A combined rescue endoscopic clip and SEMS technique for difficult upper gastrointestinal leaks

Stylianos Tzedakis, Marius Nedelcu, Antonio Durso, Didier Mutter, Bernard Dallemagne, Silvana Perretta. Nouvel Hopital Civil

INTRODUCTION: Management of leaks following foregut surgery is complex and challenging.  Standard laparoscopic exploration and drainage often precludes early oral intake and discharge from the hospital and can be associated with significant morbidity.  New endoscopic treatments such as covered self-expanding metal stents (SEMS) and over-the-scope clips (OTC) are proving to be valuable alternative therapeutic options especially when standard management is not feasible or has failed.  Severe local inflammation often makes primary closure impossible. Likewise, SEMS frequently migrate and require replacement or reoperation. Here, we present a case series where a combined SEMS and over the scope “padlock” clip (Aponos ®) fixation was used to safely and effectively treat post-operative upper GI leaks.

METHODS: Between January 2014 and June 2015 a total of 9 patients with post-operative leaks following UGI surgery were identified. The indications for endoscopic stenting were postoperative leak or fistula (n= 7) and perforation (n=2). Four patients had undergone bariatric surgery (3 conversions from sleeve to RYGBP, one primary RYGBP), two patients a laparoscopic/thoracoscopic esophagectomy for cancer, one patient had undergone a laparoscopic enucleation of a giant esophageal leiomyoma and two patients a total gastrectomy for cancer.  All patients had a 22x160mm fully covered SEMS (Hanarostent ®) placed endoscopically.  A standard sized (11mm) Padlock clip (Aponos Medical ®) was used for SEMS fixation. Overall success in closing leak, migration rate, length of hospital stay, associated morbidity/mortality and number of stents used were analyzed.

RESULTS: Technical and clinical success rates were 100% with no associated morbidity. Three leaks post total gastrectomy required a second “stent in stent “due to upstream persisting leak refluxing from the jejunal side and one due to migration .  All leaks closed in 36 days (range 29-90 days). Length of hospital stay was 31 days (range 16-90 days).  Associated morbidity was negligible.  Average number of stents used per patient was 2. Average number of endoscopic procedures per patient was 4. Removal of both stent and clip was accomplished successfully using a foreign body grasper with no esophageal injury at clip removal.

CONCLUSIONS: Over the scope clips are being used more and more frequently nowadays as an anchoring system after SEMS placement to prevent migration. Our experience with the Padlock clip supports this method as a safe and effective treatment.