Breaking through stent overgrowth: stepwise endoscopic removal using electrosurgical techniques

Abstract

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Self-expanding metal stents (SEMSs) represent the gold standard for palliation of malignant esophageal strictures 1 . However, tumor ingrowth and benign hyperplastic tissue reactions may lead to recurrent dysphagia and firm stent embedment, which makes stent removal challenging 2 . In these situations, the stent-in-stent technique is considered the standard approach; nevertheless, it increases costs and is not feasible in patients who have already undergone this strategy 3 . Thermal ablative techniques, such as argon plasma coagulation, have been used to treat hyperplastic tissue, but available data regarding their safety are limited 4 . In complex cases, the use of electrosurgical devices may allow safe and effective stent retrieval 5 .

We report the case of a 75-year-old patient with esophagogastric junction cancer who had previously undergone two SEMS placements using the stent-in-stent technique. Despite a good oncological response to therapy, the patient developed severe recurrent dysphagia ( Video 1 ). Endoscopic evaluation revealed an impassable luminal stenosis caused by tissue overgrowth at the proximal flange. Radial incisions of the hyperplastic tissue were first performed using a needle knife, exposing the stent mesh of the proximal edge and allowing the successful retrieval of the inner stent with rat-tooth forceps. Inspection of the remaining outer stent showed deep embedment of the distal flange in the gastric wall due to exuberant tissue ingrowth. As mechanical traction was unsafe, an ESD knife (ClearCut J type) was used to carefully dissect the hyperplastic tissue, allowing the complete release and extraction of the stent. The patient was discharged on the same day without adverse events. Follow-up endoscopy at 1 week confirmed restored luminal patency.

This case demonstrates that severe tissue ingrowth in stent-in-stent scenarios can be safely managed using endoscopic electrosurgical techniques. The combined use of a needle knife and an ESD knife represents a safe and effective strategy for deeply embedded stent removal, avoiding more invasive interventions.

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