A 39-year-old man underwent a distal spleno-pancreatectomy and colonic resection for
a tail pancreatic cancer infiltrating the colonic splenic flexure. Five days after
surgery, the patient experienced fever and abdominal pain. A computed tomography (CT)
scan showed a 10-cm intra-abdominal collection with free air bubbles inside; oral
contrast-medium intake revealed a passage from the colon to the abdominal collection,
highly suspicious of an anastomotic leak ([Fig. 1]).
Fig. 1 Computed tomography scan showing an extra-luminal contrast-medium passage (red arrow)
from the left colonic anastomotic region to the intra-abdominal collection located
in the splenic loggia.
Endoscopy confirmed a wide anastomotic leakage with access to a peri-anastomotic cavity
([Fig. 2 a, b]) and we decided to attempt endoscopic internal drainage in order to avoid a new
surgical procedure.
Fig. 2 Endoscopic views. a Leak (asterisks) of the colo-colonic anastomosis with an orifice (red arrow). b Wide peri-anastomotic cavity accessed through the orifice.
Under endoscopic view and fluoroscopic guidance, two double-pigtail plastic stents
(10-Fr/10-cm and 7-Fr/7-cm, Boston Scientific, Massachusetts, USA) were placed across
the leak orifice ([Video 1]) with one pigtail tip of each stent located inside the cavity. A CT scan 24 hours
later confirmed the correct placement of the two stents.
Video 1 Endoscopic internal drainage using double-pigtail stent placement to manage proximal
colo-colonic anastomotic leakage. This approach works by promoting collapse of the
collection, granulation-tissue formation and re-epithelization of the leak orifice
Follow-up CT scans showed a progressive reduction in the collection’s size up to 2 cm
at 5 weeks, so stent removal was planned. Endoscopy showed a closure of the anastomotic
leak and a single stent “in situ” that was removed with a forceps. The next CT scan
confirmed the complete collapse of peri-anastomotic collection ([Fig. 3]). After 6 months, the colo-colonic anastomosis appeared endoscopically regular with
a complete closure of the leakage ([Fig. 4]).
Fig. 3 Computed tomography scan showing a complete collapse of the peri-anastomotic collection
after stent removal.
Fig. 4 Endoscopic view of regular colo-colonic anastomosis with a complete closure of the
leak orifice (arrow) at 6-month follow-up.
Endoscopy is emerging as a first-line approach over surgery for management of post-operative
gastrointestinal leaks and fistulae [1]. While endoluminal vacuum therapy is reported as an effective method for management
of colo-rectal anastomotic leakages [2], endoscopic internal drainage by double-pigtail stent placement is described as
a conservative treatment of leaks and fistulas after upper gastrointestinal surgery,
especially in the bariatric setting [3]
[4]
[5]. The application of endoscopic internal drainage technique in this case allowed
us to successfully and conservatively manage a proximal colo-colonic anastomotic leakage
without needing a protective ileostomy or an additional surgical procedure.
Endoscopy_UCTN_Code_TTT_1AQ_2AG
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply (currently EUR
375), discounts and wavers acc. to HINARI are available.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
