Sequential endoscopic drainage and clip closure of an intrathoracic esophagogastric anastomotic dehiscence

A 69-year-old man underwent an upper gastrointestinal endoscopy, which revealed a large submucosal lesion in the distal esophagus with normal overlying mucosa. Endoscopic ultrasound (EUS) showed a hypoechoic lesion measuring 80 × 40 × 30 mm in the submucosa ([Fig. 1]). A subtotal esophagectomy was performed. Histopathological examination of the resected tissue revealed a duplication cyst.

Fig. 1 Endoscopic ultrasound (EUS) view of the hypoechoic lesion in the submucosa of the distal esophagus.

The patient developed sepsis 3 weeks after surgery. A computed tomography (CT) scan revealed evidence of dehiscence of the esophagogastric anastomosis with a large mediastinal collection ([Fig. 2]). Upper gastrointestinal endoscopy confirmed the presence of a dehiscence affecting an 8-mm section of the esophagogastric anastomosis ([Fig. 3 a]). Pus was aspirated through the fistula orifice and two double-pigtail plastic stents were placed endoscopically to drain the abscess ([Fig. 3 b]). There was rapid improvement in the patient’s clinical condition.

Fig. 2 Thoracic computed tomography (CT) scan showing a posterior mediastinal collection (arrow).

Fig. 3 Endoscopic views showing: a the esophagogastric anastomosis with an 8-mm long dehiscence; b two double-pigtail plastic stents passing through the fistula orifice to drain the mediastinal collection; c the application of argon plasma coagulation at the fistula orifice.

After 1 week, the stents were removed and an over-the-scope clip (OTSC) was applied to close the fistula. Unfortunately, despite this, a Gastrografin swallow revealed persistence of the fistula.

A third upper gastrointestinal endoscopy was performed and after removing the OTSC, we applied argon plasma coagulation (APC) and three through-the-scope clips, which effectively sealed the fistula ([Fig. 3 c]). Resolution of the mediastinal abscess as well as the fistula was confirmed on a further thoracic CT scan and Gastrografin swallow ([Fig. 4]).

Fig. 4 Gastrografin swallow after placement of a metal clip confirming that the fistula orifice had been successfully closed.

This case highlights the potentially useful role of endoscopic drainage and clipping devices in the management of a rare but serious adverse event of esophageal surgery.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Competing interests: None