Stent migration after stent-in-stent technique using a biodegradable stent.

Self-expanding metal stents (SEMS) seem to be the optimal choice for benign esophageal disorders, especially those not associated with a stricture, such as anastomotic leaks, iatrogenic perforations, and fistulas. On the other hand stent embedding can be an important limitation of SEMS placement, because this precludes safe stent removal [1]. In fact, in the literature there are only a few case series reporting the stent-in-stent technique using SEMS to remove embedded stents (14– 189 days from the placement of the first stent) [2,3]. We report a case of a 65-year-old woman whounderwent total gastrectomy for adenocarcinoma and, 3 months later, dilation of an anastomotic fibrotic stricture complicated by a visceral tear and sepsis. This was treated by placement of an Ultraflex stent (Boston Scientific, Natick, Massachusetts, USA). After 6 months, the patient complained of dysphagia, and a second longer Ultraflex stent was placed inside the first one (●" Fig.1). Because of the worsening of the patient’s dysphagia in the preceding 6 months, the patient was referred to our division. Over a 2-month period, the patient underwent two treatments of argon plasma coagulation to reduce the reactive tissue and granulomatosis involving the not-covered esophageal proximal end of the stent, with partial reduction of her dysphagia (●" Fig.2 and●" Fig.3). We decided to remove the internal stent and place a biodegradable SX-ELLA BD stent (ELLA-CS, Milady Horakove, Czech Republic), overlapping the proximal segment of the first stent, in order to improve the patient’s quality of life (●" Fig.4). The endoscopic checks at 15 and 45 days from stenting showed correct positioning and integrity of both the biodegradable and Ultraflex stents. At the third endoscopic check, after 3 months, neither stent was in place and the esophageal mucosa was completely re-epithelizated. It appeared that the biodegradable stent had been entirely absorbed, while the Ultraflex stent had migrated and been expelledwith the stool because of pressure necrosis, arising from the biodegradable stent, of the overlying mucosa (●" Fig.5). Two abdominal X-rays performed over 2 months confirmed the Fig.1 The two overlapping Ultraflex stents.