ENDOSCOPIC INTERNAL DRAINAGE (EID) USING TRANSMURAL DOUBLE-PIG-TAIL STENTS (DPT) IN LEAKS AND SUTURE-LINE DEHISCENCE FOLLOWING UPPER GI TRACT SURGERY: SIMPLE SOLUTION TO A COMPLEX PROBLEM

Aims Endoscopic management of GI postoperative leaks (POL) is challenging. Therapeutic endoscopy of POL includes intraluminal SEMS and endoscopic vacuum therapy (EVT) using bioactive sponge. Endoscopic internal drainage (EID) with double-pigtail (DPT) could be effective treatment. We report our experience with DPT-EID for leaks or suture-line dehiscence following upper GI tract surgery

Methods From May 2017 to June 2019, 10 patients (6 women; 55.3±11.5 years old) were treated at our endoscopic tertiary center. DPT drains (7-10F/5-10cm) were placed through the suture line orifice with/without associated luminal balloon dilatation, EUS-guide drainage of collections or intraluminal SEMS. Clinical and technical success were determined. Treatment success definition: absence of contrast agent leakage on CT and endoscopy after removal of DPT.

Results Seven patients presented infra-diaphragmatic POL: 5 Laparoscopic sleeve gastrectomy (LSG), 1 gastric bypass and 1 gastro-jejunostomy (Whipple procedure); 3 supra-diaphragmatic POL: 2 esophagectomy and gastric pull-up and 1 Boerhaave syndrome. 70% were ASA III-IV and 30% required ICU admission. Nine patients (90%) were treated as first-line treatment. Technical and clinical success was achieved in 10 patients and 7/8 patients (87.5%), respectively. Additional endoscopic techniques were performed; balloon dilatation in LSG (4/5), EUS-guided drainage (3/10) and SEMS insertion (1/10). Clinical success was achieved after a median of 3 days (IQR 2-3) treatment with a range of 2-8 endoscopic procedures per patient. Complications: tracheo-esophageal fistula (procedure-related) and one death (non-related embolism). Seven patients were found to be healed at endoscopy after an average of 14 weeks (range 12-23), two patients are still under treatment and one patient died.

Conclusions DPT-EIDis effective and safe. DPT-EID appears better tolerated than luminal SEMS and more efficient than ETV in the management of GI transmural defects. DPT drainage may be used as first-line or rescue treatment for POF with lower morbidity-mortality than surgery.