Safety Evaluation of Paclitaxel-Eluting Biliary Metal Stent with Sodium Caprate in Porcine Biliary Tract

BACKGROUND/AIMS: Metallic stents designed to relieve malignant biliary obstruction are susceptible to occlusive tumor ingrowth or overgrowth. In a previous report, we described metallic stents covered with paclitaxel-incorporated membrane (MSCPM-I, II) to prevent occlusion from tumor ingrowth via antitumor effect. This new generation paclitaxel-eluting biliary stent is further endowed with sodium caprate (MSCPM-III) for enhanced drug delivery. The purpose of this study is to examine the safety of its drug delivery system in the porcine biliary tract. METHODS: MSCPM-III (10% [wt/vol] paclitaxel) and covered metal stents (CMSs) were endoscopically inserted in porcine bile ducts in vivo. Histologic biliary changes, levels of paclitaxel released, and various serum analytes (albumin, alkaline phosphate, aspartate transaminase, alanine transaminase, total protein, total bilirubin, and direct bilirubin) were assessed. RESULTS: Based on the intensity of reactive inflammation and fibrosis, changes in porcine biliary epithelium secondary to implanted MSCPM-III were deemed acceptable (i.e., safe). Histologic features in the MSCPM-III and CMS groups did not differ significantly. In a related serum analysis, paclitaxel release from MSCPM-III stents was below the limit of detection for 28 days. Biochemical analyses were also similar for the two groups, and no evidence of hepatic or renal toxicity was found in animals receiving MSCPM-III stents. CONCLUSIONS: In a prototypic porcine trial, this newly devised metal biliary stent incorporating both paclitaxel and sodium caprate appears to be safe in the porcine bile duct.

A Novel High-Visibility Radiopaque Tantalum Marker for Biliary Self-Expandable Metal Stents

BACKGROUND/AIMS: Radiopaque metal markers are required to improve X-ray absorption by self-expandable metal stents (SEMSs) to enable precise stent placement. A new tantalum radiopaque marker was recently developed using an ultrasonic spray technique. The aim of the present study was to evaluate the safety and visibility of tantalum markers. METHODS: A total of three beagle dogs were used for a gastrointestinal tract absorption test. Five tantalum markers were placed in the stomach of each dog endoscopically. Excreted tantalum markers were collected, and their weights were compared to the original weights. In radiopacity tests, marker radiopacities on X-ray images were quantified using ImageJ software and compared with those of commercially available metal markers. Finally, the radiographic images of six patients who underwent biliary SEMS placement using tantalum marker Nitinol SEMSs (n=3) or gold marker Nitinol SEMSs (n=3) were compared with respect to marker brightness on fluoroscopic images. RESULTS: Absorption testing showed that the marker structures and weights were unaffected. Radiopacity tests showed that the mean brightness and total brightness scores were greater for tantalum markers (226.22 and 757, respectively) than for gold (A, 209 and 355, respectively; B, 204.96 and 394, respectively; C, 194.34 and 281, respectively) or platinum markers (D, 203.6 and 98, respectively). On fluoroscopic images, tantalum markers had higher brightness and total brightness scores (41.47 and 497.67, respectively) in human bile ducts than gold markers (28.37 and 227, respectively). CONCLUSIONS: Tantalum markers were found to be more visible than other commercially available markers in X-ray images and to be resistant to gastrointestinal absorption.

Clinical Outcomes of Bilateral Stent-in-Stent Placement Using Self-Expandable Metallic Stent for High-Grade Malignant Hilar Biliary Obstruction

PURPOSE: Endoscopic bile duct decompression using bilateral self-expandable metallic stents (SEMSs) deployed via a stent-in-stent (SIS) method is considered a preferred procedure for malignant hilar biliary obstruction (MHBO). However, occlusion thereof occurs frequently. Here, we investigated stent patency duration and risk factors related to stent obstruction with bilateral SIS placement for MHBO at two large centers. MATERIALS AND METHODS: The present study reviewed data on patients with MHBO who underwent endoscopic biliary drainage using the SIS method. Clinical outcomes, including stent patency duration and patient overall survival, were analyzed. Factors associated with stent patency were evaluated using Cox proportional hazards models. RESULTS: Seventy patients with MHBO underwent endoscopic biliary drainage using the SIS method. Median age was 68 years old, and median follow-up duration was 140 days (interquartile range, 57–329). The proportion of high-grade MHBOs (Bismuth type IV) was 57.1%. Median stent patency duration with the SIS method was 108 days according to Kaplan-Meier curves. Median patient survival analyzed by the Kaplan-Meier method was 181 days. Multivariate analysis indicated that higher baseline bilirubin (> 6.1 mg/dL) as an independent risk factor related to stent patency (p < 0.05). CONCLUSION: In endoscopic biliary decompression using SEMS placed with the SIS method, obstructive jaundice was a risk factor for stent patency. The SIS method for high-grade MHBO showed short stent patency.

Application value of biliary stent in endoscopic retrograde cholangio pancreatography for treatment of benign biliary stricture after liver transplantation / 中华消化外科杂志

Objective To explore the application value of plastic biliary stent and fully covered self-expandable metallic stent (FCSEMS) in endoscopic retrograde cholangio pancreatography (ERCP) for treatment of benign biliary stricture after liver transplantation.Methods The retrospective cross-sectional study was conducted.The clinical data of 54 patients with benign biliary stricture after liver transplantation undergoing ERCP treatment who were admitted to the First Affiliated Hospital of Xi'an Jiaotong University between January 2010 and August 2016 were collected.Among 54 patients,44 had simple anastomotic stricture and 10 had non-anastomotic stricture.All the patients underwent stent implantation by ERCP.Patients with stricture within 1 month postoperatively initially selected single plastic stent or endoscopic nasobiliary drainage (ENBD),and then changed into multiple plastic stents at the second stent replacement.Patients with stricture after 1 month postoperatively selected multiple plastic stents,multiple plastic stents after balloon dilation or FCSEMS.Observation indicators:ERCP situations,stent implantation,time of stent indwelling,postoperative complications,stent dislocation,treatment outcome and follow-up situations.Patients were followed up by outpatient examination and telephone interview up to November 2016.Clinical symptoms of patients were observed within 1 month postoperatively and liver function and abdominal ultrasound were retested.Liver function and remission degree of biliary stricture were monitored regularly once every 3 months.Measurement data were described as average (range).Results All the patients underwent successful ERCP,of which 53 completed the process of ERCP and 1 rejected treatment due to economic problems.All the 54 patients received 140 times ERCPs with an average of 2.59 times per person,21 times ENBDs,11 times FCSEMSs and 108 times plastic stent implantations (including 35 times single stent implantations,46 times double stents implantations,23 times 3-stents implantations and 4 times 4-stents implantations).All the 54 patients were followed up for 3-143 months,with an average time of 73 months.Of 44 with anastomotic stricture,34 received plastic stent implantation and 98 times ERCPs,with an average number of stent implantation of 2 (range,1-4) and an average time of stent indwelling of 10.7 months (range,9.0-13.0months);the postoperative acute pancreatitis,biliary infection,hyperamylasemia and adverse stent implantation or dislocation were detected in 4 persons every time,7 persons every time,10 persons every time and 3 persons every time,respectively;26 patients were cured and 5 were improved,with an effective rate of 91.2％ (31/34);3 patients with noneffective treatment continued to undergo ERCP and 3 patients had recurrence of anastomotic stricture.Among 10 patients with initial FCSEMS implantation,12 times ERCPs were performed,with an average time of stent indwelling of 7.6 months (range,6.0-12.0 months);postoperative biliary infection,hyperamylasemia and stent dislocation were detected in 1 person every time,1 person every time and 1 person every time,respectively;8 patients were cured,with an effective rate of 8/10;of 2 patients with persistent stricture,1 patient received contrast examination after stent removal,showing a comparative stricture in level 1 branch of intrahepatic duct and considering combined ischaemia,and then underwent the second implantation using multiple plastic stents;the other patient had elevated level of jaundice at 3 months after stents removal and received ERCP,showing anastomotic inflammatory polyp,and then underwent FCSEMS implantation again.Ten patients with non-anastomotic stricture received plastic stent implantation and 30 times ERCPs,with an average number of stent implantation of 3 (range,2-4) and an average time of stent indwelling of 11.3 months (range,10.0-14.0 months);the postoperative acute pancreatitis,biliary infection,hyperamylasemia and adverse stent implantation or dislocation were detected in 2 persons every time,5 persons every time,2 persons every time and 1 person every time,respectively;3 patients were cured and 3 were improved,with an effective rate of 6/10;of 4 patients with noneffective treatment,2 died of gradually deteriorating liver function and 2 underwent the second liver transplantation.Conclusions Stent implantation in ERCP is safe and effective for treatment of benign biliary stricture after liver transplantation,single plastic stent should be used in the early period (within 1 month) and multiple plastic stents should be used in the later period.Although FCSEMS has a higher displacement rate,it should be recommended due to a better clinical effect,lower incidence of complications and simple operation.For patients with non-anastomotic stricture,plastic stent should be used for extrahepatic biliary stricture,with a good clinical effect,and there is worse effect in stent implantation through ERCP for multiple intrahepatic biliary strictures.

Endovascular repair of spontaneous extracranial internal carotid artery dissection: observation of mid-term clinical effect in 6 patients / 介入放射学杂志

Objective To preliminary evaluate the mid-term clinical effect of endovascular repair in treating spontaneous extracranial internal carotid artery (ICA) dissection,and to observe the patency of stent.Methods The clinical data and imaging materials of 6 patients with spontaneous extracranial ICA dissection,who were treated with endovascular repair during the period from March 2012 to December 2012,were retrospectively analyzed.The U.S.National Institute of Heahh Stroke Scale (NIHSS) scores were determined before and after endovascular repair,and the postoperative stent patency condition was assessed,the results were analyzed.Results A total of 6 patients,including 4 males and 2 females with a median age of 50 years old (40.75-54.75 years old),received endovascular repair therapy.The median interval from the onset of disease to accept endovascular treatment was 10 days (one week-3 months).After the implantation of stent,the blood flow in the true lumen returned to normal immediately,although part of the false lumen was still filled with contrast agent.Embolism of retinal artery occurred in one patient during the operation,no death occurred.The median follow-up time was 54.4 months (49.7-57.9 months).The NIHSS score determined at the last follow-up visit was not significantly different from the preoperative one (P=0.102).Imaging reexamination revealed that the false lumen at the ICA stent segment disappeared in all 6 patients,and no obvious in-stent stenotic changes were observed.Conclusion Endovascular therapy of selected symptomatic extracranial carotid artery dissection with bare stents can effectively prevent the recurrence of clinical symptoms and promote ICA remodeling with excellent mid-term patency.

Percutaneous transgastric stenting of proximal jejunal obstruction secondary to direct invasion of a pancreatic carcinoma

Pancreatic cancer has been identified as one of the most common malignant causes of upper gastrointestinal obstruction. Most common sites of obstruction include the pyloric region and second and third portions of the duodenum. If surgical gastrojejunostomy is not a viable option, metallic stent placement may be performed either by transoral or transgastric approach. Transgastric technique is considered to be more invasive and is often employed only in failed attempts to insert a stent using transoral technique. This report presents a 70-year-old patient with pancreatic cancer involving the proximal jejunum. Although this is a rarely described location for stenting, the patient was successfully treated using transgastric technique.

Spontaneous Common Bile Duct Perforation Treated with Placement of Metal Stent / 대한췌담도학회지

Perforation of the biliary tree mostly results from injury to the bile duct during surgery or procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and spontaneous bile duct perforation is rare in adults. As the clinical picture varies, early diagnosis and treatment of spontaneous biliary peritonitis is difficult. A 52-year-old male patient presented with abdominal pain and intractable ascites. He already experienced severe abdominal pain 2 months ago and underwent percutaneous pigtail drainage for the ascites at nearby hospital. ERCP showed large filling defect with leakage of contrast media from the mid common bile duct (CBD) into the peritoneal cavity. We performed endoscopic sphincterotomy and extracted CBD stones with basket and balloon catheter. Then fully covered self expandable metal stent was placed in CBD. After the procedure, the symptom was improved and the amount of pigtail drainage from abdominal cavity was dramatically decreased. 6 weeks later, removing the metal stent, there was no more leakage of contrast media into peritoneal cavity. We report a very rare case of spontaneous bile leakage which was successfully managed with placement of metal stent.

Spontaneous Common Bile Duct Perforation Treated with Placement of Metal Stent / 대한췌담도학회지

Perforation of the biliary tree mostly results from injury to the bile duct during surgery or procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and spontaneous bile duct perforation is rare in adults. As the clinical picture varies, early diagnosis and treatment of spontaneous biliary peritonitis is difficult. A 52-year-old male patient presented with abdominal pain and intractable ascites. He already experienced severe abdominal pain 2 months ago and underwent percutaneous pigtail drainage for the ascites at nearby hospital. ERCP showed large filling defect with leakage of contrast media from the mid common bile duct (CBD) into the peritoneal cavity. We performed endoscopic sphincterotomy and extracted CBD stones with basket and balloon catheter. Then fully covered self expandable metal stent was placed in CBD. After the procedure, the symptom was improved and the amount of pigtail drainage from abdominal cavity was dramatically decreased. 6 weeks later, removing the metal stent, there was no more leakage of contrast media into peritoneal cavity. We report a very rare case of spontaneous bile leakage which was successfully managed with placement of metal stent.

Safety and Feasibility of Self-Expandable Metallic Stent Insertion for the Right-Side Colonic Malignant Obstruction and Its Clinical Benefits

PURPOSE: The efficacy of stenting for the right-side colonic malignant obstruction is unknown. The purpose of this study was to evaluate the safety and feasibility of self-expandable metallic stent insertion for the right-side colonic malignant obstruction and its clinical benefits. METHODS: We retrospectively reviewed clinical data from 460 patients who underwent right hemicolectomy for right-side colon cancer from January 2006 to January 2014 at Korea University Anam Hospital. Twenty four patients who developed malignant obstruction in the right -side colon were identified and analyzed. RESULTS: Self-expandable metallic stent insertion was attempted in 14 patients, and initial technical success was achieved in 13 patients (92.9%). No immediate stent-related complications were reported. Complete relief of obstruction was achieved in all of the 13 patients. Eleven patients who failed stenting underwent emergency operation. All of the 13 patients with stent underwent laparoscopic surgery and only one case was converted to open. Only three patients in the emergency group underwent laparoscopic surgery but one was converted. Operative time and number of retrieved lymph nodes did not differ between the two groups. Postoperative hospital stay (9.8+/-3.2 in stent group vs. 16.3+/-10.9 days in emergency group, p=0.082) tended to be shorter in the stent group. Estimated blood loss (38.5+/-138.7 in stent group vs. 381.8+/-411.9 in emergency group, p=0.010) and duration for resuming diet (3.2+/-2.2 in stent group vs. 6.6+/-7.0 days in emergency group, p=0.017) were significantly better in the stent group. CONCLUSION: Self-expandable metallic stent appears to be safe and feasible in the right-side colonic malignant obstruction. It facilitates minimally invasive surgery and may result in better short-term surgical outcome.

Effects of the Temporary Placement of a Self-Expandable Metallic Stent in Benign Pyloric Stenosis

BACKGROUND/AIMS: The use of self-expandable metallic stents (SEMS) is an established palliative treatment for malignant stenosis in the gastrointestinal tract; therefore, its application to benign stenosis is expected to be beneficial because of the more gradual and sustained dilatation in the stenotic portion. We aimed in this prospective observational study to evaluate the efficacy and safety of temporary SEMS placement in benign pyloric stenosis. METHODS: Twenty-two patients with benign stenosis of the prepylorus, pylorus, and duodenal bulb were enrolled and underwent SEMS placement. We assessed symptom improvement, defined as an increase of at least 1 degree in the gastric-outlet-obstruction scoring system after stent insertion. RESULTS: No major complications were observed during the procedures. After stent placement, early symptom improvement was achieved in 18 of 22 patients (81.8%). During the follow-up period (mean 10.2 months), the stents remained in place successfully for 6 to 8 weeks in seven patients (31.8%). Among the 15 patients (62.5%) with stent migration, seven (46.6%) showed continued symptomatic improvement without recurrence of obstructive symptoms. CONCLUSIONS: Despite the symptomatic improvement, temporary SEMS placement is premature as an effective therapeutic tool for benign pyloric stenosis unless a novel stent is developed to prevent migration.

A Case of Stenotic Change from Gastric Candidiasis Managed with Temporary Stent Insertion

Invasive gastric Candida infection in patient with co-morbidity can cause stenotic change if it is developed at anatomically narrowing portion, such as distal antrum, pylorus, or duodenal bulb. However, proper management of benign stenosis by diffuse gastric Candidasis is still under controversy and palliative bypass surgery has several shortcomings because high risk operative group may be included in this case. Palliative placement of self-expandable metallic stent has been settled as a standard management of malignant gastric pyloric obstruction and it is expected to be applied in benign stenotic lesions due to its gradual dilation effect. We described a case of stenosis by diffuse gastric Candidasis at anastomosis of subtotal gastrectomy, which was managed by temporary placement of self-expandable metallic stent.

Malignant Gastric Outlet Obstructions: Treatment with Self-Expandable Metallic Stents

Unresectable malignant gastric outlet obstruction (GOO) severely affects the quality of life, with complications that include nausea, vomiting, aspiration, pain, and malnutrition. Although palliative surgical procedures have been traditionally performed, they are associated with high morbidity and mortality rates. Placing self-expandable metallic stents is associated with higher clinical success rates, lower morbidity, shorter time from the procedure to starting oral intake, lower incidence of delayed gastric emptying, and a shorter hospital stay than palliative surgery. Fluoroscopic or endoscopic placement of either bare or covered self-expandable metallic stents is a safe, nonsurgical, palliative treatment option for unresectable malignant GOOs, with a high clinical success rate and a low rate of serious complications. Stent obstruction and migration are the most common complications, but most can be managed by interventional treatments. Although there have been substantial developments in stent design over the past decade, large prospective, randomized studies are required to determine the ideal stent for malignant GOOs.

Usefulness of Self-expandable Metallic Stents for Malignant Colon Obstruction

PURPOSE: Treatment for malignant colonic obstruction consists of a multiple-staged emergency operation. In recent years, some authors have reported low morbidity and mortality rates using self-expandable metallic stents. This study is designed to evaluate the usefulness of self-expandable metallic stents in patients with malignant colonic obstruction. METHODS: The records of 38 patients who had undergone surgery for malignant colonic obstruction at our institution between January 2004 and August 2006 were reviewed retrospectively. Seventeen patients were treated with elective surgery after stent insertion, bowel decompression, and bowel preparation (stent group), and 21 patients were treated with emergency surgery without stent insertion (control group). RESULTS: There were no significant differences in age, sex, tumor node metastasis (TNM) stage, or cancer position between the two groups (elective operation after stent insertion vs. emergency operation). Of the 17 patients who underwent elective operation after stent insertion, primary anastomosis was possible in 15 (88.2 vs. 57.1% in the control group), with a lower need for a colostomy (11.8 vs. 42.9% in the control group, P=0.036). Also, the number of patients with severe complications (17.6 vs. 47.6% in the control group, P=0.048) and the hospital stay (10.82 vs. 13.43 days in the control group, P=0.032) were significantly lower in the study group. CONCLUSION: Placement of a self-expandable metallic stent for malignant colonic obstruction is a safe and effective procedure. It can reduce the colostomy, mortality, and morbidity rates and the hospital fee for treatment.

The Use of Uncovered Self-Expandable Metallic Stents for Palliation ofGastric Outlet Obstruction Caused by Stomach Cancer / 대한소화기내시경학회지

BACKGROUND/AIMS: The purpose of this study is to investigate the effectiveness and safety of the use of uncovered self-expandable metallic stents as a palliative therapy for gastric outlet obstruction caused by stomach cancer. METHODS: A total of 36 patients who underwent uncovered stent insertion were investigated. Hanarostents (uncovered pyloric/duodenal stents, M.I. Tech Co., Ltd.) were used in the procedures. The technical success rate, clinical success rate, presence of clinical symptoms and complications were estimated during the study period. RESULTS: The technical success rate for stent replacement was 97.2% (35 out of 36 patients) and the clinical success rate was 91.7% (33 out of 36 patients). The mean dysphagia scores before and after the procedures were 2.44 and 0.92, respectively. The median hospital stay after stenting was 10 days and the mean follow-up period was 91 days. Thirteen patients died during the follow-up period (mean survival, 70 days). The complication rate was 22.2% (8 out of 36 patients). Restenosis occurred in four cases, bleeding in two cases, pain in one case and stent migration in one case. There were no deaths related to the procedures. CONCLUSIONS: These findings suggest that placement of uncovered self-expandable metallic stents for gastric outlet obstruction caused by stomach cancer results in good symptomatic improvement with a low rate of complications.

Usefulness of Double Esophageal Stent for Malignant Esophageal Stricture / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic self expandable metallic stent (SEMS) has become the palliative treatment of choice for inoperable malignant esophageal stricture. However, covered and uncovered stents carry limitations such as stent migration and tumor ingrowth, respectively. A double esophageal stent has been developed to overcome these problems. The aim of this study was to evaluate the usefulness of double esophageal stent (outer uncovered stent and inner covered stent) for palliation of malignant esophageal stricture. METHODS: Between February 2001 and November 2006, 32 patients with malignant esophageal stricture were treated with double esophageal stents. The patients were retrospectively assessed for the technical outcome, the clinical outcome and the complications of the process. RESULTS: Stent implantation was successful in all 32 patients (100%). The dysphasia score significantly improved from a mean of 3.22 to 1.63 (p<0.001) for all 32 patients. Eight patients had recurrent dysphagia due to stent overgrowth (6/32, 18%), stent migration (1/32, 3%) and tumor ingrowth (1/32, 3%). Symptomatic gastroesophageal reflux occurred in six patients (18%). Aspiration pneumonia occurred in two patients (6%). CONCLUSIONS: Double esophageal stent is effective for symptomatic relief of malignant esophageal stricture. It seems to reduce tumor ingrowth and stent migration, but it has limitations such as tumor overgrowth and GERD.

Self-expandable metallic stent for unresectable malignant colorectal stenosis

Self-expandable metallic stent (SEMS) was used for five unresectable patients with malignant colorectal stenosis. The SEMS was successfully inserted under a colonoscopy. The patients were able to maintain bowel activities without any serious complications during the rest of their lives. In conclusion, SEMS placement for malignant colorectal stenosis would be safe and effective.

Self-expandable Metallic Stent for the Management of Acute Malignant Large-bowel Obstruction

PURPOSE: The purpose of this study was to review our experience with the use of self-expandable metallic stents as the initial interventional management for acute malignant large-bowel obstruction. METHODS: The records of 35 patients who underwent placement of a colonic stent for acute malignant obstruction at our institution between January 2003 and December 2004 were reviewed. RESULTS: Stents were placed for palliation in 19 patients and as bridge to surgery in 16 patients. Technical success of stent placement was achieved in all patients (100%), but clinical failure occurred in two patients due to limited expansion of the metallic stent. One of them who had clinical failure underwent an emergency operation, and the other needed no further procedure because of his death. Complications occurred in 4 patients (12%), including one pelvic abscess associated with colon perforation, two minor bleedings, and one anal pain. All the patients in the bridge-to-surgery group underwent an elective colon resection without stoma. In the palliative group, stent reocclusion was observed in three patients during the follow-up (median: 65 days; range: 27~440 days), two of which were managed by reinsertion of a stent. In the remaining patients, the stent was patent until death or the last follow up date (median: 65 days). CONCLUSIONS: Placement of a self-expandable metallic stent is a safe and effective procedure for immediate decompression of acute malignant large-bowel obstruction. It provides a chance of elective surgery for patients with resectable disease, as well as relief of symptoms for those with unresectable disease.

Migration of Pyloric Self-Expanding Metallic Stent to the Esophagus / 대한소화기내시경학회지

Self-expandable metallic stent (SEMS) has been reported to provide effective treatment alternatives with minimal morbidity for patients with malignant gastroduodenal obstruction. Limitations of SEMSs are stent occlusion due to tumor ingrowth or overgrowth and stent migration. Migrated stents may remain in the stomach or travel distally. To our knowledge, however, migration of pyloric SEMS to the esophagus has not been reported. We experienced such a case in a 65-year-old woman who had undergone a gastrojejunostomy and choledochojejunostomy due to unresectable pancreatic head cancer. Pyloric SEMSs (Niti-S Pyloric Bare Stent, 18x60 mm, Taewoong Medical, Korea) were deployed at the obstructed efferent and afferent loops. After severe vomiting, a pyloric SEMS placed at the afferent loop migrated into the esophagus, which caused severe chest pain and intractable hiccup. It was removed endoscopically. This case illustrates that pyloric SEMS can migrate to the esophagus through the lower esophageal sphincter.