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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 13-15

Esophagojejunal anastomotic leak managed with self expandable metallic stent


1 Department of Medical, Rajiv Gandhi Government General Hospital, Madras Medical College (MMC), Chennai, India
2 Department of Surgical Gastroenterology, Rajiv Gandhi Government General Hospital, Madras Medical College (MMC), Chennai, India

Date of Web Publication14-Nov-2013

Correspondence Address:
Arvind Madurandagam Annapillai
E 81, First Cross Street, Anna Colony, Besant Nagar, Chennai 600090
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Esophagealjejunal anastomotic leak after gastrectomy is a serious surgical emergency with high mortality. This report describes a 57-year-old male with esophagojejunal anastomotic leak following total gastrectomy for gastric cancer and was managed successfully with self-expandable metallic stent. To our knowledge this is the first such report from India. This case report highlights the need of interdisciplinary coordination in managing this difficult clinical situation. Endotherapy with self-expandable metallic stent (SEM) provided twin benefits of improving respiratory embarrassment and the joy of eating. Therapy of such difficult cases must be individualized; however, and SEM stent usage is a viable option

Keywords: Anastomotic leak - SEM stent - Endotherapy - Esophagojejunal leak


How to cite this article:
Annapillai AM, Ramachandran BS, Ponniah S, Hemamala V, Kesavan B, Karunakaran P, Raju P, Manoharan G, Murugesan CS, Muhammed MA. Esophagojejunal anastomotic leak managed with self expandable metallic stent. J Dig Endosc 2013;4:13-5

How to cite this URL:
Annapillai AM, Ramachandran BS, Ponniah S, Hemamala V, Kesavan B, Karunakaran P, Raju P, Manoharan G, Murugesan CS, Muhammed MA. Esophagojejunal anastomotic leak managed with self expandable metallic stent. J Dig Endosc [serial online] 2013 [cited 2019 Jun 24];4:13-5. Available from: http://www.jdeonline.in/text.asp?2013/4/1/13/121384


  Introduction Top


Despite the advances in surgical techniques and improvements in peri-and-post-operative management, esophagojejunal anastomotic leak after total or proximal gastrectomy continues to be a serious problem. Intra-thoracic anastomotic leakage resulting from total gastrectomy and esophagojejunostomy are usually exclusively abdominal. Recently, placement of self-expandable metallic stents (SEMs) has emerged as an effective therapy for sealing the esophageal perforations and major anastomotic leaks after esophageal resection or total gastrectomy. Herein, we report a case of a patient who developed anastomotic leakage into the thoracic cavity after total gastrectomy and esophagojejuno-stomy for a biopsy proven growth of cardia (Siewert type III) and was successfully managed with endotherapy using SEM stent.


  Case Report Top


A 57-year-oldmale was diagnosed to have growth in cardia (Siewert type III A), [1] biopsy proven adenocarcinoma. Total gastrectomy with esophagojejunostomy was done (postoperative stage III A). Patient developed respiratory distress on 2nd post-operative day. Chest X ray showed moderate left sided pleural effusion. Pleural fluid was turbid and amylase of 716 U/L suggested anastomotic leak. Patient had Glasgow Coma Score of 13/15 at this time He also had tachycardia, tachypnea, diminished oxygen saturation, fever and a diminished air entry in left chest. Eight hundred ml of pleural fluid was drained. After insertion of intercostal chest drainage tube on left side [Figure 1].
Figure 1:

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Fluoroscopic oral contrast study confirmed leak into left thoracic cavity [Figure 2]. Esophageal covered SEMS stent placement was done under monitored anesthetic control (MAC) [Figure 3]. Patient's general condition improved and he tolerated oral feeds by 20th post-operative day. Thus SEM stent by obliterating the anastomotic leak improved respiratory embarrassment and restored joy of eating.
Figure 2:

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Figure 3:

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  Discussion Top


An abdominal leak after esophagojejunal anastomosis is expected but intra thoracic leak occurs rarely. There have only been few individual case reports and case series of 2-4 cases in worldwide literature. Theoretically, this rare complication is believed to be due to increased tension in the anastomosis as a lesion high in the stomach is resected with esophagus being dragged down for anastomosis with jejunum. Esophagus retracts back into the thorax in post surgery period and therefore, anastomotic dehiscence presents as leak into the pleural cavity. Thus, ischemia coupled with high tension in the anastomosis is postulated mechanism in such leaks. Early leaks require urgent emergent interventions. The treatment options available include repeat surgery and endotherapy. Endo therapeutic options include placement of SEM or self-expandable plastic (SEP) stent, and application of fibrin glue or clips. There is no consensus opinion regarding management. Treatment must be individualized. Surgical therapy is reserved for patients with gross mediastina/pleural soilage and is associated with high morbidity and mortality.2-4 ranging from 3-25 mm. [5] Endoscopic application of fibrin glue has been shown to be of benefit in case reports. [6] There have been case reports of use of SEM stent in such leaks with definite success.7-9 Yong Gang et al also showed that small reflux of the intestinal fluid into the thoracic cavity can still occur along the sides of the SEM stent even after the leak site is bridged although it does not affect the clinical outcome [Figure 4]. SEM stent seals leakage in 90% of cases and allows oral feeding to resume. SEP stent has the advantage of retrievability but migration rate is higher although a recent case series showed good outcomes with a lesser migration rate. [10]
Figure 4: Showing reflux of intestinal fluid into the thoracic cavity. The blue color indicates that the refluxed intestinal fluid could leak from the gap between the stent (brown color) and the jejunal wall to the thoracic cavity through the orifice

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  Conclusion Top


Use of SEM stent is an accepted treatment modality in selected cases of upper GI anastamotic leaks especially post esophagectomy leaks. Our case has shown that use of SEM stent in total gastrectomy and esophagojejunal anastomotic leak has dramatically improved general condition of the patient and also restored the joy of eating thus providing twin benefits. This is the first case of SEM stent use in esophago-jejunal anastomotic dehiscence being reported from India.

 
  References Top

1.Classification of adenocarcinoma of the esophagogastric junction. Br J Surg1998;85:1457-9.  Back to cited text no. 1
    
2.Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71-5.  Back to cited text no. 2
[PUBMED]    
3.Kakavoulis TN, Avgoustou CC, Koniaris HG, Penlidis PC. Subcutaneous esophagojejunal reconstruction in the management of esophagogastric anastomotic leak: a staged procedure. Dis Esophagus 2005;18:345-8.  Back to cited text no. 3
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4.Lang H, Piso P, Stukenborg C, Raab R, Jähne J. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000;26:168-71.  Back to cited text no. 4
    
5.Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW. Endoscopic clips for closing esophageal perforations: case report and pooled analysis. GastrointestEndosc 2007;66:605-11.  Back to cited text no. 5
    
6.Truong S, Bohm G, Klinge U, Stumpf M, Schumpelick V, et al. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 2004;18:1105-8.  Back to cited text no. 6
    
7.Yonggang LV, Shifang Yuan, Jun Yun, Qing Yao, Jianghao Chen, Jun Yi, Rui Ling, Ling Wang. Management of intrathoracic leakage after radical total gastrectomy. J Thorac Dis 2010; 2: 180-84.  Back to cited text no. 7
    
8.Profili S, Feo CF, Cossu ML, Scanu AM, Scognamillo F, Meloni F, et al. Effective management of intrathoracic anastomotic leak with covered self-expandable metal stents. Report on three cases. Emerg Radiol 2008;15:57-60.   Back to cited text no. 8
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9.Kauer WK, Stein HJ, Dittler HJ, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surg Endosc 2008; 22:50-3.  Back to cited text no. 9
[PUBMED]    
10.Fernández A, Vila JJ, Vázquez S, González-Portela C, de la Iglesia M, Lozano M, Toscano E. Self-expanding plastic stents for the treatment of post-operative esophago-jejuno anastomosis leak. A case series study. Rev Esp Enferm Dig 2010;102:704-10.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
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