Use of atrial septal occluder in the treatment of chronic fistula following post-esophagectomy anastomotic leak

Therapeutic endoscopy plays a key role in the management of gastrointestinal fistulae. Endoscopic interventions with stents [1], endoscopic clips, vacuum therapy [2], etc. have revolutionized the management of post-surgical anastomotic leaks.

A 66-year-old man diagnosed with gastro-esophageal junction adenocarcinoma underwent a minimally invasive Ivor Lewis esophagectomy with gastric pull-up. The postoperative phase was uneventful. The patient presented 8 weeks after surgery with a respiratory tract infection while receiving adjuvant chemotherapy. A computed tomography (CT) scan revealed a right paramediastinal abscess due to an anastomotic leak. Over a period of 6 months, the patient underwent CT-guided percutaneous drain placement, video-assisted thoracoscopic debridement of empyema, endoscopic insertion of a fully covered metal stent (Niti-S MEGA Esophageal Stent; TaeWoong Medical, Gyeonggi-do, South Korea), and internal drainage with double-pigtail stents. Despite these measures, the defect failed to close, resulting in recurrent chest infections and a persistently discharging sinus at the back of the right chest. We decided to proceed with fistula closure with an atrial septal occluder device [3] [4].

Following general anesthesia, the patient was positioned in the left lateral position. The first endoscopist passed a 5-mm gastroscope (GIF-XP160; Olympus, Tokyo, Japan) through the external opening of the fistula to reach the intrathoracic abscess cavity, and the defect was identified with a double-pigtail stent in situ ([Video 1]). The second endoscopist then introduced the 10-mm gastroscope (GIF-XP160; Olympus) transorally and a guidewire was introduced through the defect. Under direct visualization, the Amplatzer Cribriform Multi-Fenestrated Septal Occluder (AGA Medical Corporation, Plymouth, Minnesota, USA) with its delivery system was introduced along the guidewire into the abscess cavity [5]. The left atrial (LA) disc followed by the right atrial (RA) disc were deployed under endoscopic ([Fig. 1]) and fluoroscopic guidance ([Fig. 2]). The procedure time was 90 minutes.

Video 1 Endoscopic closure of chronic gastrointestinal fistula using atrial septal occluder device.

Fig. 1 a Defect at the esophagogastric anastomosis with guidewire in situ. b Left atrial disc of the atrial septal occluder fully deployed. c Anastomotic defect visualized inside the abscess cavity. d Right atrial disc of atrial septal defect deployed inside the abscess cavity.

Fig. 2 Fluoroscopic view of deployment of the atrial septal occluder.

CT imaging with oral contrast at 1 week and 8 weeks post-procedure showed no extravasation of contrast through the anastomotic defect ([Fig. 3]). The nasojejunal feeding tube was removed and at 3 months the patient is tolerating a liquid to pureed diet.

Fig. 3 Interval computed tomography scan at 1 week showing the atrial septal occluder device positioned between the abscess cavity and neo-esophagus.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Nguyen NT, Rudersdorf PD, Smith BR. et al. Management of gastrointestinal leaks after minimally invasive esophagectomy: conventional treatments vs. endoscopic stenting. J Gastrointest Surg 2011; 15: 1952-1960
• 2 Mennigen R, Harting C, Lindner K. et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. J Gastrointest Surg 2015; 19: 1229-1235
• 3 De Moura DTH, Baptista A, Jirapinyo P. et al. Role of cardiac septal occluders in the treatment of gastrointestinal fistulas: A systematic review. Clin Endosc 2020; 53: 37-48
• 4 Cardoso E, Silva RA, Moreira-Dias L. Use of cardiac septal occluder device on upper GI anastomotic dehiscences: a new endoscopic approach (with video). Gastrointest Endosc 2012; 76: 1255-1258
• 5 Green DA, Moskowitz WB, Shepherd RW. Closure of a broncho-neo-esophageal fistula using an Amplatzer Septal Occluder device. Ann Thorac Surg 2010; 89: 2010-2012

Publication History

Article published online:
23 August 2023