Gastroenterologie
a hepatologie

Endoscopic management of a gastroesophageal anastomotic leak and refractory stricture following robotic Ivor Lewis esophagectomy for esophageal adenocarcinoma

Kateřina Košťálová ^{Orcid.org  1}, Ján Csomor¹, Zuzana Vacková¹, Radek Pohnán ^{Orcid.org  2}, Petr Urbánek ^{Orcid.org  1}, Štěpán Suchánek¹

+ Affiliation
¹ Interní klinika 1. LF UK a ÚVN – Vojenská fakultní nemocnice, Praha
² Chirurgická klinika 2. LF UK a ÚVN – VFN v Praze

Summary

Background: An anastomotic leak following esophagectomy represents a severe, life-threatening complication. Over the past decade, endoscopic vacuum therapy (EVT) has become the preferred minimally invasive treatment modality. However, even after successful EVT, benign strictures may develop, which in some cases can be refractory to endoscopic dilation. Case presentation: We present the case of a 75-year-old female patient who underwent robot-assisted Ivor Lewis esophagectomy for esophageal adenocarcinoma and subsequently developed an extensive anastomotic dehiscence with leakage of luminal contents into the pleural cavity. The complication was successfully managed with EVT. During follow-up, the patient developed a refractory anastomotic stricture unresponsive to repeated balloon dilations, which was effectively resolved by the placement of a lumen-apposing metal stent (LAMS), resulting in rapid reintroduction of oral intake and significant improvement in the quality of life. Conclusion: This case illustrates the successful use of modern endoscopic techniques, specifically EVT and LAMS stenting, in managing severe complications after esophagectomy. Close multidisciplinary collaboration was crucial. The endoscopic approach allowed for complete healing of the defect without the need for surgical reintervention providing an effective solution for the refractory stricture, with minimal burden on the patient.

Keywords

endoscopic vacuum therapy, lumen-apposing metal stents, refractory stricture, ezofagektomie, anastomotic leak, minimally invasive endoscopy, esophageal cancer

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Literature

1. Fabbi M, Hagens ER, van Berge Henegouwen MI et al. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diag- nostics, and treatment. Dis Esophagus 2021; 34(1): doaa039. doi: 10.1093/dote/doaa039.
2. Jung DH, Yun HR, Lee SJ et al. Endoscopic vacuum therapy in patients with transmural defects of the upper gastrointestinal tract: a systematic review with meta-analysis. J Clin Med 2021; 10(11): 2346. doi: 10.3390/jcm10112346.
3. Aziz M, Haghbin H, Sharma S et al. Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: systematic review and meta-analysis. Endosc Int Open 2021; 9(9): E1371–E1380. doi: 10.1055/a-1508-5947.
4. Richter F, Hendricks A, Schniewind B et al. Eso-Sponge® for anastomotic leakage after oesophageal resection or perforation: outcomes from a national, prospective multicentre registry. BJS Open 2022; 6(2): zrac030. doi: 10.1093/bjsopen/zrac030.
5. Luttikhold J, Pattynama LM, Seewald S et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023; 55(9): 859–864. doi: 10.1055/a-2042-6707.
6. Košťálová K, Vacková Z, Pohnán R et al. Endoscopic vacuum therapy in esophageal defects treatment – our first experience. Gastroent Hepatol 2024; 78(4): 306–313. doi: 10.48095/ccgh2024306.
7. Na B, Kang CH, Na KJ et al. Risk factors of anastomosis stricture after esophagectomy and the impact of anastomosis technique. Ann Thor Surg 2023; 115(5): 1257–1264. doi: 10.1016/ j.athoracsur.2023.01.026.
8. Koshy RM, Brown JM, Chmelo J et al. Anastomotic stricture after Ivor Lewis esophagectomy: an evaluation of incidence, risk factors, and treatment. Surgery 2022; 171(2): 393–398. doi: 10.1016/j.surg.2021.07.034.
9. Zhong Y, Sun R, Li W et al. Risk factors for esophageal anastomotic stricture after esophagectomy: a meta-analysis. BMC Cancer 2024; 24(1): 872. doi: 10.1186/s12885-024-12625-8.
10. Mendelson AH, Small AJ, Agarwalla A et al. Esophageal anastomotic strictures: outcomes of endoscopic dilation, risk of recurrence and refractory stenosis, and effect of foreign body removal. Clin Gastroenterol Hepatol 2015; 13(2): 263–271. doi: 10.1016/j.cgh.2014.07.010.
11. Vermeulen BD, de Zwart M, Sijben J et al. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study. Gastrointest Endosc 2020; 91(5): 1058–1066. doi: 10.1016/ j.gie.2019.12.040.
12. Mohan BP, Chandan S, Garg R et al. Lumen-apposing metal stents, fully covered self-expanding metal stents, and biodegradable stents in the management of benign of GI strictures: a systematic review and meta-analysis. J Clin Gastroenterol 2019; 53(8): 560–573. doi: 10.1097/MCG.0000000000001228.
13. Kassis ES, Kosinski AS, Ross P et al. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thor Surg 2013; 96(6): 1919–1926. doi: 10.1016/j.athoracsur. 2013.07.119.
14. Vohra I, Gopakumar H, Sharma NR et al. Efficacy of endoscopic vacuum therapy in esophageal luminal defects: a systematic review and meta-analysis. Clin Endosc 2025; 58(1): 53–62. doi: 10.5946/ce.2023.282.
15. Scognamiglio P, Reeh M, Melling N et al. Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting. BMC Surg 2022; 22(1): 309. doi: 10.1186/s12893-022-01764-z.
16. Mandarino FV, Barchi A, D’Amico F et al. Endoscopic vacuum therapy (EVT) versus self-expandable metal stent (SEMS) for anastomotic leaks after upper gastrointestinal surgery: systematic review and meta-analysis. Life 2023; 13(2): 287. doi: 10.3390/life13020287.
17. Dell’Anna G, Fanizza J, Mandarino FV et al. The endoscopic management of anastomotic strictures after esophagogastric surgery: a comprehensive review of emerging approaches beyond endoscopic dilation. J Pers Med 2025; 15(3): 111. doi: 10.3390/jpm15030111.
18. Vanella G, Dell’Anna G, Arcidiacono PG. Plastic versus metal EUS-guided drainage of pancreatic fluid collections: do we really know when to use the hard way? Clin Gastroenterol Hepatol 2022; 20(6): e1507–e1508. doi: 10.1016/ j.cgh.2021.07.002.
19. Kumar VC, Singh S, Moond V et al. Safety and efficacy of lumen-apposing metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis. Endoscopy 2025; 57(3): 282–290. doi: 10.1055/a-2461-3773.
20. Vanella G, Dell’Anna G, Arcidiacono PG. EUS-directed transenteric ERCP with giant intrahepatic stone lithotripsy after a LAMS-in-LAMS rescue in response to a misdeployment. VideoGIE 2024; 9(3): 150–153. doi: 10.1016/j.vgie.2023.10.008.
21. Vanella G, Dell’Anna G, Bronswijk M et al. Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care. Ann Gastroenterol 2022; 35(5): 441–451. doi: 10.20524/aog.2022.0736.
22. Giri S, Vaidya A, Kale A et al. Efficacy of lumen-apposing metal stents for the management of benign gastrointestinal stricture: a systematic review and meta-analysis. Ann Gastroenterol 2023; 36(5): 524–532. doi: 10.20524/aog.2023.0819.
23. Hallac A, Srikureja W, Liu E et al. Economical effect of lumen apposing metal stents for treating benign foregut strictures. World J Gastrointest Endosc 2018; 10(10): 294–300. doi: 10.4253/wjge.v10.i10.294.