Predictive factors for the migration of endoscopic self-expanding metal stents placed in the foregut

Jordan Singer, Amir H Aryaie, MD, Mojtaba Fayezizadeh, MD, John Lash, Jeffrey Marks, MD. Case Western Reserve University/ University Hospitals Case Medical Center

Introduction:  With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aims to determine predictive factors for stent migration.

Methods: Consecutive patients who received a SEMS with or without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, type of surgery, rate of stent migration, and type of stent (fully covered, partially covered, and uncovered) was collected. Rate of stent migration were compared between those fixated vs. non-fixated.

Results: 214 consecutive stent placements for leak after foregut surgery, foregut stricture, and foregut perforation were included. Average duration of stent placement was 50.5 (range 0-358) days.  43 (19%) stents migrated after the procedure. Of those that migrated, 33 stents (15%) were removed and 27 (13%) required another stent placement. 11 (5%) procedures utilized stent fixation and 203 (95%) did not incorporate fixation of the stents. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Rate of stent migration was not different between those with and those without fixation (36% vs. 19% respectively, p=0.2). 134 (63%) procedures used a fully covered stent, 36 (17%) used a partially covered stent, and 44 (20%) used an uncovered stent. Rate of migration was significantly higher in procedures involving fully covered stents (30%, vs. 3%, vs. 5%, respectively (p<0.001). Migration occurred mostly after esophagectomy, gastric bypass, and gastero-jejunostomy (50%, 50%, and 25% respectively).

Conclusion: A big challenge with the use of SEMS in the treatment of gastrointestinal leaks, perforation and strictures is stent migration. The use of stent fixation did not appear to be associated with prevention of stent migration while the use of stent covering and type of surgery was predictive of the risk of migration.