Fistula from esophagojejunostomy is still one of the most feared complications after total gastrectomy. Despite the development of new surgical devices and techniques, it remains a major concern with an incidence around 5%10. The use of endoscopic stents has brought the possibility of another form of fistula treatment3. However, this technique hasn´t yet been fully incorporated into clinical practice. This article describes a case of an esophagojejunostomy fistula that was successfully treated with an endoscopic stent. A literature review about this issue also follows.
A 61- year-old male patient was diagnosed with an infiltrative 6 cm tumor located in the lesser curvature of the medium gastric body invading cardia. The biopsy revealed a diffuse adenocarcinoma with signet-ring cells. Co-morbidities included morbid obesity (BMI 40.8) and arterial hypertension. Staging CT-scan showed a thickening of the gastric lesser curvature without any lymph node enlargement. The patient underwent total gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction. Esophagojejunal anastomosis was performed with a 25 mm circular stapler with intact resection rings. No leakage occurred after methylene blue testing. The anastomosis was drained with bilateral tubular silicon drains. On the 5th postoperative day, the patient presented diffuse abdominal pain and drainage of enteric fluid in the tubular abdominal drain. A CT-Scan with oral contrast demonstrated a leakage in the anastomotic area as shown in Figure 1.
Since it was an early fistula associated with peritonitis, an exploratory laparotomy was performed and revealed a suture dehiscence of 40% of the posterior wall of the esophagojejunal anastomosis. No specific local factors were noted that could explain the early occurrence of the fistula. Latter, the patient confessed unauthorized drinking of liquids since the first postoperative day. A suture of the dehiscence area was performed along with a nutritional jejunostomy, nasoenteric tube for decompression, and drainage of the cavity. Two days after the revisional surgery, leakage of enteric liquid in the abdominal drain occurred again, but without clinical signs of peritonitis. After discussion and evaluation of the patient clinical status, it was decided for a non-surgical treatment of this recurrent fistula. Patient remained stable with antibiotics, parenteral and enteral nutrition.
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