Endoscopic treatment of esophagojejunostomy dehiscence after total gastrectomy with a fully covered self-expandable metallic stent

The most frequent complications after upper GI surgery are leaks and stenosis. These complications are associated with significant morbidity and mortality rates. Conservative treatments such as Self-Expanding Metal Stents (SEMS) and balloon dilatation have been described for the treatment of these complications, but stay controversial yet. We report a case of a 66-year-old woman who underwent a total gastrectomy for a neuro-endocrine tumor that developed an anastomotic dehiscence six days after surgery, successfully treated with a covered SEMS. The stent was well-tolerated and left in place for two weeks. Its ablation confirmed through endoscopic and enhanced X-ray upper series the development of a granulation tissue, along with epithelial proliferation, enough to produce a perfectly closed and healing anastomotic defect. No further surgery was required; oral feeding was started and has been well-tolerated and the patient was soon discharged. In this case where the use of surgery seemed inevitable and not risk-free, the placement of a removable SEMS was demonstrated to be a safe and efficient technique.

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Endoscopic treatment of esophagojejunostomy dehiscence after total gastrectomy with a fully covered self-expandable metallic stent

Authors

Gf Donatelli, M Gualtierotti, D Coumaros, J Marescaux

Abstract

The most frequent complications after upper GI surgery are leaks and stenosis. These complications are associated with significant morbidity and mortality rates.
Conservative treatments such as Self-Expanding Metal Stents (SEMS) and balloon dilatation have been described for the treatment of these complications, but stay controversial yet.
We report a case of a 66-year-old woman who underwent a total gastrectomy for a neuro-endocrine tumor that developed an anastomotic dehiscence six days after surgery, successfully treated with a covered SEMS. The stent was well-tolerated and left in place for two weeks. Its ablation confirmed through endoscopic and enhanced X-ray upper series the development of a granulation tissue, along with epithelial proliferation, enough to produce a perfectly closed and healing anastomotic defect. No further surgery was required; oral feeding was started and has been well-tolerated and the patient was soon discharged.
In this case where the use of surgery seemed inevitable and not risk-free, the placement of a removable SEMS was demonstrated to be a safe and efficient technique.

Classification

clinical cases

Keywords

Endoscopic treatment, esophagojejunostomy dehiscence after total gastrectomy, fully covered self-expandable metallic stent

Media type

Surgical video

Duration

04'03''

Publication

2009-05

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E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2644.htm

Endoscopic treatment of esophagojejunostomy dehiscence after total gastrectomy with a fully covered self-expandable metallic stent

1. Clinical case presentation 00'01''

This is a case of a 66-year-old woman who underwent a total gastrectomy with an end-to-lateral Roux-en-Y stapled esophagojejunostomy for a neuro-endocrine tumor (pT2N1). On day six after surgery, a routine postoperative upper series was performed to examine the integrity of the esophagojejunal anastomosis before starting oral food intake. Anastomotic leakage was then observed with extravasation of contrast solution within the peri-anastomotic abdominal drain. A CT-scan confirmed the anastomotic dehiscence. Clinically, the patient was stable with no fever, laboratory studies showing hyperleukocytosis.

2. Identification of the anastomotic leakage 00'38''

An upper endoscopy was then performed and a full-thickness defect was found at the level of the anastomosis, approximately 35cm from the incisor teeth. Contrast solution was then injected through the scope; using fluoroscopy and the dehiscence was confirmed.

3. Jejunum exploration 00'54''

The jejunum was then explored. The blind stump was visualized, and subsequently the endoscope was inserted into the jejunal segment.

4. Guide wire insertion 01'05''

A guide wire was then inserted and the scope was withdrawn at the level of the anastomotic dehiscence. Under fluoroscopy, a mark was made on the skin of the patient at the level of the dehiscence, corresponding to the lower border of the scope, in order to deliver the middle part of the stent exactly on the anastomotic defect.

5. Stent placement 01'23''

The scope was then withdrawn completely before an 8cm long and 20mm wide Self Expanding Metal Stent (SEMS) fully covered was introduced under fluoroscopy, with the middle part of the SEMS placed at the location of the mark corresponding to the dehiscence. Correct positioning was further enhanced by using continuous fluoroscopy while deploying the SEMS.

6. Endoscopic control 01'45''

The endoscope was again inserted in the esophagus and some contrast solution was injected through the stent. No leak was observed. The prosthesis was well positioned. As the patient was found to be in a good overall condition, enteral nutrition was started. Fluid output via the abdominal drain was stopped three days later and then the drain was mobilized. Seven days after the contrast solution exam, an enhanced upper series confirmed the good positioning of the SEMS and the dehiscence’s healing. The drain was then removed. Fourteen days later, we decided to proceed with a stent removal.

7. Stent removal 02'25''

The endoscopy found the stent in place and the injection of contrast solution did not show any leaks. The distal string was grasped using a biopsy forceps before the stent was removed under fluoroscopic control.

8. Endoscopic control 03'33''

The endoscopic examination showed that the anastomosis was covered by fibrin, and that the previous defect had completely sealed and the radiological control confirmed no contrast solution leaks in the surrounding tissues. In conclusion, the above-mentioned technique proves relatively safe and avoids further surgery. On the following day, the patient resumed oral liquid intake with the contrast-enhanced X-ray confirming the absence of leaks or persistent stenosis.

9. Late endoscopic control 04'34''

Three weeks later, an upper endoscopic control was performed and no signs of stenosis or leakages were found at the level of the anastomosis.