ENDOSCOPIC TREATMENT OF A SEVERE ANASTOMOTIC LEAK WITH ENDOSCOPIC VACCUM THERAPY AFTER STENT FAILURE

A 58-year-old man underwent an Ivor-Lewis esophagectomy due to an esophagus squamous-cell carcinoma. Three days later, he presented with subcutaneous emphysema and respiratory insufficiency. Chest computed tomography (CT) with oral contrast revealed a pneumomediastinum with contrast extravasation between the gastric tube and the right pleural cavity at the level of the carina, in relation with an anastomotic leakage. After multidisciplinary discussion, upper endoscopy revealed a severe anastomotic leakage 29 cm from the incisors. A fully covered 28/23/28 × 120 mm SEMS (Wallflex, Boston Scientific, Marlborough, MA) was placed. Nevertheless, SEMS migrated despite 3 clips placement. After SEMS removal, endoscopic vacuum therapy (EVT) was performed (Endo-Sponge system, B. Braun, Melsungen, Germany). The “backpack technique” was first used to place the 7 cm polyurethane foam sponge of this pre-assembled set, however, it could not be inserted into the cavity. With the assistance of two Endo-Sponge encrusted overtubes, the foam was placed well deep in the mediastinal cavity. The sponge was replaced every five days using the technique described above, with progressive clinical and endoscopic improvement (decrease of cavity dimensions, necrotic content improvement and granulation tissue formation). Third sponge replacement was hampered by drainage tube disconnection from the polyurethane foam sponge; the sponge remained inside the wound cavity and required the use of multiple devices (biopsy forceps, baskets, snares and double channel endoscope) to achieve removal. A complete closure of the anastomotic defect was achieved at fifth sponge replacement. Barium swallow and CT with oral contrast showed no leak.

The patient was discharged home 53 days after first EVT, eating normally and remains well after 6 months.

Esophageal leaks often leads to severe septic conditions. EVT is a promising new approach for their treatment, even when previous failure with SEMS. Despite the need of multiple procedures, it may lead to complete leakage closure, avoiding the need for surgery.