Anastomotic Leak After Robotic Ivor Lewis Esophagectomy Treated with Endoluminal Vacuum Therapy

Anastomotic leaks after minimally invasive Ivor Lewis esophagectomy result in high morbidity for patients, including reoperation, prolonged hospitalization, and the need for distal feeding access. The treatment of anastomotic leaks varies widely and depends on the timing of presentation, the patient’s clinical status, and the severity and extent of contamination into the pleural cavity. Management methods have traditionally included conservative management with NPO; antibiotic therapy and drainage; surgical exploration; and endoscopic therapies including stenting, clipping, and fibrin glue application, all with varied success (1).

More recently, endoluminal vacuum therapy has been described for the management of esophageal perforation and anastomotic leaks (2,3). With defect closure rates in excess of 80 percent in the reported case literature, it is becoming an attractive option for endoscopists and surgeons (3). The endoscopic approach and device management vary with operator/center experience, material availability, and institutional support. However, basic principles include intervention under general anesthesia to secure the airway and minimize aspiration risk; thorough endoscopic evaluation of the defect and surrounding structures; and transnasal or transoral passage of the endoscopic vacuum device (3).

The video above describes a case of a sixty-three-year-old male with a stage IIA GE junction adenocarcinoma who underwent a robotic Ivor Lewis esophagectomy and developed an anastomotic leak contained in the posterior mediastinum on postoperative day (POD) eleven. His clinical status enabled endoscopic therapy with placement of a nasal post-pyloric feeding tube and an endoluminal vacuum device, which resolved the leak by POD 21 and avoided the need for surgical feeding access. He developed a mild stenosis at the anastomosis that required two serial dilations on PODs 52 and 120 but otherwise recovered fully.

References

1. Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg. 2014 Oct;208(4):536-43. doi: 10.1016/j.amjsurg.2014.05.011. Epub 2014 Jul 21. PMID: 25151186; PMCID: PMC4172525.
2. Heits N, Stapel L, Reichert B, Schafmayer C, Schniewind B, Becker T, Hampe J, Egberts JH. Endoscopic endoluminal vacuum therapy in esophageal perforation. Ann Thorac Surg. 2014 Mar;97(3):1029-35. doi: 10.1016/j.athoracsur.2013.11.014. Epub 2014 Jan 18. PMID: 24444874.
3. Livingstone I, Pollock L, Sgromo B, Mastoridis S. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc. 2021 Nov;54(6):787-797. doi: 10.5946/ce.2021.240. Epub 2021 Nov 16. PMID: 34781418; PMCID: PMC8652150.

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