1835 Closure of a Large Gastroesophageal Anastomosis Leak With Endoscopic Suturing After the Failure of Stent Therapy

Abstract

INTRODUCTION: Gastroesophageal anastomotic leaks remains a potentially life-threatening post-esophagectomy complication. Surgical repair or conservative therapy have been used traditionally with suboptimal outcomes. Endoscopic methods are now an effective alternative to surgery for the management of anastomotic leak. We report a case of closure of a large Gastroesophageal anastomotic leak using a combination of endoscopic suturing with OverStitch (Apollo Endosurgery, Austin, Texas, USA) and esophageal stent after patient failed to respond to esophageal stent alone. CASE DESCRIPTION/METHODS: A 49-year-old male with a history of adenocarcinoma of distal esophagus underwent distal esophagectomy and placement of a percutaneous gastrostomy tube. The postoperative course was complicated by sepsis and empyema. Broad-spectrum antibiotics were started, and a percutaneous drain was placed in the mediastinum for drainage of empyema. EGD was then performed by the surgical team, which led to the identification of dehiscence of the gastroesophageal anastomosis and leak. A fully covered, 23 mm by 105 mm esophageal metal stent was placed. The patient was not able to tolerate liquids orally and continued to complain of nausea and vomiting. He continued to have a large amount of drainage from the mediastinal percutaneous drain. Repeat esophagram 8 weeks post op revealed persistent leak at the anastomosis (Figure 1). Gastroenterology was then consulted for endoscopic closure of the leak. Endoscopy was performed, and the fully covered metal stent was removed. Endoscopic examination after stent removal revealed a gastroesophageal anastomosis defect about 20 mm in diameter with necrotic appearing mucosa at the site of the leak (Figure 2). The anastomotic defect was then successfully closed with approximating the healthy gastric and esophageal mucosa. A figure-of-8 pattern of endoscopic sutures was placed using the Apollo OverStitch device. Another layer of reinforcement sutures was also placed. One fully covered 23 mm by 105 mm esophageal stent was placed over the anastomosis. The patient was started on a clear liquid diet. Esophagram performed on day 5 (Figure 1) showed no anastomotic leak. Diet was then further advanced, and the patient was discharged home. DISCUSSION: Large gastroesophageal anastomotic leak remains a potentially life-threatening complication post-esophagectomy. Patients failing stent therapy usually with large leaks can be successfully treated with a combination of endoscopic suturing and stent placement.