Traumatic esophageal fistula secondary to self-expandable metal stent placement

A 40-years-old male with an anastomotic leak following esophagectomy for epidermoid cancer was treated endoscopically with a fully covered esophageal self-expandable metal stent (SEMS) (SX-ELLA Stent Esophageal HV 20 mm × 110 mm). The stent migrated distally and, although technically it was difficult, it was repositioned with a rat tooth retrieval forceps and fixed to the esophageal wall using a hemostatic clip of 11 mm (Resolution Clip 360™ – Boston Scientific, USA).

At 4 weeks of follow-up, an esophagram indicated that the leak had not completely healed, so the stent was maintained. The patient did not attend a scheduled esophagram at 6 weeks. The week after, he was admitted due to fever, cervical pain and erythema. A CT scan revealed an esophageal-subcutaneous fistula. The internal fistula orifice was originated at the upper SEMS end (Fig. 1A). The endoscopy showed that the steel retrieval wire of the SEMS was penetrating the esophageal wall. So, the SEMS was removed, and healing of the anastomotic leak was confirmed (Fig. 1B–E). The patient was discharged 3 days after and completed antibiotic therapy for 10 days.

Figure 1.

(A) Cervical CT image showing the esophageal fistula penetrating the subcutaneous cellular tissue (red arrow) secondary to the steel retrieval wire of the SEMS (yellow arrow). (B, C) Endoscopic image showing the esophageal SEMS and the steel retrieval wire penetrating the esophageal wall transmurally before its removal. (D) SEMS image after removal, verifying that the steel retrieval wire was deformed. (E) Endoscopic view of the esophageal mucosa after removal of the SEMS, where healing of the anastomotic dehiscence was observed, so a new SEMS was not placed. SEMS: self-expandable metal stent.

Temporary esophageal SEMS placement is an effective alternative in the management of anastomotic leaks.^1,2 Some SEMSs have a steel retrieval wire that facilitates removal.^3,4 In our case, when the stent was repositioned, the steel retrieval wire was deformed and contacted perpendicular with the esophageal wall, penetrating it until generating a fistula.

As conclusion, traumatic esophageal fistula is a potential adverse event when repositioning a metallic esophageal stent and therefore, care should be taken in its handling when it needs to be repositioned.

Funding

None.

Conflict of interest

Authors declare no conflict of interests for this article.