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.