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SC Grover, CS Wang, MB Jones, M Elyas, P Kortan
Division of Gastroenterology, St Michael's Hospital, Toronto, Ontario

Endoluminal stenting of the esophagus is the most commonly employed form of palliation for inoperable malignant esophageal stenoses, and self-expanding metallic stents (SEMS) are the most common endoluminal prostheses used. Late complications of SEMS insertion include stent migration, esophagorespiratory fistula, recurrent food bolus obstruction, esophageal bleeding, stent fracture and airway compression. Here we present for the first time an iatrogenic intussusception of a SEMS in a patient with multiple esophageal stents.
A 77-year-old man with inoperable adenocarcinoma of the gastric cardia, with extension into the distal esophagus and metastatic deposits of the anterior stomach wall, was initially managed with a 12 cm Ultraflex (Boston Scientific, USA) nitinol covered SEMS followed by three cycles of combination chemotherapy. His course was complicated by recurrent food bolus obstruction and tumour overgrowth, managed by the deployment of a 15 cm Ultraflex SEMS completely overlapping the initial stent.
Five months following the second SEMS insertion, the patient presented with recurrent dysphagia, and endoscopy showed distal tumour overgrowth. A Savary guidewire was inserted under direct vision, but became lodged in the wall of the 15 cm SEMS. After initial attempts at withdrawal were unsuccessful, the guidewire and endoscope were removed together using gentle force. Fluoroscopy done immediately afterward showed intussusception of the distal end of the stent into the proximal, resulting in complete esophageal obstruction. The patient underwent a second procedure, wherein the 15 cm SEMS was removed using rigid alligator forceps. Gross examination of the 15 cm SEMS confirmed the intussusception with unpeeling of the nitinol covering.
With the ease and frequency of SEMS insertion for palliation of malignant esophageal stenoses, a greater number of patients will require multiple endoscopic procedures for management. There is little in the literature regarding the risks and complications of multiple stent insertion. The endoscopist should remain aware of iatrogenic complications - including stent intussusception - of repeated endoscopic procedures in the patient with multiple SEMS.