Over-the-scope clip for anastomotic leak after total gastrectomy

A 57-year-old man who underwent total gastrectomy for gastric adenocarcinoma presented with fever and elevated inflammatory markers on postoperative day 2. Computed tomography (CT) scan and esophagogastroduodenoscopy (EGD) were unremarkable. The patient developed an evisceration and intra-abdominal infected collection, which was managed with a new surgical intervention and antibiotic treatment. He was discharged on postoperative day 33.

However, 1 week later he was admitted with persistent fever and dyspnea. CT scan confirmed a left subphrenic collection. EGD with fluoroscopic guidance (after contrast extravasation, [Fig. 1]) revealed a 3-mm leak located 3 mm away from the anastomosis ([Fig. 2 a]), with abundant purulent drainage ([Fig. 2 b]). Endoscopic closure with an over-the-scope clip (OTSC) was successful ([Fig. 3], [Video 1]) and the patient was discharged 7 days later. At the 3-month follow-up, he was asymptomatic.

Fig. 1 Fluoroscopic view. Contrast extravasation at the esophagojejunal anastomosis.

Fig. 2 Endoscopic view. a Identification of a 3-mm leak, 3-mm away from the esophagojejunal anastomosis. b Abundant purulent drainage from the anastomotic leak.

Fig. 3 An over-the-scope clip was deployed for leak closure.

Video 1 Use of an over-the-scope clip for anastomotic leak after total gastrectomy.

Postsurgical leaks are an important complication with significant morbidity and mortality. Conservative and surgical management of this complication are also associated with high morbidity and mortality. Several endoscopic treatments, such as stents, OTSC/clips, suturing devices, tissue sealants, and endoluminal vacuum therapy, have shown efficacy and a favorable safety profile [1] [2]. Management of postoperative esophagojejunal anastomotic leakage after total gastrectomy represents a very challenging event [3] [4]. In this case, OTSC application was effective, with no early or late complications.

Endoscopy_UCTN_Code_TTT_1AO_2AI

 

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Willingham FF, Buscaglia JM. Endoscopic management of gastrointestinal leaks and fistulae. Clin Gastroenterol Hepatol 2015; 13: 1714-1721
• 2 Ward MA, Hassan T, Burdick JS. et al. Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost. Surg Endosc 2019; 33: 3970-3975
• 3 Carboni F, Valle M, Federici O. et al. Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment. J Gastrointest Oncol 2016; 7: 515-522
• 4 Makino H, Nomura S, Maruyama H. et al. Endoscopic application of clipping, over-the-scope clip (OTSC) and stenting for a fistula and anastomotic leakage of upper gastro-intestinal tract. Integr Cancer Sci Ther 2019; 6: 1-5

Publikationsverlauf

Artikel online veröffentlicht:
04. März 2020