Challenging delayed bleeding after an Ivor Lewis oesophagectomy

Area of Science:

• Gastroenterology
• Surgical Oncology
• Interventional Radiology

Background:

• Minimally invasive oesophagectomy for oesophageal adenocarcinoma is a standard procedure.
• Post-operative upper gastrointestinal bleeding can be a serious complication.
• Oesophago-gastric (OG) anastomosis integrity is crucial for preventing complications.

Observation:

• A patient presented with massive upper gastrointestinal bleeding 8 days post-minimally invasive oesophagectomy.
• Endoscopies revealed a prominent luminal vessel at the OG anastomosis.
• Angiography confirmed contrast extravasation at the OG anastomosis from the gastro-epiploic arcade.

Findings:

• Coil embolization successfully controlled the bleeding without causing ischemia.
• The standard 4.8-mm staple height for the end-to-end anastomosis circular stapler (DST™ Series EEA™) was implicated.
• A modified technique using a 3.5-mm staple height and clearing omental tissue improved haemostasis.

Implications:

• Adjusting staple height in circular staplers may reduce anastomotic bleeding.
• Careful preparation of the anastomosis site, including omental tissue clearance, is vital.
• Interventional radiology techniques like coil embolization are effective for managing anastomotic bleeding.