomy. One week after discharge, she was found to have abdominal wall purulent discharge from an abscess caused by a gastrectomy, which was then drained by a precutaneous drain. This CT image shows the extra-luminal air and small complex collections of perigastric fluid. This upper GI series demonstrates extravasation of small amount of contrast from the upper portion of the sleeve gastrectomy. She was initiated on parenteral alimentation. One EGD showed this image of a proximal anastomotic gastric leak with a 5-millimeter opening. To manage this leak, a fully covered nitinol-self-expandable esophageal metal stent with a 16 centimeters long and 18 millimeters diameter was deployed from the distal esophagus to the distal antrum. This was the radiograph of the esophageal stent. The patient tolerated the procedure well. Three weeks later, she was readmitted with vomiting and inability to tolerate oral medication. A CT scan and an upper GI series were unremarkable. She was managed conservatively and later discharged. Six weeks later, she presented with intractable nausea and belows vomiting for one week. An abdominal radiograph revealed the stent to be in position. The decision was made to remove the stent. We report a case in which a fully covered metal stent fractured in vivo at an unknown time point and was noted during endoscopic removal. This stent was placed for treatment of a post-sleeve gastrectomy leak. The fracture led to exposure of wires, which were embedded into the gastric wall at the time of endoscopy. This led to impalement of the stent and therefore difficulty to be removed by standard stent removal technique. It was apparent that the exposed wires can potentially cause injury to the gastroesophageal junction or esophagus during removal. Therefore, an overtube was inserted to facilitate safe stent removal by protecting the mucosa. The gastric overtube ensures mucosal protection and prevents fluid leaks. Alligator rescue rat tooth grasping forceps were inserted through a single lumen endoscope and were used to grasp the stent. Stent location was identified and the partial distal breakers was noted. The proximal end of the stent appeared to have been migrated distally to the proximal stomach. Using a standard maneuver, the distal string of the stent was grasped, but the stent could not be pushed down due to the embedded wires in the mucosa. After multiple attempts, the distal thread was grasped and the stent was advanced distally. Subsequently, a gastric overtube was inserted into the esophagus in a standard fashion. The proximal string of the stent was grasped and the stent was pursed. A steady traction on the forceps combined with advancing the overtube resulted in a smooth delivery of the stent through the overtube without any complications. Thereafter, the overtube was removed. Following extraction, the scope was advanced again into the stomach and surrounding areas were carefully inspected to rule out any perforations or lesions. Small shards of loose wiring were removed from the gastric wall. This image shows the fracture at the distal two-thirds of the stent. An upper GI series was performed the following day, which ruled out any leaks. The patient was advised to return to bariatric diet as tolerated while remaining on high-dose omeprazole therapy. She was discharged home two days after the procedure. Unexpected difficulties occurred during stent removal and they were managed using a unique approach. The embedded wires in the gastric mucosa prevented standard retrieval of the stent. Therefore, rat-tooth forceps were used to grasp the stent while simultaneously an overtube was advanced around the stent to facilitate extraction and prevent mucosal wall injury. Overtube-assisted retrieval of foreign bodies, including esophageal stents, has been reported before, but our approach is different. Advancing the overtube synchronously with the stent extraction resulted in a safe and smooth removal. In conclusion, we have encountered a rare complication of an impaled, fractured, fully covered esophageal metal stent that has been successfully managed by the unique technique of advancing an overtube. We believe that reporting this case can aid future endoscopists when encountered with a similar scenario.

fractured fully-covered esophageal metal stent

sleeve gastrectomy

in vivo stent fracture

overtube-assisted removal

endoscopic complication management