Medical thoracoscopy and gastroscopy for the treatment of intrathoracic anastomotic leakage following esophagectomy

Abstract

Abstract. Intrathoracic anastomotic leakage following esophagectomy is extremely difficult to manage appropriately. The outcomes of conservative management strategies are often disappointing, particularly in patients who develop adhesions of the pleural cavity and multiloculated empyema. This study describes a novel approach using combined thoracoscopy and gastroscopy in two cases. Thoracoscopy under local anesthesia was used to dissect the septations within the multiloculated empyema and remove the infected focus by direct visualization, and gastroscopy was subsequently performed to place a nasogastric or sump tube around the leak. The outcomes of both procedures were satisfactory: the empyemas almost completely resolved, the anastomotic leak closed quickly and there was adequate lung re-expansion. Accordingly, the combination of thoracoscopy and gastroscopy for the treatment of intrathoracic anastomotic leak post-esophagectomy may be an effective, safe, minimally-invasive, simple and inexpensive procedure. IntroductionIntrathoracic anastomotic leakage is an extremely intractable complication that occurs following esophagectomy, with an incidence that ranges from 1.3 to 5.1% (1-3). The mortality rate is 12-46.2% (1-3). In general, the effect of conservative treatments, including conventional chest tube drainage, nasogastric decompression and nutritional support, is often poor, particularly in patients with adhesions of the pleural cavity and multiloculated empyema (1-4). This study describes the combined application of medical thoracoscopy followed by gastroscopy for the treatment of an intrathoracic anastomotic leak in two patients. The study was approved by the IRB of Sun Yat-sen University Cancer Center. Consent was obtained from both of the patients. Case reportsCase 1. A 58-year-old male patient with middle-third thoracic esophageal squamous carcinoma was confirmed to have an intrathoracic anastomotic leak 10 days after esophagectomy and a right-sided contained empyema 4 weeks after esophagectomy. The condition of the patient did not improve following jejunostomy, conventional chest tube drainage and gastrointestinal decompression for 8 weeks. Gastroscopy (Fig. 1A) confirmed that a large intrathoracic anastomotic leak existed in the posterior right-sided wall of the esophagus. Two nasogastric tubes were then respectively placed into the residual stomach and the sump around the leak. A computed tomography scan was performed prior to thoracoscopy in order to select the incision accurately to facilitate exploration, debridement and drainage. Thoracoscopy was then performed under continuous sedation and local anesthesia. The port was inserted through a trocar via an incision on the right mid-clavicular line, between the second and third intercostal spaces. These adhesions and septations were dissected with biopsy forceps and electrocautery. After removing the infected focus, the anastomotic leak could be observed at the upper pole of the empyema cavity with some refluxed stomach content. The lateral side of th...