How to diagnose esophageal stent migration?

Diagnosing Esophageal Stent Migration

Endoscopic evaluation is the gold standard for diagnosing esophageal stent migration, which should be performed promptly when migration is suspected based on recurrent dysphagia, chest pain, or other symptoms. 1

Clinical Presentation

Stent migration occurs in approximately 30% of cases, particularly with fully covered self-expanding metal stents (FCSEMS) 2, 1. Patients with stent migration may present with:

• Recurrent dysphagia (primary symptom)
• Chest pain (occurs in 15.6% of patients)
• Abdominal pain (if migration to small bowel)
• Vomiting
• Respiratory symptoms (if proximal migration)
• Asymptomatic (migration may be detected on routine follow-up)

Diagnostic Algorithm

Step 1: Clinical Suspicion

• Suspect stent migration when patients develop recurrent dysphagia after initial improvement
• Be particularly vigilant in patients with risk factors for migration:
  • Fully covered stents (higher migration risk than partially covered)
  • Stents crossing the gastroesophageal junction
  • Absence of stricture to anchor the stent
  • Prior esophagectomy 3

Step 2: Immediate Diagnostic Tests

1. Plain Radiography

   • Chest and abdominal X-rays to identify stent position
   • Most stents are radiopaque and visible on plain films
   • Can detect gross migration but lacks detail

2. Endoscopic Evaluation (Gold Standard)

   • Direct visualization of stent position
   • Can assess for:
     • Complete migration (stent no longer in intended position)
     • Partial migration (stent displaced but still partially functional)
     • Complications related to migration (mucosal injury, perforation)
   • Allows for immediate intervention if needed 1

3. Computed Tomography (CT)

   • Indicated when:
     • Endoscopy is not immediately available
     • Complete migration is suspected beyond endoscopic reach
     • Complications like perforation are suspected
     • Patient presents with severe symptoms (abdominal pain, signs of peritonitis) 3
   • Can identify the exact location of migrated stent throughout the GI tract

Management Based on Diagnostic Findings

Once diagnosed, management depends on the extent and location of migration:

• Partial proximal or distal migration: Endoscopic repositioning using grasping forceps or snares 4
• Complete migration into stomach: Retrieval using an overtube, endoloop, or large polypectomy snare 4
• Migration into small bowel: Close monitoring if asymptomatic; surgical intervention if obstruction or perforation occurs 3

Prevention of Future Migration

After diagnosing and managing stent migration, consider preventive measures for future stent placements:

• Stent fixation techniques:
  • Endoscopic clips to anchor the proximal flange (reduces migration from 34% to 13%) 5
  • Endoscopic suturing for high-risk locations 2
  • Over-the-scope clips 2
• Stent design considerations:
  • Larger diameter stents when crossing the gastroesophageal junction 2
  • Stents with larger flanges or double-layered designs 4, 6

Common Pitfalls and Caveats

• Delayed diagnosis: Regular follow-up is essential as symptoms may develop gradually
• Overlooking small bowel migration: Can lead to serious complications including perforation and peritonitis 3
• Incomplete retrieval: Ensure complete removal/repositioning to prevent further complications
• Inadequate follow-up: Patients with esophageal stents require regular monitoring to detect migration early 3

By following this diagnostic approach, clinicians can promptly identify esophageal stent migration and implement appropriate management strategies to minimize complications and improve patient outcomes.