Case Report Open Access
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 6, 2021; 9(1): 262-266
Published online Jan 6, 2021. doi: 10.12998/wjcc.v9.i1.262
Endoscopic salvage treatment of histoacryl after stent application on the anastomotic leak after gastrectomy: A case report
Hee-Sung Kim, Joung-Ho Han, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju-si 28644, South Korea
Yook Kim, Department of Radiology, Chungbuk National University Hospital, Cheongju-si 28644, South Korea
ORCID number: Hee-Sung Kim (0000-0001-7559-4438); Yook Kim (0000-0003-2162-419X); Joung-Ho Han (0000-0003-4469-9215).
Author contributions: Kim HS and Kim Y contributed equally to this work; Kim HS and Kim Y collected the patient’s clinical data and wrote the paper; Han JH designed the report; all authors read and approved the final version of the manuscript.
Supported by 2020 Research Fund of the Chungbuk National University.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Joung-Ho Han, MD, PhD, Professor, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Chungdae-ro 1, Seowon-gu, Cheongju-si 28644, South Korea. joungho@cbnu.ac.kr
Received: September 21, 2020
Peer-review started: September 11, 2020
First decision: September 29, 2020
Revised: October 9, 2020
Accepted: November 21, 2020
Article in press: November 21, 2020
Published online: January 6, 2021
Processing time: 102 Days and 8.6 Hours

Abstract
BACKGROUND

Endoscopic approach could effectively manage postoperative anastomotic leakage. Various endoscopic methods have been developed for the treatment of anastomotic leakage.

CASE SUMMARY

A 53-year-old woman developed anastomotic leak after laparoscopic proximal gastrectomy. Endoscopic clip closure failed due to strong wall tension; therefore, a fully covered self-expandable esophageal metal stent (fc-SEMS) was placed to cover the leak after it was filled with a mixture of fibrin glue and histoacryl. However, fluoroscopy with gastrograffin showed dye leaking out of the fc-SEMS. Using the previous fluoroscopic image for guidance, a catheter was inserted at the leakage site. The radiocontrast dye was injected and was seen spreading along the sinus tract. Thereafter, histoacryl was injected. Seven days after the last procedure, upper gastrointestinal contrast studies showed no leaks. The patient was subsequently discharged 9 d after histoacryl injection without any complications.

CONCLUSION

To seal an anastomosis leak after stent application, salvage technique using histoacryl injection at the leakage site with fluoroscopy guidance could be considered cautiously.

Key Words: Anastomotic leak; Stent; Histoacryl; Endoscopy; Gastrectomy; Gastric cancer; Case report

Core Tip: Endoscopic treatment including stent deployment, clipping or fibrin glue is considered as a safe and effective treatment options for anastomotic leakage after gastrectomy. We successfully treated esophago-gastric anastomotic leakage with endoscopic salvage treatment of add-on histoacryl after fully covered self-expandable esophageal metal stent (fc-SEMS). Histoacryl injection after fc-SEMS application on the anastomotic leak should be considered as treatment option.



INTRODUCTION

Laparoscopic approach for treating gastric cancer has fewer complications than open approach[1]. Aside from Intra-abdominal bleeding, anastomotic leakage was the most common complication[2]. Treatment options include surgery, conservative approaches, or endoscopic interventions[3]. Being as high mortality following revisional surgery for anastomotic leakage, conservative endoscopic method developed to decrease complication. Endoscopic clip, fibrin glue, endoscopic placement of stents has a crucial role in the management of anastomotic leakage. Depending on the size and location of defect, a variety of endoscopic procedures can be selected[4]. There have been several reports of endoscopic treatment for anastomotic leak. However there have been no reports of combining endoscopic management with injection of histoacryl after stent application on anastomotic leak. Herein, we present a case of anastomotic leak treated with combining endoscopic management with stent and histoacryl.

CASE PRESENTATION
Chief complaints

A 53-year-old women consulted gastroenterology for anastomotic leak after proximal gastrectomy for gastric cancer.

History of present illness

A 53-year-old woman underwent a laparoscopic proximal gastrectomy for early gastric cancer. Daily drainage via Jackson-Pratt (JP) drain was not decreased until the fourth postoperative day. Fluoroscopy with gastrograffin revealed leakage from the anastomotic site.

History of past illness

Apart from present illness, she has had no previous significant medical history.

Personal and family history

Her family history had any relevance to this present illness.

Physical examination

On the fourth postoperative day, the patient developed abdominal pain. Physical examination revealed a temperature of 37.3 ℃, a blood pressure of 110/60 mmHg, a pulse of 118/min, a respiratory rate of 22/min, and a diffusely tender abdomen without rebound or guarding.

Laboratory examinations

A complete blood count showed that the white blood cell count of 11.6 × 106, hemoglobin 11.2 g/dL, and a platelet count of 164 × 109/L. Other blood biochemical tests were normal.

Imaging examinations

On the fourth postoperative days, upper gastrointestinal (UGI) contrast studies revealed a leakage from anastomotic site, and endoscopy showed a lesion (Figure 1A). A fully covered self-expandable esophageal metal stent (fc-SEMS) (12 cm length, outer diameter 2.2 cm, Hanaro, Seoul, Korea) was placed to cover the leak. Subsequently, drainage was diminished to 15-20 mL/d. However, fluoroscopy with gastrograffin showed dye leaking out of the fc-SEMS. (Figure 1B)

Figure 1
Figure 1 Anastomotic leak after gastrectomy and subsequent histoacryl injection using fluoroscopy and catheter after failed stent application. A: A 4 mm diameter leak was identified at the esophago-gastric anastomotic site; B: A leak (arrow) still existed 3 d after stent application; C: Estimating the location using previous radiocontrast study, the catheter was introduced into sinus tract after puncturing stent membrane (arrow), then it was filled with histoacryl.
FINAL DIAGNOSIS

Unsuccessful sealing anastomotic leak with fc-SEMS after laparoscopic proximal gastrectomy.

TREATMENT

Using the previous fluoroscopic image (Figure 1B) for guidance, a catheter (MTW Endoskpie, Dusseldorf, Germany) was inserted at the leakage site after puncturing the stent membrane. The radiocontrast dye was injected and was seen spreading along the sinus tract. Thereafter, 8 mm of histoacryl was injected into the sinus tract as the catheter was withdrawn (Figure 1C).

OUTCOME AND FOLLOW-UP

Seven days after the last endoscopic procedure, UGI contrast studies showed no leaks (Figure 2A). One month later, endoscopy was performed to remove the stent and remnant histoacryl (Figure 2B arrow) was observed covering the site without leakage (Figure 2B).

Figure 2
Figure 2 Contrast examinations finding after 1 mo after injection of histoacryl to the leak after puncture the stent membrane. A: The leak was obliterated with histoacryl; B: Endoscopy after stent removal showed remnant histoacryl (arrow) and complete closure.
DISCUSSION

Anastomotic leakage following gastrectomy for gastric cancer is a life-threatening complication, and revisional surgery has a high mortality rate. The treatment includes conservative management, endoscopic treatment, and surgery[5]. Surgery is generally recommended for patients in critical condition. Otherwise, conservative management with endoscopic management is sufficient for minimal anastomotic leakage. Endoscopic management including stent deployment, clipping or tissue sealant had been considered safe and effective for anastomotic leak[6-9]. Stent implantation achieved 70% complete healing in 115 patients with anastomotic leakage[10]. However stent migration often occur and stent-related pain, stricture were reported following repeated stent placement[11,12]. Endoscopic repair using clips proven to be effective for only small defect[13,14]. The use of tissue sealants may be effective in small leaks with long tracts. Histoacryl occludes leak instantly after contact with liquid and it also promote inflammatory reaction which improve vascularity and healing[15]. High-output gastrointestinal fistula are less likely to close with the tissue sealant alone[16]. In case series, the reported outcomes showed that combination therapy by using clips and stents along with glue are more successful[17]. To achieve best result, the quality of the tissue surrounding the defects, interrupting flow across defect, confirmation of continued integrity need to be considered[16].

Depending on the size and location of the defect, a variety of endoscopic procedures can be selected[4]. In failure to seal an anastomosis leak with a stent after gastrectomy, salvage technique using histoacryl injection at the leakage site, with fluoroscopy guidance could be considered cautiously.

CONCLUSION

Postgastrectomy esophago-gastric leak is a serious complication. The endoscopic placement of fc-SEMS has become preferred treatment for esophageal anastomotic leakage. However, in failure to control leakage with fc-SEMS, salvage treatment with add-on histoacryl injection should be considered as a treatment option.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Medicine, research and experimental

Country/Territory of origin: South Korea

Peer-review report’s scientific quality classification

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P-Reviewer: Wu W S-Editor: Fan JR L-Editor: A P-Editor: Xing YX

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