Initial trimming followed by complete removal of an esophageal self-expandable metal stent for stent-related symptoms.

Placement of long, protruding self-expandable metal stents (SEMSs) into the gastrointestinal lumen may cause related symptoms. A few reports have described the usefulness of argon plasma coagulation (APC) for trimming or fenestrating a SEMS [1–4]. We report a trimming technique for a covered SEMS in the esophagus using APC in a retrograde fashion, followed by its complete removal. A 67-year-old woman presented with dysphagia. Esophagogastroduodenoscopy (EGD) showed a large ulcerated tumor in the esophagus with tumor excavation. A 12-cm partially covered SEMS was placed across the tumor. Subsequently the patient was able to resume eating solid food and underwent chemotherapy. However, 1 month after stent placement, she developed epigastric pain and dysphagia from impaction of the stent into the proximal stomach (●" Fig.1a). The distal portion of the stent was trimmed with APC using a generator at a setting of 80W and a flow rate of 2L/min (●" Fig.1b;●" Video 1). The procedure was performed with the scope in a retroflexed position to prevent esophageal mucosal injury. A length of the stent (approximately 4cm) was completely severed in a circumferential manner and was successfully removed from the stomach (●" Fig.2). After the procedure, the patient’s pain and dysphagia improved. After 3 months, however, she developed severe acid reflux and we decided to remove the remainder of the stent. Hyperplastic tissue at the uncovered proximal part of the stent was leveled using a stiff snare and APC to free up some of the mesh from the mucosa. The distal part of the stent was then grabbed with a rattoothed forceps, and the endoscope was withdrawn in a steady rotational fashion, such that the mesh eventually inverted, was dislodged, and then was successfully removed en bloc (●" Fig.3;●" Video 2). A subsequent esophagogram demonstrated Fig.1 Endoscopic images showing: a the esophageal covered metal stent with its distal edge protruding into the stomach wall (retrograde view); b the esophageal covered metal stent being trimmed using argon plasma coagulation in retroflexed view.