Nasogastric Perforation of Post-Oesophagectomy Conduit: Successful Ovesco Clip Salvage “Case Report”

Abstract

Oesophagectomy for malignant oesophageal cancer is potentially a morbid procedure with pulmonary, cardiovascular and anastomotic leak the most concerning complications. We present two patients with conduit leak, caused by a nasogastric tube (NGT) perforation of the distal gastric conduit, successfully treated endoscopically with an over the scope clip (Ovesco, Endotheraputics, Sydney, Australia). Prospective record of the treating oesophageal surgical consultant was extracted for this report. Illustrations were prospectively stored on a password protected computer. Perforation of the oesophagogastric conduit by the nasogastric tube following oesophageal reconstruction is unreported in the literature. The use of a novel technique of endoscopic ‘ovesco’ clip greatly reduced the potential morbidity of reoperation in two cases that presented masquerading as an anastomotic leak.

Introduction

Perforation of the gastric conduit by naso-gastric tube (NGT) following oesophageal reconstruction is extremely rare and is unreported in the literature. Leaks are a concerning complication which can have serious complications or mortality. Management can involve substantial morbidity and mortality, long hospital stay. Two cases are presented with a clinical picture similar to anastomotic leak which were managed with minimal morbidity using a novel technique of endoscopic “ovesco” clip.

Methods

Prospective patient data was collated from a password protected practise data base and collated for publication. The data base was approved by the institutional ethics (CH62/6/2011–092).

Case Presentation(S)

A 55 year old male diagnosed with a distal oesophageal adenocarcinoma underwent neo-adjuvant chemotherapy followed by Ivor-Lewis oesophagectomy. Subsequent histology demonstrated T3N3 disease. Nasogastric (NG) removal was delayed due to poor gastric emptying. On day 12 he became septic with increasing respiratory distress.

A further case was a 57 year old male who presented with recurrent aspiration secondary to dilated end stage achalasia. He underwent an Ivor-Lewis oesophagectomy. The NGT removal was also delayed due to poor gastric emptying. On day 21 he became septic, with NG tube still in place due to high output.

In the first patient the white cell count (WCC)(19) and C-reactive protein (CRP) (156 mg/L) became elevated. Chest X-ray showed a left sided pleural effusion. A CT of the chest and abdomen was performed. There was contrast extravasation in the distal gastric conduit above the level of the hiatus (Fig. 1). The site of leak was localized to where the NGT can be seen traversing the gastric wall.

Fig. 1
figure1

CT Lateral showing nasogastric tube outside gastric lumen

The second patient presented similarly and demonstrated raised WCC and CRP. A contrast x-ray demonstrated the NGT traversing the gastric wall. A CT scan showed no collection (Fig. 1).

The differentials for a patient with sepsis post-op Ivor-Lewis Oesophagectomy are broad with anastomotic leak the most concerning. Other sources may be excluded including pulmonary, urinary and wound and IV-line infections. These cases represent an uncommon cause for post-operative sepsis following Ivor-Lewis oesophagectomy, and delayed NGT removal, mimicking anastomotic leak.

Gastroscopy was performed for confirmation and assessment for endoscopic therapy. In each case gastroscopy revealed a healthy anastomosis with no leak. The gastric conduit appeared healthy with evidence of perforation through the gastric conduit on the non-stapled side of the conduit. In each case the NGT was traversing the gastric wall just above the level of the hiatal opening (Fig. 2 demonstrates fistula post-removal of NGT). Each perforation was treated with the an OTSC (Ovesco). The gastric conduit perforation was suctioned into the cap device with the clip deployed around the site of perforation. No intercostal drainage was required.

Fig. 2
figure2

Endoscopic view of gastric conduit: NG perforations after tube removal

Outcome & Follow up

In each case, following endoscopic treatment, a contrast swallow was performed the following day which demonstrated no active contrast extravasation. The NG tube was removed, and oral intake commenced. Clinical signs of sepsis were controlled, and antibiotics ceased after 5 days in both patients.

Discussion

Nasogastric tube placement after oesophagectomy is routine. Placement of nasogastric tubes has been associated with both oesophageal and gastric perforations. Gastric perforations have been described in patients with previous gastric surgery [1] (Roux-en-Y bypass) and those with connective tissue disorders [2]. Most cases listed in the literature follow immediately after insertion of NGT [3,4,5], however these cases represent a delayed perforation which appeared secondary to pressure necrosis from the tip of the NGT against the gastric conduit for prolonged NG drainage. It occurred where the curvature of the stomach impinged on the straight NG tube. Fig. 1 shows the undesirable positioning of the tube, and all tubes are now placed a shorter distance and away from perpendicular position against conduit wall to prevent this complication.

Traditionally post-oesophagectomy perforation has been managed surgically, however is associated with high morbidity and mortality. The most common endoscopic techniques include use of oesophageal stents for perforations [6], and appear to be an effective and feasible alternative to surgery, especially in iatrogenic perforation of the oesophagus. Endoscopic Clipping has also been utilized for direct closure of oesophageal defects [7, 8] but not thought feasible in these cases due to induration of the tissues. The OTSC utilized in our cases, has been documented in a variety of case studies and series. OTSC are thought to provide more durable and full-thickness closure when compared to standard endoscopic clips. For the treatment of acute perforations or leaks successful closure of perforations is achieved in between 73 and 90% of patients. A difficulty of placement is tangential application, which is more difficult in the narrow cylindrical oesophagus compared with stomach. Similarly, a stent would not occlude a leak in a capacious gastric conduit.

Conclusion

The application of OTSC in our patients demonstrates that is demonstrably effective where there is minimal intra-thoracic contamination. It also demonstrates an unusual complication following oesophagectomy which can mimic a post-operative oesophageal anastomotic leak.

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Contributions

All authors (DPM, SY and GLF) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.

Corresponding author

Correspondence to Gregory L. Falk.

Ethics declarations

Prospective patient data was collated from a password protected practise data base and collated for publication. The data base was approved by the institutional ethics (CH62/6/2011–092).

Conflict of Interest

Authors declare no conflict of interest.

Ethical Approval

Institutional ethics (CH62/6/2011–092).

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This article is part of the Topical Collection on Surgery

Main novel aspects:

• Perforation of the oesophagogastric conduit by the nasogastric tube following oesophageal reconstruction is unreported in the literature.

• The use of a novel technique of endoscopic ‘ovesco’ clip greatly reduced the potential morbidity of reoperation in two cases that presented masquerading as an anastomotic leak

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Mitchell, D.P., Yeluri, S. & Falk, G.L. Nasogastric Perforation of Post-Oesophagectomy Conduit: Successful Ovesco Clip Salvage “Case Report”. SN Compr. Clin. Med. (2020). https://doi.org/10.1007/s42399-020-00362-5

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Keywords

  • Oesophagectomy
  • Leak
  • NG perforation
  • Endoscopic therapy
  • Nasogastric tube