Fix it and feel free to work: endoscopy beside the stent

A 45-year-old man underwent bariatric surgery (gastric bypass with Roux-en-Y anastomosis) and subsequently developed an anastomotic leak with an intra-abdominal fluid collection and septic status. He underwent a reintervention with complete washing of the cavity, insertion of abdominal drainage, and placement of a percutaneous surgical gastrostomy in the excluded stomach. However, he showed no clinical improvement after 2 weeks and was referred to our institution for endoscopic treatment.

Gastroscopy showed a leak in the upper side of the anastomotic site with extraluminal contrast diffusion ([Fig. 1]). A fully covered enteric stent was placed and fixed at its proximal side with endoscopic sutures [1] [2] [3]. After 2 weeks and still no improvement in the patient’s status, X-ray and computed tomography scan with oral contrast were performed, showing a low amount of contrast flowing in the percutaneous drainage ([Fig. 2]), despite the stent being well positioned. A second gastroscopy performed to treat the leak showed the stent still fixed in place thanks to the endoscopic sutures. We therefore decided to perform the revision without removing the stent, and instead inserted the endoscope parallel to the stent, into the space between the stent and the wall ([Video 1]). After careful maneuvering of the endoscope beside the stent, endoscopy showed the abdominal drainage into the blind intestinal loop ([Fig. 3]), so it was moved and re-positioned in the abdominal cavity under both direct endoscopic and radiologic visualization.

Fig. 1 Radiography showed extraluminal contrast diffusion into the abdominal cavity (blue dotted area) through a gastric leak (red dotted line indicates the gastric lateral wall where anastomotic leak is located).

Fig. 2 X-ray before computed tomography scan after intake of oral contrast, which flowed through the stent but also into the abdominal cavity and drainage (red arrow).

Video 1 Endoscopic treatment of post-surgery anastomotic leak included placement of an enteric stent fixed with endoscopic sutures. When the leak persisted, endoscopic re-evaluation without removal of the stent was possible.

Fig. 3 Endoscopic examination with the stent in place. a Endoscopic view of the space next to the stent (white arrow), which the endoscope explored moving in parallel to the stent. Dislocation of the abdominal drainage (red arrow) to the residual gastric cavity (into the space beside the stent) through the anastomotic leak (black arrow) was seen. b Radiologic view of the endoscope (red arrow) next to the stent, which maintained its position due to the sutures.

The patient improved and fluid collection gradually decreased, until removal of the abdominal drainage (2 weeks later).

After 40 days, endoscopic revision of the leak was performed once again, moving the endoscope beside the stent, as we could not remove the stent before being sure that the leak had resolved. After direct endoscopic and radiologic evidence of healing of the leak ([Fig. 4]), the stent was removed.

Fig. 4 Resolution of the gastric leak in the residual gastric cavity, which was explored without removing the stent (red arrow) and by maneuvering the endoscope beside it.

At 3 months’ follow-up, the patient did not complain of any sign or symptom of leak recurrence. In conclusion, moving the endoscope alongside the stent appeared to be feasible and safe after appropriate stent fixation, thus avoiding the need to remove a well-positioned stent.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kantsevoy SV, Bitner M. Esophageal stent fixation with endoscopic suturing device (with video). Gastrointest Endosc 2012; 76: 1251-1255
• 2 Wright A, Chang A, Bedi AO. et al. Endoscopic suture fixation is associated with reduced migration of esophageal fully covered self-expandable metal stents (FCSEMS). Surg Endosc 2017; 31: 3489-3494
• 3 Law R, Prabhu A, Fujii-Lau L. et al. Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis. Surg Endosc 2018; 32: 675-681

Publication History

Article published online:
16 September 2022