Endoscopic vacuum therapy for cervical leakage following esophagectomy under monitored anesthesia care: a case report

Although esophagectomy is a standard treatment for esophageal cancer, anastomotic leak after esophagectomy is a relatively common complication and its incidence is 10-25% for cervical anastomosis. Endoscopic vacuum therapy (EVT) is a feasible primary treatment of esophageal perforations and leaks. Currently, there are no anesthesia guidelines for EVT, however, it is usually performed under general anesthesia with endotracheal intubation, especially for cervical EVT. Here, we report a successful EVT under monitored anesthesia care (MAC) without any complication, which doesn't need to intubate the patient. A 64-year-old male with upper esophageal cancer underwent an Ivor-Lewis operation with cervical anastomosis. Vacuum assisted closure (VAC) was performed for cervical leak under general anesthesia, but there was no further improvement. Although EVT was attempted under sedation with midazolam in an endoscopy room, the procedure was discontinued because of desaturation. Furthermore, the thoracic surgeon was concerned about the possibility of dyspnea and hypoxia even after the procedure. EVT was scheduled under MAC at the request of a thoracic surgeon and medical doctor, as EVT was expected to lead to patient discomfort and difficult airway. EVT was performed successfully with no respiratory depression or patient movement using target controlled infusion with 2% propofol and remifentanil. The patient was discharged on the 78th POD without any other complications. EVT for cervical leak after esophagectomy can be successfully performed with MAC, and understanding the general condition of the patient, cooperation with the patient and the surgeon, and providing continuous oxygen supply to the patient are necessary for a successful procedure under MAC.