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An 84-year-old man underwent abdominothoracic esophagectomy with gastric pull-up and an intrathoracic stapled anastomosis for advanced cancer of the cardia with involvement of the distal esophagus. A contrast study at 1 week after surgery detected anastomotic leakage. Endoscopy showed intermediate anastomotic leakage (●" Fig.1), and a 23×125-mm WallFlex FC stent (Boston Scientific, Natick, Massachusetts, USA) was placed [1]. A persistent purulent efflux from the chest drains was observed, and computed tomography (CT) revealed a 30×20-mm encapsulated perianastomotic septic collection in the mediastinum. The stentwas checked formigration and removed, and a persistent small leak was detected (●" Fig.3a). Because of continued contamination of the mediastinum through the leak, adequate drainage of the peri-esophageal mediastinum was needed,with endoscopic closure of the dehiscence. Under fluoroscopic control and endoscopic guidance, a hydrophilic guidewire was advanced percutaneously and grasped with a snare inserted endoscopically through the esophageal side of the fistula into the collection (●" Fig.2a). A biliary balloon catheter was passed through the scope into the cavity, and the percutaneous access to the collection was dilated to 10mm (●" Fig.2b). A 10.2-Fr drainage catheterwasplacedon theguidewire and advanced through the skin into the collection and left in situ for 4 weeks (●" Fig.2c,●" Video1) [2–3]. Theadequacy of percutaneous drainage was assessed with CT (●" Fig.3d). The anastomotic residual leak was closed endoscopically by inserting Vicryl mesh with fibrin glue (●" Fig.3b,c) [4]. Complete healing was achieved after three treatment sessions. The catheter was removed when the daily output diminished to less than 10mL/d. CT at 4 weeks showed stranding in the region of the previous collection without recurrence.

endoscopy

Radiosurgical endoscopy: fluoro-endoscopically guided percutaneous placement of a catheter for drainage of a complicated intrathoracic anastomotic septic collection