Aspiration of esophageal mucosa after esophageal stent removal

A 59-year-old man with achalasia underwent thoracoscopic myotomy of the circular muscle layers and resection of a midesophageal diverticulum. This procedure was complicated by a small midesophageal staple line defect with development of a fistula to the right side of the chest. Because of the dilated esophageal lumen and the risk for stent migration, it was decided to place a 10-cm-long, 23-mm-diameter, partially covered self-expandable metal stent (SEMS) (Ultraflex; Boston Scientific, Natick, MA) to close the fistula and prevent migration. However, the fistula could only be partly covered by the SEMS, and 2 weeks later it was decided to remove the SEMS. There was already significant hyperplasia at both ends of the stent, and the stent was firmly fixed to the esophageal wall. Therefore, by use of a two-channel endoscope, both sides of the distal margin were grabbed with two rat-toothed forceps, and the SEMS was inverted and removed. Immediately afterward, the patient became stridorous. Reintroduction of the endoscope revealed that a 7-cm-long circular segment of esophageal mucosa (E) had become stripped, had been aspirated, and had prolapsed inside out into the trachea (T) while still connected to the proximal esophagus (A). The tubular segment of esophageal mucosa was removed from the trachea, reinverted, and pushed back inside the esophagus by use of the endoscope. Two months later, the fistula had closed under conservative management with intrathoracic drains (D) (B); however, a refractory stricture had formed at the distal end of the stripped mucosa. The patient is scheduled for esophagectomy with gastric pull-up reconstruction.