Gastric microperforation following bariatric surgical procedures is often treated with endoluminal esophagogastric stent placement [1][2][3][4]. Stent migration is a common occurrence, reportedly occurring in 30–50% of stent placements following sleeve gastrectomy micro leaks [2] [5] [6]. In most cases, antegrade stent migration is treated with repeat endoscopy and repositioning of the stent [5]. In rare cases, however, stent migration may result in intestinal injury or perforation and require surgery. Methods of stent fixation within the lumen have been proposed and include use of clips and the use of endoluminal suturing devices [7] [8] [9] [10]. We present five cases of stent migration including one resulting in jejunal perforation, and we report our experience with the use of endoluminal suturing to secure endoluminal stents and prevent migration.

Case 1
A 56-year-old male with morbid obesity who underwent a laparoscopic sleeve gastrectomy in Mexico two weeks prior to presentation at our center with sepsis due to a leak at the proximal staple line. He underwent a laparoscopic washout and drainage procedure followed by endoscopic placement of a fully covered endoluminal esophagogastric stent (fully-covered 150x23 mm WallFlex, Boston Scientific). His sepsis resolved, and improved clinically, tolerating clear liquids orally while being primarily nourished with total parenteral nutrition. After 15 days after of stent placement he developed abdominal pain and vomiting. Computed tomography scan demonstrated the stent had migrated beyond the pylorus to the jejunum (Figure 1). He developed increased pain and fever and underwent laparotomy at which time he was found to have a perforation of the jejunum due to the migrated stent. He underwent a resection of a segment of jejunum as well as removal of the stent. An attempt at suture closure and omental patching of the proximal gastric fistula was performed.

In the days following his recovery from laparotomy, the gastric fistula was evident from the drain output. He underwent repeat endoscopy and placement of a new endoluminal stent (fully-covered 150x23 mm WallFlex, Boston Scientific), this time secured to the esophageal wall with two endoluminal sutures through the proximal stent flange and the esophageal wall (absorbable suture Apollo Overstitch). For the next 12 weeks, the stent remained in position with the patient tolerating oral liquids and nourished with TPN. Repeat endoscopy was then performed and the stent was removed. The patient was able to advance to a regular diet, and no further gastric fistula recurred.

Case 2
A 46-year-old female with a history of morbid obesity and diabetes who underwent a laparoscopic sleeve gastrectomy procedure complicated by a delayed microperforation from the proximal gastric staple line and a subdiaphragmatic abscess. She underwent laparoscopic drainage and endoscopic stent placement (fully-covered 150x23 mm WallFlex, Boston Scientific). The stent resulted in the elimination of gastric fistula, but three times in the ensuing six weeks, the stent migrated antegrade to the pylorus, producing pain and vomiting (Figure 2). In each case, the stent was endoscopically repositioned. The final procedure included endoluminal fixation of the stent by suturing it to the esophageal wall with two sutures to the proximal stent flange (Apollo OverStitch). After the endoluminal suture fixation, the stent remained in position and was removed 10 weeks later, resulting in successful resolution of the gastric leak.

Case 3
A 38-year-old female with morbid obesity and hypertension who underwent a laparoscopic sleeve gastrectomy procedure and presented three weeks later with fever and left sided chest pain. She was found to have a gastric microperforation with fluid above and below the diaphragm. At surgery, a laparoscopic washout and drain placement were performed with tube thoracostomy and endoscopic placement of a fully covered stent (150 x 20 mm Evolution, Cook Medical). She quickly improved clinically and went home with a drain and stent in position, on TPN only to return three weeks postop with epigastric pain and retching due to migration of the stent. The perigastric drain turned cloudy and purulent and increased in volume, indicating a return of the gastric fistula. Repeat endoscopy was performed to reposition the stent, and it was secured with endoluminal sutures to the esophageal wall (Figure 3). No further migration occurred. The stent was removed after 12 weeks and the leak resolved.

Case 4
A 44-year-old female developed a leak from the proximal stomach 4 weeks after undergoing sleeve gastrectomy. She was treated with laparoscopic washout and drain placement followed by endoscopic stent placement. The stent migrated antegrade within two weeks and was replaced by two stents positioned in tandem (150x23 mm and 120x23 mm WallFlex, Boston Scientific). Three weeks later ,the stents migrated and were replaced by a single stent, secured with two endoluminal sutures to the esophageal wall (Figure 4). The stent remained in place until it was removed 12 weeks later.

Case 5 is that of a 49-year-old female with a history of gastric banding and recurrent obesity. She underwent concomitant removal of the band and conversion to sleeve gastrectomy. Two weeks postoperatively, she presented with sepsis and evidence of a leak from the proximal staple line. Open surgical washout and drain placement was performed, and attempted primary closure of the fistula was unsuccessful. Endoscopic stent placement was performed (fully-covered 150x23 mm Wallflex, Boston Scientific), resulting in resolution of the gastric fistula, and the patient improved clinically. After three weeks the stent migrated distally and required repeat endoscopic positioning, this time secured with endoluminal suturing using two absorbable sutures through the proximal stent wall and the esophageal wall (Apollo OverStitch). No further stent migration occurred, and the patient eventually fully recovered.

Endoluminal stenting has proven to be an effective mode of treatment for esophageal and gastric leaks, perforations, structures, and fistulae [1] [2][3][4]. With the growth of sleeve gastrectomy, there has been a parallel growth in delayed microperforation, the most serious and frequent complication of sleeve gastrectomy. Endoluminal stent migration, while normally fairly innocuous does cause vomiting and epigastric pain for the patient. It also requires an additional procedure for repositioning of the stent. However, as this first case presented here points out, it is a potentially very serious and life-threatening complication.

In this paper, we report five cases in which antegrade migration of endoluminal esophagogastric stents occurred at least once following stent placement for sleeve gastrectomy leaks. One of these cases resulted in a severe complication of jejunal perforation. In each case, repeat endoscopy was performed to reposition the stent and secure the stent in position with an endoluminal suturing technique. In each of those cases of stent fixation utilizing endoluminal sutures to the esophageal wall, no stent migration occurred. No complications of the suture fixation technique occurred.

Migration of endoluminal stents has been a reported and vexing complication occurring in a significant number of cases [2] [5][6]. Reports that emphasize use of clips, tandem stenting, or other fixation techniques have suggested that the techniques may provide greater security, although that has not been well demonstrated. In case one reported above, the patient experienced a serious complication of jejunal perforation following stent migration. In an effort to prevent such complications, our practice turned to a procedure of suture fixation utilizing an endoluminal suture device technique (Apollo Overstitch).

Other authors have reported use of endoscopic clip placement, utilization of tandem stents, and the use of partially covered stents in order to reduce stent migration [3] [5]. In our experience, the endoluminal suturing technique has proven successful, potentially more robust than clipping, and easy to perform.

Endoluminal suturing is technically straightforward and successful in preventing endoluminal stent migration. After some practice, it adds only a short amount of additional time to the procedure, normally less than 15 minutes. At this point, given our experience resolving a devastating complication of stent migration, and after multiple repeat endoscopies to reposition migrated stents, endoluminal suture fixation has become standard approach to any endoluminal stent placement. Potential risks of routine suture fixation of endoluminal stents include bleeding or perforation from the esophageal wall suture placement, something we have not seen in clinical practice, and we are unaware of its having been reported to date. Concerns of esophageal wall suture placement must be balanced against the frequency and the risks of stent migration.

1. Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 2008 May;206(5):935–8; discussion 938–9.   [CrossRef]   [Pubmed]    
2. Simon F, Siciliano I, Gillet A, Castel B, Coffin B, Msika S. Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time. Obes Surg 2013 May;23(5):687–92.   [CrossRef]   [Pubmed]    
3. Gonzalez JM, Garces Duran R, et al. Double-type metallic stents efficacy for the management of post-operative fistulas, leakages, and perforations of the upper gastrointestinal tract. Surg Endosc 2015 Jul;29(7):2013–8.   [CrossRef]   [Pubmed]    
4. van Boeckel PG, Dua KS, Weusten BL, et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012 Feb 29;12:19.   [CrossRef]   [Pubmed]    
5. Galloro G, Magno L, Musella M, Manta R, Zullo A, Forestieri P. A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series. Surg Obes Relat Dis 2014 Jul-Aug;10(4):607–11.   [CrossRef]   [Pubmed]    
6. Martins BC, Retes FA, Medrado BF, et al. Endoscopic management and prevention of migrated esophageal stents. World J Gastrointest Endosc 2014 Feb 16;6(2):49–54.   [CrossRef]   [Pubmed]    
7. Fujii LL, Bonin EA, Baron TH, Gostout CJ, Wong Kee Song LM. Utility of an endoscopic suturing system for prevention of covered luminal stent migration in the upper GI tract. Gastrointest Endosc 2013 Nov;78(5):787–93.   [CrossRef]   [Pubmed]    
8. Irani S, Baron TH, Gluck M, Gan I, Ross AS, Kozarek RA. Preventing migration of fully covered esophageal stents with an over-the-scope clip device (with videos). Gastrointest Endosc 2014 May;79(5):844–51.   [CrossRef]   [Pubmed]    
9. Kantsevoy SV, Bitner M. Esophageal stent fixation with endoscopic suturing device (with video). Gastrointest Endosc 2012 Dec;76(6):1251–5.   [CrossRef]   [Pubmed]    
10. Sharaiha RZ, Kumta NA, Doukides TP, et al. Esophageal Stenting With Sutures: Time to Redefine Our Standards? J Clin Gastroenterol 2015 Jul;49(6):e57–60.   [CrossRef]   [Pubmed]