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UEG Week Berlin 2025 Recordings Gut Guide online

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Clinical Case Summary

A 67 old male patient with Hx of DM, HTN, IHD and previous repair of paraumbilical hernial defect. He had history of multiple previous ERCP with difficult stone extraction and stent placement to secure biliary drainage.
He presented with fever and abdominal pain mainly at re-herniated defect at paraumbilical region. By examination we found ulcerated skin over the hernial sac with a small foreign body protruding from it. He was sent for radiology and performed abdominal CT examination which commented on a mispositioned/slipped biliary stent along with CBD dilatation. Initial labs showed elevated TLC and bilirubin. he admitted that he neglected the instructions to make an appointment for stent exchange after 3 months as he was told after the last ERCP 2 years ago.
Surgical consultation was done to inspect the ectopic stent, they removed it and recommended for follow up of the fistulous opening only as the CT didn't show serious injuries or any abdominal free fluid.
The ectopic stent was impacted inside an intestinal loop inside the hernial sac and couldn't take the natural pathway out of the body with the excreta.
When we saw the slipped stent that punctured its own way out through the hernia out of the patient's body, we thought that this strange finding was the only surprise that the patient can give us.
Patient was planned for ERCP to secure biliary drainage.
After cannulation while performing ERCP, the cholangiogram revealed another surprise, The patient had another hidden stent, an internally migrated one.
It was removed by balloon sweeping and another new double pigtail stent was inserted to ensure more stability.
Upon our request we brought the previous ERCP reports to be revised. We found that the last procedure 2 years ago reported a missed stent already and he put a new one. This means that the hernial stent was the older slipped one and kept in place for this whole time till it decided to get out and the newer stent was internally migrated.

MISSED STENT? BETTER DOUBLE CHECK

Ahmed M. Gaheen 1, Ahmed Altonbary 2

1 Specialized Medical Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt

2 Mansoura Specialized Medical Hospital, Mansoura, Egypt

Conference

UEG Week Berlin 2025

Topics

Hepatobiliary

Submission format

Clinical Case

Session

CLINICAL CASES (Posters)

Published

2025

UEG Presentation

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MANAGEMENT OF DELAYED PERFORATION AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING VAC-STENT

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Introduction

The vacuum-assisted closure stent (VAC-stent) is a novel approach for managing esophageal defects, combining endoscopic vacuum therapy (EVT) and metal stent support to promote effective tissue healing [1].
We present a case of esophageal perforation following circumferential Endoscopic Submucosal Dissection (ESD), successfully managed with a VAC-Stent (video 1).

Aims & Methods

We report a case of a 59-year-old man with a 40mm lesion involving 75% of the esophageal circumference (Paris 0-IIa + Is), arising in Barrett’s esophagus (Prague C4M5) and consistent with adenocarcinoma, who was referred to our unit. CT scans excluded metastatic disease, and after multidisciplinary consultation, ESD was planned.

Results

Circumferential ESD was performed using a triple-tunnel approach. After the resection, muscular tears were closed with through-the-scope (TTS) clips, and pre-emptive Endoscopic Vacuum Therapy (EVT) was applied to enhance granulation and healing.
Due to rising inflammatory markers and fever onset, an esophagogastroduodenoscopy (EGD) was performed on the 3rd Post-Operative Day (POD). The EGD revealed two <5mm perforations 4cm apart, and a VAC-stent was placed to bridge the defects. At the follow-up EGD on the 9th POD, a single defect remained, and a new VAC-Stent was placed. The patient showed progressive clinical improvement and successfully resumed a liquid diet. By the 15th POD, the perforations had healed.
The patient was discharged in good clinical condition on the 18th POD.
At the EGD on the 30th POD, homogeneous healing tissue was observed, with no stricture detected at the resection site.
Histological analysis of the ESD specimen revealed moderately differentiated adenocarcinoma with submucosal invasion: pT1b (sm1) pNX G2, with R0 resection achieved and no high-risk pathological features. An oncological and endoscopic follow-up was planned.

Conclusion

Our case demonstrates that the VAC-Stent is a safe and effective method for treating perforations following esophageal ESD. In cases of circumferential ESD, VAC-stent use may also help prevent strictures.

References

[1]. Dell’Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New “Kid on the Block” Who Marries the Best of Old Techniques—A Review. Journal of Clinical Medicine 2024; 13: 3805. doi:10.3390/jcm13133805