Historically, a large anastomotic leak after Ivor Lewis esophagogastrectomy are treated surgically with rethoracotomy and drainage. This video demonstrates the management of a large semi-circumferential leak (40% disruption) at the esophagogastric anastomosis with a covered stent.

A 55 year old male with T2, N0 squamous cell carcinoma of the mid-esophagus underwent a minimally invasive Ivor-Lewis esophagectomy. The patient presented to the emergency department three weeks post-operatively with complaints of shortness of breath. A CT scan of the chest and abdomen with contrast conveyed a large leak at the anastomosis with a large mediastinal collection. Endoscopy revealed a significant disruption of the anastomosis encompassing 40% of the anastomotic circumference. We use the endoscope to exit through the anastomotic defect into the mediastinal cavity to drain the collection. Upon drainage of the collection, a 22 mm self-expandable, covered eopshageal stent was deployed under fluoroscopy to cover the anastomotic defect.

The procedure was completed in 35 minutes without complication. Postoperatively, the patient was placed on intravenous antibiotic and jejunostomy tube feeding and was discharged at 1 week. The patient was resumed on oral liquid at 3 weeks post-procedure. The stent was removed endoscopically after 6 weeks and endoscopic evaluation noted completed healing of the anastomotic defect.

The use of endoscopic covered stent is an effective minimally invasive modality for treatment of a large intrathoracic anastomotic leak. Natural orifice management of esophageal leaks has changed the paradigm in the management of anastomotic leaks.