P1.045. Management of a Large Esophagojejunostomy Defect After Laparoscopic Total Gastrectomy Using Endoscopic Vacuum Therapy and Adjunctive Stenting
TL;DR
Prolonged EVT is an effective minimally invasive strategy for managing extensive EJ anastomotic disruption after total gastrectomy and combined endoscopic approaches may offer a viable organ-preserving alternative in complex postoperative leakage.
Abstract
Benign Disease: Other Esophagojejunostomy (EJ) leakage after total gastrectomy remains a life-threatening complication. While endoscopic vacuum therapy (EVT) has emerged as an effective treatment option, management of large anastomotic disruption and subsequent stenosis remains challenging. We report a case successfully managed with repeated EVT and subsequent stent placement. An 80-year-old woman with antral gastric cancer underwent planned totally laparoscopic distal gastrectomy. After ligation of the left gastric artery, poor remnant gastric perfusion was noted, and the procedure was converted to totally laparoscopic total gastrectomy with Roux-en-Y esophagojejunostomy. On postoperative day (POD) 7, the patient developed fever. Computed tomography demonstrated loculated fluid–air collection and free air, raising suspicion of anastomotic leakage. Emergency reoperation revealed disruption of the EJ anastomosis. Continuous primary repair and sump drainage were performed. On POD 10 after reoperation, enteric content was observed through the sump drain. Endoscopy confirmed a large peri-anastomotic defect. Endoscopic vacuum therapy (EVT) was initiated and performed six times over three weeks until marked reduction of the defect was achieved. Follow-up endoscopy demonstrated mucosal healing but significant anastomotic stenosis associated with dysphagia, requiring endoscopic stent insertion. Endoscopic stent placement was successfully performed to relieve obstruction and maintain luminal patency. Following stenting, oral intake was gradually resumed without recurrence of leakage Prolonged EVT is an effective minimally invasive strategy for managing extensive EJ anastomotic disruption after total gastrectomy. Even in cases requiring multiple sessions, satisfactory defect closure can be achieved without additional major surgery. Anastomotic stenosis following healing may occur but can be effectively managed with endoscopic stent placement. Combined endoscopic approaches may offer a viable organ-preserving alternative in complex postoperative leakage.