LAUSR

Oesophageal leaks following minimal invasive oesophagectomy (MIE) present significant challenges to upper GI surgeons, with reported rates ranging from 11% to 21%. Management strategies include: conservative, endoscopic, and surgical interventions. These vary based on patient clinical status and institution. Here, we propose a hybrid approach involving thoracoscopic washout coupled with antegrade T-tube insertion via gastroscopy for managing these complex leaks. We describe the case of a 66-year-old male who underwent MIE via the McKeown approach for Siewert 1 Gastro-oesophageal adenocarcinoma. His neoadjuvant chemotherapy had been interrupted by a complex ischiorectal abscess and thus a decision was made to proceed for surgery. The surgery proceeded with a cervical anastomosis using a linear stapled technique and closure with 3.0 PDS. Postoperatively, the patient deteriorated on day 2, necessitating intubation due to decreased oxygen saturation. The chest tube output looked slightly bile stained. A subsequent CT scan revealed mediastinal fluid accumulation, prompting urgent intervention. Diagnostic thoracoscopy revealed contamination of the right chest and posterior mediastinum, necessitating extensive washout. A 2cm necrotic patch and perforation were identified on the gastric side of the oesophago-gastric anastomosis. Intraoperative gastroscopy localized the leak with a positive air bubble test. A Maryland forceps was passed through the defect to confirm the defect. Subsequently, a guidewire was passed antegrade into the cavity using the gastroscope. Decision was made to purse-string the defect (around the guidewire) using 3.0 PDS and the T-tube was exchanged transorally via the guidewire into the cavity and exteriorized through a 5mm port to the skin. Existing large-bore chest and Blake drains were retained, and a feeding jejunostomy was established. This hybrid management approach, combining endoscopy and thoracoscopic washout with T-tube insertion, offers an alternative for addressing complex anastomotic leaks following MIE. By avoiding resection and diversion, this technique potentially reduces morbidity. Follow-up scans demonstrated resolution of the leak allowing the patient to be discharged. https://1drv.ms/v/s!Aghd8kXfo8oQlX6QyliVLgRDmIu-?e=EGN5YD