Alyssa Choi, MD1, David P. Lee, MD, MPH1, Jason Samarasena, MD, FACG1, Ellyn Smith, MD2, Ninh Nguyen, MD2, Kenneth Chang, MD, FACG1; 1University of California Irvine, Orange, CA; 2University of California Irvine Medical Center, Orange, CA
Introduction: Esophageal leaks from nonhealing fistulas are difficult to treat, oftentimes failing therapy with stents, endoscopic suturing, or over-the-scope clips. We describe a case of occlusion of a nonhealing esophagogastric anastomotic dehiscence with a novel technique using an atrial septal occluder (ASO), typically used to close cardiac septal defects, and a combination of common tools to convert to endoscopic use.
Methods: A 71-year-old woman with stage III poorly differentiated neuroendocrine tumor status-post neoadjuvant chemotherapy and laparoscopic esophagogastrectomy, was found to have a large intra-abdominal fluid collection. Intra-operative endoscopy demonstrated a 9mm anastomotic dehiscence, and a fully covered esophageal stent was placed. Unfortunately, the patient developed hematemesis with profuse bleeding due to stent irritation of the ulcerated anastomotic tissue, and the stent was removed. Given friability of the surrounding tissue, clips and suturing were felt to be high risk for worsening bleeding. Therefore, mechanical occlusion was performed. Pediatric forceps were advanced through a 10Fr biliary stent delivery catheter. A 12mm ASO was grasped with the forceps and backloaded into the catheter. The entire construct was then advanced down the working channel of a therapeutic gastroscope. The distal flange was deployed within the cavity and the proximal flange was deployed in the esophageal lumen. The pediatric forceps were then used to adjust the occluder into optimal position. Fluoroscopy confirmed the device apposing the wall on each side of the defect and contrast flow from esophagus to stomach without diversion into the prior cavity. Discussion: Gastrointestinal transmural defects can be closed using various endoscopic techniques. However, there is a lack of options for the occlusion of such defects endoscopically. An ASO consists of two self-expandable discs connected by a 4mm waist, made with Nitinol wire mesh filled with Dacron polyester fabric. It comes with a 70cm delivery catheter, too short to be passed through an endoscope. We were able to modify a biliary stent delivery catheter and pediatric forceps to create an endoscopically compatible ASO delivery system, with the added advantage of allowing for fine manipulation after deployment. This may be the first reported case of applying an ASO to a surgical anastomotic dehiscence and speaks to the utility of occlusion devices in such cases.
Disclosures: Alyssa Choi indicated no relevant financial relationships. David Lee indicated no relevant financial relationships. Jason Samarasena indicated no relevant financial relationships. Ellyn Smith indicated no relevant financial relationships. Ninh Nguyen indicated no relevant financial relationships. Kenneth Chang indicated no relevant financial relationships.