Journal of Minimally Invasive Surgery · 3 authors, 2 centres
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This retrospective study of 205 total gastrectomy patients found a 4.9% esophagojejunostomy leakage rate. Endoscopic Histoacryl injection successfully managed leakage in 87.5% of treated patients, with a mean post-injection hospital stay of 13.8 days and ability to drink water within 1-6 days. Histoacryl injection is a simple, effective, and repeatable treatment option for selected patients with small anastomotic leaks.
**Background:** Esophagojejunostomy leakage after total gastrectomy for gastric cancer is a serious, life-threatening complication with reported incidence of 4-15% and mortality up to 60%. While various treatments exist, including conservative management, stents, and surgery, optimal management remains controversial. Endoscopic Histoacryl (n-butyl-2-cyanoacrylate) injection has been used for variceal bleeding and other applications, but its role in anastomotic leaks is not well established. This study evaluates complications after total gastrectomy and outcomes of endoscopic Histoacryl injection for esophagojejunostomy leakage.
**Methods:** This single-center retrospective study included 205 patients who underwent total gastrectomy with Roux-en-Y esophagojejunostomy for gastric cancer between January 2016 and December 2021 at Dong-A University Hospital. All patients followed a standardized clinical pathway. Esophagojejunostomy leakage was diagnosed using clinical symptoms, CT, fluoroscopy, and endoscopy. Among 10 patients with leakage, 8 underwent endoscopic Histoacryl injection (0.5 mL Histoacryl + 0.5 mL Lipiodol mixture injected 1 mL at a time). The number of injections depended on leakage size. Fluoroscopy with Gastrografin was performed 2 days post-injection, and diet was advanced if no leakage was seen. Data on clinicopathologic characteristics, surgical outcomes, and leakage management were collected.
**Key Results:** Among 205 total gastrectomy patients, postoperative complication and mortality rates were 25.4% and 0.9%, respectively. Serious complications (Clavien-Dindo ≥IIIb) occurred in 6.3%. Ten patients (4.9%) developed esophagojejunostomy leakage at a mean of 11.2 days postoperatively. Of these, 8 patients received endoscopic Histoacryl injection, and 7 (87.5%) were successfully managed without injection-related complications. Among the 8 injected patients, 6 were injected once and 2 were injected three times. Leakage sizes ranged from 4 to 6 mm. Mean post-injection hospital stay for successfully managed patients was 13.8 days, and they could drink water within 1-6 days after injection. Two patients died of sepsis from leakage (one after late diagnosis, one after recurrence despite initial successful injection). Three patients underwent reoperation (one successfully treated with three injections postoperatively, one required video-assisted thoracic surgery, one died).
**Clinical Implications:** Endoscopic Histoacryl injection appears to be a simple, effective, and repeatable treatment for selected patients with small esophagojejunostomy leaks (≤6 mm) after total gastrectomy. It offers advantages including high patient compliance, no procedure-related pain, no need for additional drainage, rapid return to oral intake, and low cost. The success rate (87.5%) is comparable to reported stent outcomes (88% success). However, this treatment is not suitable for all patients, particularly those with large defects or severe sepsis. Limitations include the retrospective design, small sample size, and lack of standardized protocol. Prospective randomized multicenter studies are needed to confirm these findings and establish optimal patient selection criteria.