Endoscopic salvage of a large esophagojejunostomy dehiscence

Abstract

Esophagojejunostomy anastomosis (EJA) dehiscence is not uncommon (up to 3% to 15%).1, 2 Management can be challenging depending on the size and location, and it frequently requires surgical repair, which is associated with significant morbidity and mortality. 3 Although endoscopic clipping is commonly described in the literature for a dehiscence smaller than 2 cm, 4 we describe the successful endoscopic salvage of a large 4-cm EJA dehiscence by use of a combined technique of flexible endoscopic suturing and covered metal stent placement. Our patient was a 34-year-old woman with invasive diffuse gastric adenocarcinoma who underwent total gastrectomy with en bloc splenectomy, distal esophagectomy, subtotal pancreatectomy, and intraoperative percutaneous jejunal tube placement. Seven days postoperatively she experienced septic shock, empyema, and tension pneumothorax, resulting in the placement of chest tubes. An EJA leak was suspected, and upper endoscopy showed a greater than 50% circumferential dehiscence of the EJA (Fig. 1). On endoscopy, lavage of the pleural cavity was done with a total of 500 mL of 1.5% hydrogen peroxide and normal saline solution with scant indigo carmine. The latter was used to observe the change in color of chest tube output and to determine whether this cavity was actively being drained. This was followed by placement of an 18 mm × 150 mm fully covered metal stent as a bridge for surgery (Fig. 2). The stent was clipped to the esophageal wall to prevent stent migration. Clipping was possible, given that an adequate fold was obtained, with sufficient grasp of tissue and stent allowing for a fixation. Suturing can help to obviate migration, but migration can still occur with sutures as a result of metal scaffold cutting into the thread. Furthermore, the use of clips is less expensive than the endoscopic suturing kit. Figure 1 Upper endoscopy showing >50% circumferential dehiscence of esophagojejunostomy anastomosis. Figure 2 Fully covered metal stent (18 mm × 150 mm) was placed as a bridge for surgery. Four weeks later, she was still dependent on 1 chest tube, and an esophagogram showed a persistent leak at the EJA, even though the stent was in place. A multidisciplinary team, including the patient and her family, reached a consensus to attempt endoscopic closure of the EJA dehiscence instead of surgery. At subsequent endoscopy, the old stent was removed and the dehiscence was evaluated (Fig. 3). Lavage of the pleural cavity was repeated. The surface of the EJA dehiscence was debrided, and the proximal loop of the jejunum was approximated toward the distal tip of the esophagus while the tissue anchor drove the suture material through the jejunal and the esophageal walls at the anastomosis site. This dehiscence was closed with 7 interrupted endoscopic sutures by use of an over-the-scope endoscopic suturing device (Figure 4, Figure 5, Figure 6, Figure 7; Video 1, available online at www.VideoGIE.org). Next, a new fully covered metal stent (18 mm × 150 mm) was deployed traversing the anastomosis, in suspicion of an area of narrowing distal to the anastomosis that could create a back pressure leak. The stent was again clipped to the esophageal wall to prevent stent migration because this approach was successful with the first stent. The patient improved clinically, and the chest tube was removed in 1 week. One month later, the stent was removed endoscopically, showing an intact anastomosis site without dehiscence (Fig. 8). No leak was seen on an esophagogram (Fig. 9). At 6 months, she had no upper GI symptoms. Figure 3 Repeat endoscopy to re-evaluate esophagojejunostomy anastomosis dehiscence for persistent leak. The metal stent was removed. Figure 4 Endoscopic suturing system. The helix device is shown, which helps in placement of full-thickness sutures. Figure 5 Full-thickness suture being placed. Figure 6 The curved hollow needle has to be reloaded with the suture before placement of further sutures. Figure 7 Endoscopic view after placement of 7 interrupted endoscopic sutures with over-the-scope endoscopic suturing device. Figure 8 Intact esophagojejunostomy anastomosis after over-the-scope endoscopic suturing (1 month follow-up). Figure 9 Esophagram before and after over-the-scope endoscopic suturing. A new fully covered metal stent (18 mm × 150 mm) was deployed traversing the anastomosis (right). Esophageal endoscopic suturing has been described in animal models for defects up to 2.5 cm and in 1 human patient up to 2 cm.5, 6 Endoscopic suturing of large esophageal defects is uncommon, and the clinical experience has been limited, although it is evolving. 4 However, our success at closing a 4-cm EJA dehiscence with significant clinical improvement on long-term follow-up supports the use of endoscopic therapy in selected cases with larger defects. We provide important evidence that the management of esophageal full-thickness wounds by use of a combination of endoscopic suturing and stenting is possible, relatively quick, and safe when done in experienced centers. Disclosure All authors disclosed no financial relationships relevant to this publication.