Komdej Thanavachirasin, Eric Marcotte, Assistant, Professor, Pornthep Prathanvanichn, MD, Bipan Chan, Associate, Professor. Loyola Hospital Medical Center
Background: Anastomotic dehiscence after upper gastrointestinal surgery is associated with high morbidity and mortality. Therapeutic endoscopy has become a viable option in treating such severe complications. However, there is not one universally accepted method in dealing with such a complication as each scenario may pose its own challenge. We believe multimodality endoscopic therapies have the greatest chance of success. The premise of these includes novel methods to provide diversion of enteral flow and drainage (both internally and externally). Highlighted are details of Endoscopic Vacuum therapy (EVT) via percutaneous trans-esophageal esophagostomy tube (PTET) and stent diversion with drainage.
Method: We present a video (7 min) of a 80 year old woman that initially presented with a large symptomatic para-esophageal hernia and right colon cancer. She underwent an attempted laparoscopic para-esophageal hernia repair and concomitant right colectomy. However, she suffered an acute early herniation of the stomach into the mediastinum with gastric outlet obstruction. She subsequently required total gastrectomy with an end to side esophagojejunostomy secondary to gastric ischemia at the time of repeat surgery. Six days postoperatively, she has signs and symptom of mediastinal leak with CT imaging showing a very large posterior mediastinal collection. She had no systemic manifestations of sepsis. This anastomotic dehiscence and collection was managed with endoscopic therapy.
Result: Endoscopy provided detailed information of the size and extent of mediastinal collection, degree of sepsis, presence of ischemia, and degree of anastomotic dehiscence. The esophago-jejunal dehiscence was 100 % of the circumference with separation of the bowel ends of greater then 8 cm. The size of the mediastinal abscess was 7.5 x 12 cm. There was no evidence of ischemia of the bowel ends.
Endoscopic treatment took 66 days to demonstrate complete healing with spontaneous re-anastomosis of the EJ , collapse of cavity, and control of sepsis. Modalities to achieve success include PTET with EVT, 3 partially covered metallic stents, surgical drainage and enteral feeding access. No peri-operative complications occurred.
Conclusion: Endoscopic therapy for complex anastomotic dehiscence with large abscess can safely be performed when abiding by the principles of surgery (i.e. diversion, drainage, sepsis control and nutritional support). Multimodal and novel endoscopic techniques can be successfully employed in the correct scenario with proper training.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 77562
Program Number: V076
Presentation Session: Endoscopy Video Session
Presentation Type: Video