Internal medicine

Stent

Cancer

Dehiscence

Surgery

Metallurgy

Materials science

Esophageal stent

Perforation

Punching

Endoscopy

Gastrectomy

Medicine

Anastomosis

The American Journal of Gastroenterology

INTRODUCTION: Esophageal perforations are typically managed surgically; however, these surgeries are associated with a significant risk for mortality and morbidity. Endoscopic vacuum therapy, a minimally invasive procedure, may be offered as an alternative for such patients. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of non-alcoholic liver cirrhosis was diagnosed with gastroesophageal junction (GEJ) (image 1) adenocarcinoma that was managed with chemoradiation and surgery. The patient's Roux-en-Y total gastrectomy was complicated by posterior perforation of his anastomosis, with leakage into the thoracic cavity. EGD was performed with the placement of a vacuum sponge into the periesophageal fluid collection (video). Subsequent weekly EGD for sponge vacuum exchange progressively displayed diminished amount of purulent material; endoscopic sponge vacuum was removed and overlapping fully covered esophageal stents were secured across esophagojejunal dehiscence (image 3). The patient gradually improved, tolerated a full liquid diet, and was ultimately discharged to a rehabilitation center. DISCUSSION: Esophageal perforation with intrathoracic leakage is one of the most common yet serious complications of esophageal procedures, with the incidence ranging from 5 to 30%. As surgical management is often associated with significant mortality and morbidity, minimally invasive procedures are more commonly utilized. Some of these include self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), endoscopic clipping, suturing, and endoluminal vacuum therapy. Brangewitz et al. noted successful wound closure (84.4% vs. 53.8%) and lower incidence of strictures (9.4% vs. 28.2%) with EVT when compared to SEMS or SEPS. EVT offers several advantages over stents including its accessibility in the intensive care unit, availability for regular inspection, and tension-free healing of the leak. On the other hand, some limitations of EVT include a requirement for repeated endoscopic procedures, the necessity of maintaining nasal tube, technically demanding placement of sponge into the leaks, and the possibility of bleeding from the base of the wound. In conclusion, endoscopic vacuum therapy is a management alternative among the gastroenterologists, which provides highly effective treatment, for an otherwise complicated disease process, by reducing the necessity for invasive surgical procedures.Figure 1.: Endoscopy revealing gastroesophageal junction mass.Figure 2.: Esophageal sponge placement.Figure 3.: Stent placement at the site of perforation.

S3409 Endoscopic Vacuum Therapy in Management of Esophageal Perforation With Leakage Following Roux-en-Y Gastrectomy