Infolding of Ultraflex self-expanding metal stent on insertion.

an advanced stage, without curative op− tions in 50 % ±60 % of cases. Of the major complications, the principal ones are lu− minal obstruction and esophagorespira− tory fistulas [1]. Among palliative measures, self−expand− ing metal stents (SEMS) have provided good quality of life for patients and are cost−effective [2]. Despite these advanta− ges, the use of SEMS is not free of compli− cations, namely incomplete expansion, migration, perforation, hemorrhage, tra− cheal compression, or food impaction [1]. Recently some authors have demonstrat− ed accurate and safe stenting using only endoscopic guidance, without fluoro− scopic support [3,4]. The Ultraflex stent has been associated with more occurrences of incomplete ex− pansion and migration as well as infold− ing after deployment, as its construction favors a smaller radial force; thus, whilst preventing the risk of major trauma, it oc− casionally requires balloon dilation [5]. We report an unusual event after inser− tion of a covered 12−cm Ultraflex SEMS under sedation and without fluoroscopic control. The patient was a 52−year−old man with inoperable lower third esopha− geal cancer, who had previously under− gone chemotherapy and radiotherapy and currently had grade 3 dysphagia (l" Fig. 1). After deployment the stent adopted a bi− zarre “B type“ infolded conformation with maintenance of double lumen pa− tency (l" Fig. 2 and 3), whilst successfully covering the fistula holes. After 24 hours, repeat endoscopy revealed the same find− ings. Balloon dilation was done unsuc− cessfully. Biopsy rat−tooth forceps were used to displace the stent, which allowed it to unfold but uncovered the fistula opening (l" Fig. 4). A second attempt, using the same instrument, correctly po− sitioned the prosthesis (l" Fig. 5 and 6). The patient remained asymptomatic for the following 6 months and required no further endoscopic examinations. This report highlights a possible and pre− viously unconsidered adverse event, and is a reminder of the importance of impro− visation and of the necessity for improve− ments in stent design.