Two-step removal of a migrated double-layered stent through a neoplastic stenosis using another double-layered stent and endoloops.

Double layered self-expanding metal stents (SEMSs) are an effective treatment when placed across the gastroesophageal junction for malignant esophageal obstructions. Thedouble layer provides effective prevention of stent migration, with the advantages of a covered stent [1]. However, should the stent migrate, the double layer makes endoscopic removal more difficult. A 79-year-old manwith symptoms of dysphagia was diagnosed as having a distal esophageal neoplasm during an esophagogastroscopy performed in another hospital. Biopsies confirmed a diagnosis of adenocarcinoma. Because of his persistent dysphagia it was decided to place a double-layered SEMS before he started chemotherapy. After the first cycle of chemotherapy, the patient presented to our hospital with symptoms of aphagia. Gastroscopy was performed, which revealed a malignant stricture that was preventing passage of the endoscope. An abdominal radiograph showed a migrated double-layered stent within the gastric chamber.After explaining to the patient and his family members, we decided to place a new 100×18-mm double-layered SEMS under fluoroscopic control. Thepatient showedan improvement in his symptoms and remained in the hospital for48hours on liquid feeding. Subsequently he underwent a repeat endoscopy, at which the double-layered SEMS was shown to be fully expanded (●" Fig.1a). The new stent allowed the endoscope to be passed into the stomach, where the migrated double-layered SEMS could be seen (●" Fig.1b). Because we knew that the inner diameter of the new esophageal stent was less than the size of the ends of the migrated stent, we decided to use endoloops (Polyloop, HX-400U-30; Olympus) to reduce the radial size of themigrated stent.Weplaced four endoloops along the stent body, reducing considerably its size (●" Fig.1c,d). We then used a grasping forceps (Polygrab