A 65-year-old male who had received definitive chemoradiation therapy for cuT3N0 esophageal squamous cell carcinoma (SCC), with an initially complete clinical response, was found to have recurrent cancer 2 years later located at 30 cm from the incisors on surveillance endoscopy. He underwent a salvage 3HMIE. A gastric conduit was constructed using serial firing of staplers. After creation of the conduit, perfusion was confirmed using Pinpoint fluorescence angiography (Novadaq Technologies Inc, Ontario, Canada) (Fig. 1a). A side-to-side, but functional end-to-end, esophago-gastric anastomosis was created in the left neck using staplers below the transition point. On postoperative-day (POD) 3, the patient developed acute respiratory distress and a CXR demonstrated a partial white-out on the right (Fig. 1b). He was emergently intubated, and a bedside bronchoscopy was performed which did not demonstrate a mucus plug. Therefore, a right-sided pleural effusion was suspected and a second chest tube was placed that did not resolve the effusion (Fig. 1c). Due to a concern for an anastomotic leak, he was taken for a thoracoscopic exploration and neck drainage. Multiple serous fluid collections were found in the right chest with a significant amount of diffuse thick rind, requiring decortication (Fig. 1d). An on-table endoscopy revealed ischemic changes of the gastric conduit spanning about 2 cm at 24 cm from the incisors. The anastomosis was intact at 20 cm. This suggested partial necrosis of the conduit and leak from the staple line into the thoracic cavity. A 23 mm × 155 mm WallFlex partially-covered self-expanding metal stent (pcSEMS, Boston Scientific, Natick, MA) was deployed under fluoroscopy, and bridled in place using umbilical tape. A completion esophagram confirmed appropriate stent placement without an active leak (Fig. 1e). Final surgical pathology returned as ypT1bN0 stage IB SCC. Twenty-five days after the pcSEMS placement, repeat endoscopy and stent retrieval was performed. Upon stent removal, macerated mucosa underneath the stent was seen with a 1 cm defect approximately 4 cm below the anastomosis. An on-table esophagram confirmed a small contained leak at the gastric conduit staple line, which prompted re-placement of a pcSEMS. Two weeks later, the second pcSEMS was removed, and the leak site was found to be completely healed. He was started on a liquid diet and gradually advanced to a regular diet. Two months later, the patient developed a stricture just below the anastomosis (Fig. 1f) that required serial balloon dilations with Kenalog (Bristol-Myers Squibb, Princeton, NJ) injection with complete resolution of symptoms after 6 months.

A 71-year-old male with cuT2N2 distal esophageal adenocarcinoma in the presence of Barrett’s esophagus extending up to the thoracic inlet underwent 3HMIE after neoadjuvant chemoradiation. A gastric conduit was constructed via serial firing of staplers, and its perfusion was confirmed with Pinpoint fluoroscopy (Fig. 2a). Once again, anastomosis was created in the left neck using staplers below the transition line. On POD 5, bilious chest tube drainage was noted. Upon endoscopy, a 2 cm ischemic area was found just distal to the anastomosis. Therefore, a 23 mm × 155 mm pcSEMS was placed with its proximal end at the upper esophageal sphincter (Fig. 2b) and bridled with umbilical tape. His neck incision was drained. Despite the stent, the patient had persistent bile leak into the chest tube. It was felt that perhaps given the site of the leak in the thoracic inlet, it was not appropriately covered by the pcSEMS. Thus, he returned to the operating room for thoracoscopic decortication of the right lung. Upon stent removal, a 5 cm long dehiscence in the conduit was visualized along the gastric staple line (Fig. 2c). A V-Loc (Covidien, Mansfield, MA) 2-0 prolene suture was used thoracoscopically to reapproximate the gastric staple line dehiscence. Despite initial resolution of the bile leak, bilious chest tube output recurred in the next 48 h. On repeat endoscopy, the dehisced area was seen with inadequate closure (Fig. 2d). Since a pcSEMS failed the first time, a fully-covered 100 mm × 23 mm SEMS was placed. Eighteen days later, repeat endoscopy and stent removal showed a well-healing gastric conduit with a small, contained area of leakage. This time, a 23 mm × 155 mm pcSEMS was inserted to exclude the area of leakage and prevent stent migration. Three weeks later, the third stent was removed, and the gastric conduit was completely healed. His final pathology was ypT1aN0 stage IA esophageal adenocarcinoma. This patient also developed a stricture (Fig. 2e) that required serial balloon dilations. However, he has overall done well and is asymptomatic 9 months after his original procedure.