Endoscopic internal drainage using double-pigtail stent placement to manage a case of proximal colo-colonic anastomotic leakage

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.

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Competing interests

Dr. Roberto Di Mitri is consultant of Boston Scientific; the other authors have no conflicts of interest.

• References

• 1 Cereatti F, Grassia R, Drago A. et al. Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?. World J Gastroenterol 2020; 26: 4198-4217
• 2 Abdalla S, Cotte E, Epin A. et al. Short-term and long-term outcome of endoluminal vacuum therapy for colorectal or coloanal anastomotic leakage: results of a nationwide multicenter cohort study from the French GRECCAR Group. Dis Colon Rectum 2020; 63: 371-380
• 3 Donatelli G, Dumont JL, Cereatti F. et al. Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series. Endosc Int Open 2016; 4: E647-E651
• 4 Gonzalez JM, Lorenzo D, Guilbaud T. et al. Internal endoscopic drainage as first line or second line treatment in case of postsleeve gastrectomy fistulas. Endosc Int Open 2018; 6: E745-E750
• 5 Donatelli G, Spota A, Cereatti F. et al. Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients. Surg Obes Relat Dis 2021; 17: 1432-1439

Publication History

Article published online:
27 September 2021