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Background: Fully covered self-expandable metal stents (FCSEMSs) have been proposed for the treatment of benign esophageal diseases., Objective: To review our experience with FCSEMSs in patients with benign esophageal diseases., Design: Retrospective case review of patients who underwent FCSEMS placement for benign esophageal diseases, including (1) benign strictures from GERD--caustic and idiopathic causes, (2) radiation-induced strictures, (3) anastomotic strictures, (4) esophageal fistulae/leaks, and (5) esophageal perforations., Setting: Tertiary-care medical center., Patients: This study involved 37 male and 19 female patients (average age 60 years, range 25-94 years) who underwent FCSEMS placement., Intervention: FCSEMS placement., Main Outcome Measurements: Technical success with stent placement and removal, stent migration, long-term and short-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging., Results: Stent placement was successful in 100 of 107 (93%) procedures, with a total of 104 stents placed. Migration was noted in 37 of 104 (35.6%) stents and was seen more frequently with proximal stents and stents placed for anastomotic strictures. Initial treatment success was seen in 56% of patients with any stricture and in 38% of patients with a fistula/leak or perforation, although data to document long-term resolution were lacking., Limitations: This was a retrospective review with patients selected from a tertiary-care medical center. Two endoscopists performed the majority of procedures., Conclusion: Temporary placement of FCSEMSs for benign esophageal diseases has moderate clinical efficacy and is limited by stent migration. Removability was easily demonstrated. Newer developments in stent design may improve clinical outcomes for these patients., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery., Objective: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass., Design: Case series., Setting: Federal University of Pernambuco and São Paulo University., Patients: This study involved 39 consecutive patients who were screened for inclusion., Intervention: Endoscopic dilation with an achalasia balloon., Main Outcome Measurements: Technical success and safety of the procedure., Results: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months)., Limitations: This was not a randomized, comparison study, and the number of patients was relatively small., Conclusion: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Endoscopic removal of malfunctioning self-expandable metallic biliary stents (SEMS) is difficult and not well described. The aim of this study is to review the indications, the techniques, and the results of SEMS removal in a cohort of patients with malfunctioning stents., Methods: All patients who underwent an attempt at endoscopic removal of biliary SEMS over a 5-year period were retrospectively identified. The main indications for SEMS removal were the following: distal migration of the stent or impaction to the duodenum, impaction into the bile-duct wall, tissue ingrowth, and inappropriate length of the stent causing occlusion of intrahepatic ducts. SEMS were removed by using foreign-body forceps or polypectomy snares., Results: Endoscopic removal of 39 SEMS (13 uncovered and 26 covered) was attempted in 29 patients (17 men; mean age, 66 years). SEMS extraction was attempted after a mean of 7.5 months (8.75 months standard deviation) post-SEMS insertion. Removal was successful in 20 patients (68.9%) and in 29 SEMS (74.3%). Covered SEMS were effectively removed more frequently than uncovered ones: 24 of 26 (92.3%) and 5 of 13 (38.4%), respectively (p < 0.05). No major complications were recorded. Multivariate analysis showed that the time interval between insertion and removal, SEMS length, stent-mesh design (zigzag vs. interlaced), and indication for removal were not predictive of success at stent removal., Conclusions: Endoscopic removal of biliary SEMS is feasible and safe in more than 70% of cases. Because only 38% of uncovered SEMS were removable, the presence of a stent covering is the only factor predictive of successful stent extraction. The presence of diffuse and severe ingrowth was the main feature limiting SEMS removal.

Background: Intragastric migration is a known complication of gastric banding for morbid obesity., Methods: Instead of immediate reoperation, complete migration of the Swedish Adjustable Gastric Band (SAGB) into the gastric lumen was awaited in 4 patients who were asymptomatic., Results: After completed migration, the episternally placed access port was removed with the patient under local anesthesia, and the disconnected adjustable band was retrieved endoscopically. All 4 patients underwent rebanding with SAGB within 3 months after extraction., Conclusions: With this procedure, patients who are asymptomatic can be spared laparotomy and possibly gastrostomy.

Background: Extraction of a migrated esophageal stent may be extremely difficult with a substantial risk of complications including esophageal perforation and hemorrhage., Methods: Retrospectively 242 patients were evaluated who underwent implantation of self-expanding metal stents (SEMS) and 13 (5.4%) were identified with distal stent migration. In all cases of stent dislocation into the stomach, extraction of the stent was not attempted and a new stent was inserted., Results: Twelve patients had dysphagia. One patient underwent surgery because of stent impaction in the colon, 3 had unrecognized passage of the stent per rectum, and 9 had evidence of the stent into the stomach. Further severe complications were not observed in any patient and all stents remained into the stomach., Conclusion: Complications arising from migrated esophageal stents are uncommon. Further studies are warranted to determine which patients with migrated SEMS warrant stent retrieval.

Background: Endoscopic retrieval of proximally migrated biliary plastic stents may be technically challenging and sometimes unsuccessful. Despite the widespread use of such stents, there are few reports on the technique for retrieval of migrated stents., Methods: We reviewed the records of patients who were found to have proximally migrated biliary stents during the last 3 years at a tertiary referral center. Our study analyzed the various techniques used for endoscopic retrieval and evaluated the factors influencing the choice of a particular technique., Results: Endoscopic retrieval of a proximally migrated stent was attempted in 41 patients and was successful in 37 (90%). The retrieval techniques included Dormia basket, balloon, balloon and basket, basket and ball tip catheter, forceps, and Soehendra stent retriever. The Dormia basket technique was successful in the majority of cases., Conclusion: Proximally migrated biliary stents can be successfully removed endoscopically in most cases. The choice of a retrieval technique is dependent on several factors including biliary ductal dilatation, depth of stent migration, distal stent impaction and biliary stricture distal to the migrated stent. The placement of an additional stent alongside an irretrievable stent is a satisfactory alternative to retrieval.

Background: Migration of biliary endoprostheses is a recognized complication of bile duct stenting. Removing a stent that has migrated is usually straightforward, but this can be challenging when the stent is firmly impacted in the opposite wall of the duodenum or within a diverticulum. We describe a new technique for removing such impacted stents using a guidewire/basket lasso., Methods: To perform the lasso technique, a retrieval basket and a guidewire are passed side-by-side through the accessory channel of the duodenoscope. The basket catheter is advanced underneath the stent and the guidewire manipulated over the stent; the basket is opened and the guidewire advanced through it. Closure of the basket creates a loop around the stent that can then be removed using gentle traction., Results: The lasso technique was successfully used in three cases where other maneuvers failed., Conclusions: Biliary endoscopists should find this technique useful for retrieval of distally migrated biliary stents that are impacted against mucosa or the wall of a diverticulum so as to prevent standard basket extraction.

Background: When self-expanding metal stents are used in the palliative treatment of malignant stenoses complications can occur and require the endoscopic extraction of the stent., Methods: Three Gianturco-Z stents and two EsophaCoil stents had to be extracted because of migration (4 patients) and strangulation of healthy esophageal tissue between the coil loops during EsophaCoil stent release (1 patient). Because of the strong expansion force of the Gianturco-Z stent, the plastic sheath of a polypectomy snare was replaced by the steel sheath of a basket used for mechanical lithotripsy of bile duct stones. The sufficient resistance of the steel sheath allowed the stents to be compressed. The EsophaCoil stents were gradually retracted with a polypectomy snare over a plastic tube., Results: All stents could be extracted successfully. There were no severe complications related to extraction., Conclusion: By means of the endoscopic extraction techniques described above, it is possible to safely remove self-expanding esophageal stents.

Background: Proximal migration of a biliary stent is an uncommon event, but its management can present a technical challenge to the therapeutic endoscopist., Methods: We reviewed the methods that have been used for retrieval of proximally migrated biliary stents in a referral endoscopy center., Results: Forty-four cases were identified; 38 stents (86%) were extracted successfully. Half of the stents were retrieved after first passing a guide wire through the stent lumen. Various accessories were then used to withdraw the stents, the Soehendra device being the most popular. Nearly one third were retrieved by grasping the stents directly, usually with a wire basket or forceps. The remainder were recovered after using a stone retrieval balloon alongside the stents to provide traction indirectly. Interventional radiology techniques were needed in two cases, and surgery in one., Conclusions: Cannulating the stent lumen with a wire is often the best approach in patients with a biliary stricture or a nondilated duct. An over-the-wire accessory can then be used to secure the stent. In patients with a dilated duct, indirect traction with a balloon or direct grasping of the stent with a wire basket, snare, or forceps is usually successful. Using these techniques, most proximally migrated biliary stents can be retrieved endoscopically.