Post written by Mohan Ramchandani, MD, DM, from the Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, Telangana, India.

A 73-year-old man was diagnosed with a case of carcinoma gastroesophageal junction. He underwent total gastrectomy with regional lymphadenectomy (D1 gastrectomy) and intrathoracic oesophagojejunostomy with Roux-en-Y jejunojejunal anastomosis. Post operatively he developed an anastomotic leak. After stabilization with supportive care and placement of chest tube, we planned for fully covered metal stent placement for the management of the leak.

During endoscopic placement of the long oesophageal stent, iatrogenic perforation occurred in the jejunal loop by the distal end of the stent. Fluoroscopic imaging revealed air under the diaphragm. Immediately, the pneumoperitoneum was decompressed using a 16-gauge venous catheter connected to an underwater seal, and the stent was removed immediately. A 1.5- to 1-cm perforation was identified in the jejunum. The perforation was closed using ‘king closure’ technique using a novel predetachable endoloop with ligation device (LeClamp ligation device; Leo Medical Co Ltd, Changzhou, China) and clips.

The steps used to close the defect were as follows:

(1) A pre-detached endoloop was delivered fixed to the hemoclip (Resolution clip, Boston Scientific, Boston, Mass, USA) using a single- channel endoscope (GIF-HQ190 Olympus, Tokyo, Japan);

(2) the endoloop was anchored near the margin of the defect, and consecutive hemoclips were deployed to fix the endoloop along the margin of the defect;

(3) finally, a hook device (endoloop delivery system) was used to reattach the endoloop, and the defect was closed in a purse-string fashion.

Subsequently, a 0.035-inch guidewire was placed into the jejunum, and a 10-cm-long fully covered oesophageal self-expanding metal stent (Wallflex, Boston Scientific) was placed across the anastomotic leak and fixed with the help of hemoclip .

Post-procedure contrast fluoroscopic imaging showed no leak at the anastomotic site or the perforation site. The patient was started on proton pump inhibitors, and broad-spectrum antibiotics were continued. Intercostal drain output decreased with resolution of the hydropneumothorax after 72 hours. Contrast-enhanced CT was done after 48 hours and showed no perianastomotic site collection.

The main teaching point of this video is to know the importance of early identification of the iatrogenic perforation. Quick repair b  purse-string closure of a perforation with routinely available accessories like an endoloop and hemoclips is a useful technique especially in a restricted luminal working space.

Full thickness closure can be achieved by single-loop and clips technique (KING closure), early identification of the adverse event and prevention of peritoneal contamination is the key to success. Other closure devices like OTSC clips and suturing devices are alternative techniques in such situations.

Read the full article online.

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