Ivor Lewis Esophagectomy and Endoscopic Management of Anastomotic Leak
Jaclyn R. Dempsey, Gal Levy.
University of Texas Medical Branch, Galveston, TX, USA.
OBJECTIVE: Anastomotic leak after esophagectomy occurs in 4-26% of cases [1,2]. We present a case of anastomotic leak in which source control was achieved by performing endoscopic drainage of the mediastinum and stenting over nasogastric tube drainage for source control.
METHODS: 58-year-old male with stage IIIa (T3N1M0) esophageal squamous cell carcinoma post neoadjuvant chemotherapy with carboplatin plus paclitaxel and concurrent radiation underwent robotic-assisted Ivor Lewis esophagectomy. The procedure was uncomplicated with negative margins on frozen section of resected tumor and good perfusion of the conduit confirmed by fluorescence imaging. Anastomosis was performed with a stapler in side-to-side fashion and sewn with barbed suture. The patient initially progressed well postoperatively until postoperative day five, at which point he had increasing leukocytosis and developing respiratory failure leading to intubation. A posterior mediastinal air-fluid collection was demonstrated on subsequent CT, concerning for anatomic dehiscence. The patient returned to the OR where endoscopy was performed revealing an anterior anastomotic breakdown approximately 9mm in diameter. The mediastinal collection was drained using a nasogastric tube guided across the dehiscence into the mediastinum prior to placement of a covered esophageal stent to close the defect.
RESULTS: Patient status improved with ongoing trans-defect drainage of mediastinum and stent exclusion for source control.
CONCLUSIONS: Nasogastric tube placement for drainage across anastomotic dehiscence with endoscopic stenting presents a potential option for nonoperative source control of post-esophagectomy anastomotic leaks.
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