PTH-034\u2005Endoscopic apollo overstitch system in management of esophageal leaks; the first reported uk case series

Abstract

Introduction Esophageal leaks, either after anastomosis following esophagectomy in malignancy or after esophageal perforation (Boerhaave syndrome), have a mortality rate of 35% which can rise to 100% if not diagnosed early. Traditional management involves adequate resuscitation, broad spectrum antibitics, parenteral nutrition, percutaneous drainage and timely surgical intervention. The Apollo Overstitch is a minimally invasive endoscopic suturing device which can be mounted over a twin-channel gastroscope and allows full thickness suturing without the need for surgery. It is utilised in bariatric endoscopy but is also very effective in closing perforations and fistulas as well stent fixation to reduce the risk of stent migration. Here we describe the first case series in the United Kingdom of management of esophageal leaks by the Apollo OverStitch device. Methods Of the 3 cases of esophageal leaks, one case was from an anastomosis after esophagectomy in malignancy and the other 2 were esophageal perforation (Boerhaave syndrome). In addition to the clinical diagnosis of a critically ill patient, esophageal leaks and perforation were diagnosed by contrast enhanced CT scan. Initial management was conservative (antibiotics, antifungals and TPN) due to high respiratory requirements. Gastroscopy under screening was undertaken to identify the leak position. Biological glue was used to close the leak in one case. In another the perforation was sutured using the Apollo device. In all 3 cases a Taewong Beta stent was inserted across the leak/perforation which was then fixed proximally with placement of further sutures to successfully prevent stent migration. Results Patient recovery was uneventful in all 3 cases, with early introduction of oral intake. In an average of eight weeks post-operatively, patients underwent a repeat gastroscopy and stent removal. Direct visualisation and intra-procedure contrast testing demonstrated an intact oesophagus with no further leak and this was confirmed by contrast enhanced CT. We have also just successfully treated a fourth patient with stent insertion and fixation. Conclusions The Apollo OverStitch system can be used in the management of esophageal leaks and has proven efficacy and safety. Although this technique does require expertise, it provides a successful minimally invasive method that can help in the management of these often critically ill patients. This is the first reported case series of successful utilisation of the Apollo OverStitch System in combination with a stent in the management of esophageal leaks.