Successful Endoscopic Esophageal Stent Placement for Esophageal Anastomotic Leak

Abstract

An anastomotic leak is one of the leading causes of death following gastric bypass surgery and sleeve gastrectomy. In patients who undergo sleeve gastrectomy, the most common site for these leaks is the proximal one-third of the stomach, near the gastroesophageal junction. Evaluation by Upper GI (UGI) contrast study will show extravasation at the site of the leak. Treatment options include surgical management, conservative management with percutaneous drainage, or endoluminal stent placement. This case report presents an endoscopic challenge that was overcome with the replacement of an esophageal stent and subsequent resolution of an esophageal anastomotic leak. A 60 year-old Hispanic female with a past medical history of morbid obesity status-post laparoscopic sleeve gastrectomy presented to the emergency department with a one day history of subjective fever, chills, right upper quadrant abdominal pain, and one episode of non-bloody diarrhea. A UGI series would reveal a proximal gastric anastomotic leak. An EGD was subsequently performed which revealed a fistula approximately 35cm from the incisors; as such, a 25mm diameter/12cm length self-expandable metal esophageal stent was deployed and appropriate placement was confirmed endoscopically and by fluoroscopy (Figure 1). After removal of the esophageal stent, there was persistence of the anastomotic leak, so a new 28mm diameter/12cm length self-expandable metal esophageal stent was placed to cover the fistula. Approximately 6 weeks after the deployment of the 2ndesophageal stent, an EGD was repeated to remove the stent (Figure 2) and a UGI series revealed no extravasation of contrast from the site of the previous anastomotic leak.2966_A Figure 1 No Caption available.2966_B Figure 2 No Caption available.Multiple sources have cited more favorable outcomes with early recognition and prompt management of anastomotic leaks. Criteria for removal of a patient's esophageal stent vary slightly from clinician to clinician, but some common factors include: (1) lack of a leak on esophagram, (2) lack of fever, (3) lack of leukocytosis, (4) absence of an ipsilateral pleural effusion, and (5) resolution of ileus. Despite aggressive therapy, mortality rate of postoperative esophageal leaks remain as high as 20%, with treatment delays being associated with higher mortality rates. Although our experience with esophageal stent placement has evolved and matured, there are unfortunately still complications that arise during and after the procedure.