Restoration of luminal continuity endoscopically We have no disclosures Background Anastomotic leak is associated with increased patient morbidity and mortality, longer hospital stays, and higher total costs of hospitalization. Symptomatic gastroesophageal anastomotic leaks incur a mortality reported to be as high as 60%. Surgical takedown and repair of the anastomosis with buttressing of the staple line, extensive debridement, and drainage is the standard treatment for post-operative anastomotic leaks. However, there are patients who have comorbidities and risk factors making them unfit surgical candidates. We present the case of a 55-year-old patient with surgical history of Roux-en-Y gastric bypass who developed ischemic colitis post-lung resection for squamous cell cancer. Post-operative period was complicated by multiple anastomotic breakdowns, fistulae, and intra-abdominal abscesses. The patient spent a year in the ICU, frequently requiring pressure support. As the patient was unfit for surgery due to ongoing systemic inflammatory response syndrome, palliative care discussions were held. We decided to perform a novel endoscopic procedure to re-establish bowel continuity. The patient's GI anatomy had three discontinuous segments with a leak at every segment. The pharynx leads to a blind-ending esophageal pouch that had an esophago-gastric fistula opening into a cavity extending to pelvis, a remnant stomach and duodenum ending at the ligament of treats with a venting gastrostomy tube placed in the remnant stomach, the remaining jejunum with a feeding jejunostomy tube, a disrupted ileocolonic anastomosis with a leak in retroperitoneal space, and beyond the anastomosis, the colon was continuous to the anus. CT image demonstrating the discontinuous bowel segments, the blind-ending esophagus with an esophago-gastric stump outlined in red, the gastric remnant and the duodenum ending at ligament of treats outlined in blue, and the remainder jejunum continuous to the anus outlined in black, abdominal and pelvic abscesses indicated in orange. Shown here is the retroperitoneal cavity extending from the diaphragm to the pelvis indicated in orange that required multiple drains indicated in red arrows. We decided to perform a multi-staged procedure to restore the continuity of the gut at multiple levels. Endoscopic methods. Bowel continuity was established in three sessions. To address the esophago-gastric stump leak and fistula, we decided to place a bridging stent across the site. An 18 mm covered stent was placed to bypass the fistula between esophago-gastric stump and the remnant stomach. Contrast showed no leak thereby re-establishing continuity between the esophagus and the remnant stomach and bypassing of the fistula. Further, to allow for gastric content to pass from stomach to jejunum, an endoscopic connection was created from the greater curvature of the patient's stomach to the common channel of the small intestine via a stent. EOS was used to achieve good apposition between the gastric wall and the common channel. Once the common channel was identified, a EOS guided wire was placed across the gastric wall. The tract was balloon dilated and a 15 mm diameter and a 10 mm long self-retaining lumen-opposing stent was deployed via jejunostomy. Contrast injection into the stomach demonstrated patency of the stent and passage into the jejunum. The jejunostomy tube was replaced. Use of fistula plug and glue placement at disrupted staple line at the ileocolonic anastomosis. Image demonstrating restored bowel continuity with a stent from the esophago-gastric stump to the remnant stomach and a stent from the greater curvature to the jejunum. Arrows indicate venting gastrostomy and feeding jejunostomy. Clinical Implications In this patient heading to palliative care through novel stepwise endoscopic approaches, we restored gut continuity, resolved leakage of gastrointestinal contents and infection, allowed the patient to resume normal gut function. At 6 years follow-up, this patient still has the gastrojejunal stent but is otherwise leading a normal life. Conclusions We have successfully demonstrated the use of endoscopy including stent placement in the management of discontinuous GI tract and complications such as fistula and leaks.

endoscopic procedures

bowel continuity restoration

anastomotic leaks

unfit for surgery

comorbidities