Anastomotic insufficiency with leakage is a life-threatening complication after radical
gastrectomy. Surgical reintervention may be associated with high rates of recurrence
and increased morbidity [1 ]. Placement of a fully covered self-expandable metal stent is commonly performed
as a first line conservative treatment. However, success rates after endoscopic stenting
range between 63 % and 91 % [2 ]. Endoscopic vacuum therapy is a novel technique that allows continuous drainage
of the leak, control of infection, and secondary wound healing process, and has shown
high clinical success rates [3 ]
[4 ]
[5 ].
A 35-year-old man who underwent total gastrectomy and termino-lateral esophagojejunal
anastomosis for gastric cancer at an outside hospital presented with an anastomotic
leakage 5 days after surgery. Re-operation was unsuccessful. On postoperative Day
10, the patient was referred to our center with septic shock. The computed tomography
(CT) scan confirmed the persistence of an anastomotic leak ([Fig. 1 ]). An upper endoscopy showed a wall defect at the level of the anastomosis, which
affected 30 % of the circumference and gave access to a 10 cm (depth) × 5 cm (diameter)
cavity with necrotic debris.
Fig. 1 Computed tomography scan (Day 7 of admission, after third sponge replacement). The
yellow lines highlight the leakage of the oral contrast at the level of the esophagojejunal
anastomosis, which was still visible after the third sponge replacement. The tip of
the sponge (*) inside the cavity is seen distal to the leak, between the left hepatic
lobe and the body of the pancreas.
An Eso-SPONGE (B. Braun, Melsungen, Germany) was placed with endoscopic guidance inside
the cavity and connected to a vacuum with a negative pressure of 100 mmHg ([Video 1 ]). The sponge was replaced 2 – 3 times per week ([Fig. 2 ]). The septic shock quickly resolved with antibiotic therapy, and after 36 days of
endoscopic treatment and 12 sponge replacements, the remaining wound cavity was < 2 cm
(depth) × 1 cm (diameter) and the endoscopic therapy was discontinued. An upper endoscopy
10 days later ([Fig. 3 ]), and a CT scan and a barium swallow confirmed absence of leakage ([Fig. 4 ], [Fig. 5 ]). The patient was discharged 2 days later with good tolerance to an oral diet, and
continued to do well at 3 months’ follow-up.
Video 1 Resolution of a large infradiaphragmatic leak with endoscopic vacuum therapy after
total gastrectomy.
Fig. 2 Placement of the Eso-SPONGE (B. Braun, Melsungen, Germany) in the distal part of
the cavity.
Fig. 3 Upper endoscopy (10 days after the end of vacuum therapy). a The wall defect on the level of the anastomosis measured only 7 mm and was not accessible
by a conventional gastroscope. b A pediatric gastroscope was used to access the cavity, which was only 2 cm long and
had completely healed.
Fig. 4 Computed tomography scan (10 days after the end of vacuum therapy). There was no
evidence of contrast leakage and the cavity was completely resolved (*).
Fig. 5 The barium swallow was performed 10 days after the end of therapy and there was no
evidence of a leak.
Endoscopy_UCTN_Code_CPL_1AH_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a highhttps://mc.manuscriptcentral.com/e-videos
