Endoscopic removal of a mesh penetrating into the esophagus using overtube-assisted endoscopy, fully covered metal stent, and over-the-scope clip

A 67-year-old woman with a history of abdominal wall hernia repair and surgical removal of mesh 18 months previously, presented with dysphagia and odynophagia of 2 weeks’ duration. On EGD, a large piece of mesh was clearly visible in the distal esophagus (Fig. 1; Video 1, available online at www.giejournal.org). A diagnosis of mesh migration with transluminal penetration was made. Endoluminal removal of the mesh was performed by the use of advanced endoscopic methods. The key steps of the procedure were as follows: (1) endoscopic and radiologic definition of the status of the distal esophagus and gastroesophageal junction with clear localization of the mesh and its screw; (2) over-the-wire, through-the-scope controlled-radial-expansion balloon dilation of the distal esophagus to liberate the mesh from fibrotic adhesions and increase the distal esophageal diameter; (3) careful inspection of the fundus to rule out other lesions and penetrations; (4) overtube placement allowing countertraction against the gastroesophageal junction wall during endoscopic removal of the foreign material; (5) placement of a fully covered self-expanding metal stent to expand the fibrotic stenosis and allow for recanalization of the lacerated gastroesophageal junction; and (6) anchoring of the self-expandable metal stent with an over-the-scope clip. This case is an example of extreme endoscopy, in which multiple instruments, skills, and techniques become mandatory to solve a complex endoscopic problem.