The data of patients with esophagojejunal fistula treated by interventional therapy at our hospital between June 2012 and May 2020 were retrospectively reviewed. Patients were eligible for inclusion in this study if they 1) had undergone total gastrectomy and esophagojejunostomy for treatment of gastric cancer; 2) had esophagojejunal fistula confirmed by the methylene blue test, imaging, or endoscopy; and 3) had received transnasal placement of abscess drainage tube, jejunal nutrition tube, and jejunal decompression tube under fluoroscopy. Patients were excluded if 1) they had esophagogastric anastomotic fistula after non-total gastrectomy; 2) they had duodenal stump fistula; or 3) the esophagojejunal fistula had healed after conservative treatment, surgical treatment, or endoscopic treatment.
The following data were collected for analysis: sex, age, and comorbidities; history of gastric cancer–related chemotherapy; pre-procedure American Society of Anesthesiologists (ASA) score and Procedural Severity Score (PSS) ; pre- and post-procedure laboratory test results and Eastern Cooperative Oncology Group (ECOG) performance status; time from surgical resection to diagnosis of fistula; fistula size, location, and classification (according to Clavien–Dindo classification ); time from diagnosis of fistula to interventional treatment; abscess cavity extent and presence of communications; volume of drainage from abscess cavity; pus culture results during treatment and follow-up; morphological changes in fistula and abscess cavity; complications (infection, bleeding, shock, and so on); laboratory and imaging examination results; ECOG performance status at last follow-up; time of healing of fistula or death; and cause of death.
Ethics committee of our hospital approved this study; the need for informed consent was waived because of the retrospective nature of the study.
Preoperatively, all patients underwent blood routine examination, liver and kidney function tests, serum electrolytes estimation, electrocardiogram, methylene blue test, upper gastrointestinal contrast study, and plain and enhanced chest CT scan. Pre-procedure preparation was with fasting, gastric mucosal protective agents, parenteral nutrition, and prophylactic antibiotics. Patients with dyspnea or oxygen saturation <90% received oxygen by nasal cannula and, if necessary, tracheal intubation and ventilator-assisted breathing.
Esophagography was performed first. The nasal cavity, pharynx, and esophagus were anesthetized with tetracaine gel 10 min after the esophagography. With the patient supine on the digital subtraction angiography table, ioversol was administered orally. Frontal and 45° left anterior oblique views of the esophagus were studied to determine the position and size of the esophagojejunal anastomotic leakage and the extent of spillage of contrast.
Transnasal insertion of jejunal nutrition tube and decompression tube
Under fluoroscopy, a 0.035-inch hydrophilic membrane guide wire (Cook Medical LLC, Bloomington, IN, USA) and a 5F vertebral artery catheter (Cook Medical) were passed through one nostril and advanced through the pharynx and esophagus, across the esophagojejunal anastomosis area into the upper jejunum. The catheter was withdrawn, and a No. 14 jejunal nutrition tube was passed over the guide wire 40–50 cm into the jejunum. In the same way, a decompression tube was inserted through the other nostril into the jejunum 5–10 cm beyond the esophagojejunostomy (Fig.1).
Transnasal insertion of abscess drainage tube
The drainage catheter and guide wire were introduced along the side of the jejunal decompression tube into the esophagus. Transcatheter esophagography was performed to display the location of the esophagojejunal fistula, and the catheter and guide wire were then advanced into the abscess cavity through the fistula. The lowest pole of the abscess cavity was gently probed, and a 5F PERFORMA® vessel catheter (Merit Medical, USA) was exchanged and advanced until the tip was at the lowest pole of the abscess cavity. If the abscess cavity was large, a 5F pigtail catheter (Merit Medical) was inserted into the abscess cavity in the same way (Fig.1).
Percutaneous abdominal drainage tube replacement
For patients with a percutaneous abscess drainage tube inserted during previous surgery, the tube was exchanged for a 10.2F or 12F external drainage tube, which was then connected to a negative pressure suction system up to −125 mmHg.
Postoperative treatment and follow-up
Post procedure, the patients received fasting, jejunal nutrition, appropriate intravenous nutritional supplements, and continuous negative-pressure suction through the abscess drainage tube. Antibiotics were prescribed according to culture results. Normal-saline lavage was performed 1–2 times per day through the transnasal or percutaneous drainage tube.
Esophagography and chest CT were repeated 5–7 days after the procedure to assess abscess cavity size and the efficacy of suction. When the distal part of the abscess cavity had healed, the position of the drainage tube was adjusted under fluoroscopy so that the tip was at the proximal part (Fig.2). The position of the drainage tube was adjusted every 2 weeks after checking the healing of the abscess cavity; when necessary, the drainage tube was replaced. The percutaneous drainage tube was removed when 5–7 days had passed without any drainage. The transnasal abscess drainage tube was removed when contrast injected into the cavity showed only a thin line. The jejunal feeding tube and decompression tube were retained for another week. Oral intake was restarted after esophagography confirmed healing of the fistula.
Follow-up quality of life was evaluated by ECOG performance status. The effectiveness of treatment was defined as the reduction of the abscess cavity by >50% in an individual patient under radiography of the abscess and the improvement of the patient’s ECOG performance status, which was recorded at the first admission and the last follow-up. Treatment success was defined as complete disappearance of the abscess and healing of the fistula, with no recurrence over 6 months of follow-up. Treatment failure was defined as persistence of abscess cavity or fistula, or fistula recurrence within 6 months. Need for surgical intervention, or death due to esophagojejunal leak–related complications during treatment, was also regarded as treatment failure.