A 69-year-old woman was referred to our department with abdominal discomfort. The endoscopy examination revealed early gastric antrum cancer, and duodenal ulcer with stenosis. Then, the patient underwent ESD procedure which went smoothly and the lesion was removed completely. The pathology revealed high-grade intraepithelial neoplasia. On postoperative day 4, the patient suffered significantly abdominal pain after outdoor activity. Physical examination revealed entire abdominal tender with rebound tenderness. Laboratory tests indicated elevated white blood cell counts (13.52×109/L, normal 3.5-9.5×109/L) and PCT level (9 ng/ml, normal <0.094 ng/ml). Computed tomography (CT) found gastric perforation and the presence of abdominal infection (Fig.1A). Emergency endoscopic therapy was performed due to her refusal of surgery.
A large defect was found in the wound of ESD (Fig.1B). First, endoscopy with a transparent cap was introduced into peritoneal cavity from the defect, and fully flushed whole peritoneal cavity with normal saline (Fig.1C). Then, successful closure of the defect was achieved using a kissing-suture technique(1) (Fig.1D). An endoloop was fixed on the transparent cap attached to the endoscope, and placed on the defect. A clip was used to fix 1 side of the endoloop to 1 edge of the defect and a second clip was then used to anchor the endoloop to the opposite edge of the defect. Then, the endoloop was ligated, fixing the defect “kissing” together. Finally, clips were used to closure of the defect completely. We then performed double percutaneous abdominal puncture catheter insertion, locating at the left and right lower abdomen respectively. One catheter was used for irrigating normal saline, whereas the other was connected to the drainage bag which could form an efficient circulation pathway to achieve continuous peritoneal irrigation. The color of output from the peritoneal irrigation clear gradually. The patient without any discomfort and the inflammatory markers returned to normal level after 3 days treatment. Then the continuous irrigation was stopped on day 4, and the patient discharged on day 7. Endoscopy follow-up on day 14 showed the closure was tightly (Fig.1E). At 9 months follow-up, endoscopy showed a linear scar (Fig.1F), and the duodenal stenosis was treated successfully with endoscopic balloon dilation.
Gastric leak after ESD is rare, especially in gastric antrum without muscularis propria injury(2). For this patient, we speculate that the gastric antrum leak was caused by increased abdominal pressure due to duodenal stenosis and outdoor activities. Gastric leak is difficulty to repair, especially for those with uncontained leaks(3). In this case, we showed kissing-suture combined with continuous peritoneal irrigation achieved good results, providing an alternative treatment for the patients with gastric fistula. Further larger studies are needed to validate this approach.