Ann Thorac Surg 2006;82:1913-1914
© 2006 The Society of Thoracic Surgeons
Case Reports
Removal of Metallic Stent by Using Polyflex Stent in Esophago-Colic Anastomotic Stricture
Bülent Tunçözgür, MDa,*,
Muhammet Cemil Sava
, MDb,
Ahmet Feridun I
k, MDa,
Akn Sarmehmeto
lu, MDa,
Maruf 
anl, MDa,
Levent Elbeyli, MDa
a Department of Thoracic Surgery, Gaziantep University Medical School, Gaziantep, Turkey
b Department of Gastroenterology, Gaziantep University Medical School, Gaziantep, Turkey
Accepted for publication March 21, 2006.
* Address correspondence to Dr Tunçözgür, Thoracic Surgery Department, Gaziantep University Medical School, Gaziantep, 27310 Turkey. (Email: tuncozgur{at}gantep.edu.tr).
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Abstract
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Benign strictures or anastomoses of the esophagus can be treated by stents. However, short-term and long-term complications, including migration and hyperplastic tissue reaction can occur. Bowel reconstruction by interposition has been performed after esophagectomy. Stricture of cervical anastomosis is an important late complication. Self-expandable metallic stents have been used to improve this problem. To remove the obstructed metallic stent, self-expandable covered plastic stents can be used. Herein we present the removal technique of tissue-embedded self-expandable metallic stents by using self-expandable covered plastic stents after colon interposition in a case of benign cervical anastomosis of the esophagus due to caustic stricture.
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Introduction
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Stents have been primarily used in patients with advanced esophageal carcinoma [1–3]. Other indications are (1) anastomotic strictures, (2) external obstruction of the esophagus caused by primary or secondary tumors of the mediastinum, (3) tracheoesophageal fistula, (4) esophageal perforation, (5) symptomatic treatment of malignant gastroesophageal anostomotic leak, and (6) benign esophageal or gastrointestinal strictures [1, 4].
Early complications of stents can be described as chest pain, bleeding, perforation, aspiration, fever, and fistula. Late complications include dysphagia, bleeding, ulceration, perforation, fistula, stent torsion, and migration [1–3]. The application of self-expandable metallic stents (SEMS) is a method that provides comfort for patients. However, recurrent strictures are important and new interventions are costly [1]. Removal of SEMS is also an important problem when the stent passage is obstructed by hyperplastic tissue.
Herein we present the removal of tissue-embedded and occluded SEMS by using self-expandable covered plastic stents (SEPS) before revision of anastomosis in a patient who underwent an operation for caustic stricture of the esophagus.
In November 2002, a 32-year-old woman presented to the emergency unit due to the intake of a caustic substance. Multiple esophageal and gastric strictures had developed, which had not responded to multiple endoscopic dilatations. Esophagectomy, partial gastrectomy and esophagocolostomy had already been performed in another institution. She presented to our clinic in postoperative month 4 with dysphagia. An anostomotic stricture was found in barium swallow radiography. Endoscopic examination also revealed the anostomotic stricture at the 20th to 24th cm. A jejunostomy was performed. In the follow-up period, bougie and pneumatic dilatations were performed 6 times. However, dysphagia did not resolve. For this reason, a covered SEMS (Nanjing Microtech Co, Jiangsu, China) was inserted onto the stricture line (Fig 1A). Migration occurred on the second day after stent insertion. The stent was removed and oral intake was stopped. Ten days later, a new SEMS was inserted to improve dysphagia. However, hyperplastic tissue developed at the proximal and distal ends of the stent 1 month later. Endoscopic dilatations were performed 5 times. Two months later, hyperplastic tissue filled the stent lumen (Fig 1B). A SEPS (Polyflex Stent, Rüsch-Germany) was inserted through the SEMS, but 3 months later granulation tissue developed on the proximal and distal ends of the SEPS. To operate and reconstruct the anastomosis line, both SEMS and SEPS were removed after 3 months. A re-mediansternotomy and revision of the anostomotic line by freeing the colon and re-anastomosis were performed. Oral intake was begun on the postoperative day 10. A jejunostomy was installed at the same time. Endoscopy was performed on postoperative day 45, which revealed an intact anastomosis with no fistula and mild stricture. She underwent a control examination in postoperative month 9 and was found to have no symptoms.
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Fig 1. (A) A covered self-expandable metallic stent (SEMS) was inserted to solve the dysphagia problem due to an anostomotic stricture that had not responded to multiple endoscopic balloon dilatations. (B) Granulation tissue development through a SEMS was observed at the endoscopic examination.
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Comment
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Treatment of esophageal caustic strictures is very difficult and time consuming. Some authors suggest the use of covered SEMS or SEPS during the healing period [1]. Hyperplastic tissue growth is an important problem in these patients. The SEPS can be applied to solve this problem [5]. However, in most series, surgery seems to be the best method for improvement of dysphagia [6–8]. Reconstruction with colon interposition has been applied for benign strictures of the esophagus [6–8]. Late postoperative complications are cervical pseudodiverticulum, anostomotic stricture, subdiaphragmatic redundance, and pyloric obstruction [8]. Anostomotic stricture can be managed by using stents, but the results are unsatisfactory [4]. Furthermore, stents can cause some important complications like migration, perforation, and re-stenosis [1–4]. Self-expandable metallic stent implantation involves some difficulties. The most important one is that it cannot be applied easily at all levels. The rates of perforation and fistula development have been reported as 10% to 20% in some series [1, 2].
Removal of the SEMS was impossible, especially in the late period because of granulation tissue development or tumoral growth in cases in which no additional interventions have been performed [1]. For this purpose we used SEPS through SEMS. The SEPS causes necrosis in the hyperplastic tissue and makes removal of both SEMS and SEPS easier. Stents can be considered as solution for benign and anostomotic strictures. However, SEMS is not suitable for benign strictures when SEPS can be used to improve dysphagia. According to most series, we can conclude that surgical repair is the best method to improve dysphagia due to stricture [6–8]. As a matter of fact we obtained the definitive solution with surgical repair of the anostomotic stricture, as many authors have suggested.
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References
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Abstract
Introduction
