ENDOSCOPIC SUCTION CHAMBER TO TREAT COMPLEX DUODENAL LEAKS AFTER UPPER GASTRO-INTESTINAL SURGERY: A SINGLE CENTER EXPERIENCE

Aims Leaks from duodenal stump after upper-gastrointestinal surgery are difficult to manage and usually require re-do surgery.

Vacuum-assisted drainage has been used in endoscopic management of colorectal, esophageal anastomotic leaks and duodenal perforations. However, it has never been reported to treat leaks from duodenal stump.

We report our single-center experience on endotherapy of duodenal stump leaks after upper-gastrointestinal surgery using an innovative approach.

Methods Between January 2016 and December 2018, 5 consecutive patients (M:F 3:2, mean age 43) were referred to our unit for complex dehiscence of the duodenal stump. Previous upper-gastrointestinal surgery included 3 subtotal gastrectomy with Roux-en-Y reconstruction and one with Braun reconstruction; one gastric bypass.

All underwent a re-do surgery that failed.

We created a Suction Chamber: a fully-covered SEMS was inserted with the distal crown into peritoneum through the duodenal leak. Subsequently, common bile duct and main pancreatic duct were endoscopically drained inserting a biliary and a pancreatic stent through the meshes of the enteral stent. An aspirative naso-duodenal tube, with the tip 1-2 cm outside the enteral stent´s distal crown was placed. The surgical drainage was pulled 3 cm away from the leak to favorite the peritoneal-enteral pressure gradient.

Results Technical and clinical success were achieved in all the patients (5/5 100%).

Mean duration of aspiration was 36 (23-103) days. An abdominal CT scan was generally performed 2 days after the procedure (to verify the reduction of intraperitoneal fluid collections) and 30 days after to decide to stop the aspiration. Stent removal was scheduled at 6 months. No mortality neither long-term adverse events related to the procedures were reported.

Conclusions Endotherapy for duodenal stump leaks is feasible and effective in tertiary referral endoscopy centers with expertise in management of post-surgical complications. Our Suction Chamber offers the possibility to treat complex leaks especially if re-do surgery failed.