Vocal cord paralysis due to self-expandable metal stent in the proximal esophagus.

A 56-year-old man was referred for endoscopic treatment of benign postoperative stenosis of an esophagogastric anastomosis with a proximal fistula to the neck. He had previously undergone chemoand radiotherapy for squamous cell carcinoma of the proximal esophagus. Because of recurrent malignancy, esophageal resection with tubular gastric reconstruction was performed. Postoperative dysphagia and cutaneous fistula to the neck occurred. Endoscopic examination revealed pinpoint stenosis at 2cm distal to the upper esophageal sphincter with a fistula below the sphincter (●" Fig.1). Under fluoroscopic guidance, and with the patient under general anesthesia, balloon dilation of the stenosis up to 8mm was performed and an 8-cm-long, fully covered self-expandable metal stent (SEMS) was placed, covering the fistula (●" Fig.2). Barium swallow confirmed sealing of the fistula and good stent position and deployment (●" Fig.3). The patient experienced no pain or dysphagia and was allowed to eat semifluids. Four days later he was admitted to the emergency room because of hoarseness and severe stridor. Endoscopy showed bilateral vocal cord paralysis without edema or compression and a good stent position immediately below the upper esophageal sphincter (●" Fig.4). After endotracheal intubation, the stent was removed by inversion, revealing a dilated stenosis (●" Fig.5). After weaning 2 days later, the vocal cord paralysis gradually improved Fig.3 Barium swallow confirming closure of the internal opening of the proximal cutaneous fistula. Fig.2 Placement of a fully covered metal stent under fluoroscopic guidance with two external markers identifying the location of the upper esophageal sphincter and the stenosis.