Post written by Omar Mousa, MBBS, from the Department of Gastroenterology and Hepatology, Mayo Clinic Florida.
A 34-year-old woman with invasive gastric adenocarcinoma underwent total gastrectomy with en bloc splenectomy, distal esophagectomy, subtotal pancreatectomy, and intraoperative percutaneous jejunal tube placement. An esophagojejunostomy anastomosis (EJA) dehiscence was suspected 7 days after the initial procedure when the patient presented with septic shock, empyema, and tension pneumothorax. An upper endoscopy confirmed a dehiscence greater than 50% of the anastomosis circumference. Also during the upper endoscopy, a pleural cavity lavage was performed, with a total of 500mL of 1.5% hydrogen peroxide. Normal saline solution with scant indigo carmine was used to examine the change in color of the chest tube output and to determine the adequate drainage of this cavity. An esophageal stent was placed as a bridge for surgery.
Several weeks later, the patient’s esophagogram showed the stent still in place, but a persistent leak at the EJA level was found. A multidisciplinary team decided to attempt endoscopic closure of the EJA dehiscence instead of surgery. The subsequent endoscopy, with debridement and suture of the dehiscence with new stent placement, was very successful. Within 1 week, the patient had her chest tube removed, and in 1 month, the stent was removed endoscopically showing an intact anastomosis site without dehiscence. At 6-month follow-up, the patient had no upper gastrointestinal symptoms.
Endoscopic suturing of large esophageal defects is an evolving field, in which more research is needed. Nevertheless, it is possible and could avoid a much more invasive therapeutic approach. Even a large EJA dehiscence can be endoscopically managed with the combination of endoscopic suturing and stenting.
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