S4154 Bridging the Gap: Intraoperative Esophageal Stent Utilized as a Scaffold for Treatment of a Post-Surgical Complete Gastroesophageal Anastomosis Dehiscence

Introduction: Esophago-gastric (EG) anastomotic leaks (EAL) are an uncommon but dreaded complication following esophagectomy. As part of a step-up approach, endoscopic placement of a stent across the anastomosis has become an increasingly popular first option to allow the dehiscence to heal naturally over time. Here we present a unique, multidisciplinary case of complete anastomotic dehiscence treated with endoscopic stenting to re-create the EG anastomosis. Case Description/Methods: A 62-year-old man with locally advanced mid-body esophageal adenocarcinoma who underwent tri-incisional esophagectomy 12 days prior presented with dyspnea. An empyema was found with chest tube output high in amylase, suggesting an EAL. Therefore, the patient was taken to the operating room with thoracic surgery. The anastomosis was identified at the level of the thoracic inlet and characterized by gross dehiscence, prompting interventional gastroenterology consultation for stent placement. The scope was advanced to the anastomosis but could not reach the gastric conduit given complete dehiscence. With robotic surgical guidance, the scope was traversed through the mediastinum and into the stomach distally. A guidewire was placed from the stomach across the dehiscence and out of the mouth. Then, dehiscence was stented with a single fully covered self-expandable metal stent and fixed with an over-the-scope clip. This allowed for the surgeon to identify the conduit edge and esophageal hood. The stent was used as a mold to prevent stricture formation and interrupted sutures were placed for re-approximation. Lastly, a biological mesh was sutured over the anastomosis using the stent as a scaffold. The patient was subsequently monitored in the intensive care unit and de-escalated to the hospital ward after 24 hours. After 60 days, the patient had removal of his chest drain in the clinic given no clinical concern for remaining leak. His diet was advanced to clear liquids with adjunctive tube feedings. Discussion: EAL can be a devastating complication that is difficult to resolve. The surgical approach has historically consisted of high-risk primary surgical repair or drain placement leading to possible enterocutaneous fistula. Primary repair was not feasible in this case due to the location and extent of initial resection. As the hope is to regain luminal function, an endoscopically placed luminal stent as a scaffold for primary repair is not only novel but also a promising technique as evidenced by the clinical success in this case. Watch the video: https://tinyurl.com/25ACGS4154