Endoloop application for the removal of a self-expandable metallic stent (SEMS) in an esophagocolonic anastomotic stricture.

Anastomotic strictures occur in 3%–46.2% of patients after colonic reconstruction of the esophagus [1]. Self-expanding metal stents (SEMS) are increasingly considered for refractory or complex benign strictures of the esophagus [2]. Migration is a common complication and the stent should be removed to avoid gastrointestinal complications. A 54-year-old manwas referred to our department for dysphagia following esophagectomy with colonic interposition to treat an esophageal adenocarcinoma. On esophagoscopy, a 5-mm wide and 3-cm long stricture, corresponding to the esophagocolonic anastomosis at 25cm from the incisors, could not be traversed. After five dilation sessions at 2-week intervals the patient was still dysphagic and a fully covered stent (HanaroStent, 80mm in length, 18mm in diameter; MI Tech, Seoul, Korea) was positioned. The patient reported clinical improvement for 2weeks but then the dysphagia recurred. Radiographic examination disclosed stent migration. Endoscopy confirmed its location at the distal part of the colonic segment, proximal to the cologastric anastomosis, and the persistence of the proximal anastomotic stenosis. We decided to re-dilate the stenosis up to 15mm (●" Video 1), and mobilize the stent proximally and try to remove it using endoloops to reduce the stent diameter. With the stent positioned in the colonic segment, four detachable ligating devices (MAJ 254; Olympus, Tokyo, Japan) were applied. Because of the eversion of its distal edge and the risk of the stent getting caught in the tissue, it was rotated and then retrieved by utilizing the “lasso” stitch at thestentedgeandpulling it against the endoscope. The whole assembly was subsequently removed under fluoroscopic control through the stricturewithout complications. The removal of migrated SEMS is technically challenging and different methods have been reported, including the use of endoloops [3–5]. To our knowledge this is the first video report of a stent retrieved from an esophagocolonic anastomosis.