data synthesized from existing randomised controlled trials show that pyloric drainage procedures reduce the occurrence of early post - operative gastric outlet obstruction after oesophagectomy with gastric reconstruction ( 1,2 ) .
pyloromyotomy and pyloroplasty are generally considered simple procedures , however , they may be complicated by stricture , leak , and even death ( 3 ) . because of these complications some advocate not performing an emptying procedure during oesophagectomy ( 3 ) .
a 61-year - old gentleman presented in january 2010 with dysphagia for solids and regurgitation .
this arose from a long segment of multifocal dysplastic barrett s metaplasia ( 22 - 39 cm ) .
full pre - operative staging investigations diagnosed a poorly differentiated mid to distal oesophageal adenocarcinoma ( t3 , n1 , m0 ) .
the patient was recruited to the oeo5 trial in april 2010 and underwent neo - adjuvant chemotherapy with 5-fluorouracil and cisplatin . in may 2010 he underwent 3-stage mckeown oesophagectomy with
a formal heineke - mikulicz pyloroplasty ( 2-layer , interrupted closure with omental patch ) .
final histology of the resected specimen revealed t3 , n1 ( 2/22 ) , m0 , poorly differentiated adenocarcinoma with microscopically involved margins ( circumferential ) with vascular and lymphatic invasion . on post - operative day 7 a routine post - operative contrast swallow was performed .
this identified a spill of contrast due to a 5 mm anterior defect at the level of the oesophago - gastric anastomosis suggestive of focal ischaemia .
a further contrast swallow revealed contrast aggregating around the drain ( figure 1 ) and that the covered oesophageal stent was appropriately positioned with no evidence of on - going leak ( figure 2 ) .
a contrast swallow demonstrating contrast aggregating around the drain & a covered oesophageal stent appropriately positioned with no evidence of leak on post - operative day 11 , at routine dressing change on the ward , a full thickness abdominal wall dehiscence was identified .
the patient was managed with washout , drainage and re - suturing of the abdominal wall over a vicryl mesh .
the original intra - abdominal tube drain was left undisturbed . on post - operative day 16
the defect at the pyloroplasty suture line was now visible endoscopically and a covered pyloric stent was located appropriately across the defect .
due to proximal stent migration this was unsuccessful in controlling the leak ( figure 4 ) .
a late pyloroplasty leak diagnosed on contrast swallow & a contrast swallow demonstrating proximal stent migration and evidence of on - going leak the patient was now stable and he requested to eat and drink . a surgical approach to the management of fistula after pyloroplasty was deemed inappropriate because of the recent surgery for intra - abdominal sepsis and the presence of an abdominal wall mesh . a novel approach to the management of a fistula after pyloroplasty was employed .
a combined endoscopic and fluoroscopic procedure was performed where a radiologically placed snare was inserted through the abdominal drain and manipulated into the gastric tube through the defect in the pyloroplasty .
a gastroscope was used to introduce a t - tube into the gastric tube and into the snare . the abdominal drain and snare were withdrawn and the t - tube placed appropriately , plugging the hole in the pyloroplasty , under direct vision .
a further guide wire was left in place along the tract of the tube drain and was used to deploy a pigtail drain alongside the pyloroplasty ( figures 5 and 6 ) .
an intra - operative image demonstrating the combined endoscopic and fluoroscopic procedure a pictorial representation of the result of the procedure follow up ct , with contrast both orally and through the t - tube , showed no evidence of ongoing leak from the pyloroplasty .
tube satisfactorily plugged the hole through the anterior wall of the pyloroplasty , best demonstrated in the lateral decubitus position ( figures 7 and 8) .
the patient was discharged with a capped off t - tube in situ and made a good recovery .
a follow - up ct demonstrating no evidence of on - going leak from the pyloroplasty & a follow - up ct demonstrating the flanged t - tube satisfactorily plugging the hole through the anterior wall of the pyloroplasty
treatment of leaks by direct suture repair , revision , patching , and application of fibrin glue to leaks have failed to gain widespread acceptance owing to a high failure rate ( 4 ) .
alternative methods of controlling leaks such as the placement of covered stents are feasible but can be complicated by stent migration ( 4 ) and inadequate drainage of associated collections . to our knowledge
this is the only reported case of management of late pyloroplasty leak following oesophagectomy with a combined endoscopic and radiological placement of a t - tube .
the t - tube provided an ideal plug at the site of leak which enabled the patient to consume a normal diet and return home safely .
 management of upper gastrointestinal anastomotic leaks is an inter - disciplinary challenge . 
 we present a case of late pyloroplasty leak following 3-stage oesophagectomy . 
 we describe a novel , combined endoscopic and fluroscopic procedure to introduce a t - tube into the anastomotic leak proving an ideal plug at the site of leak which enabled the patient to consume a normal diet and return home safely . 
INTRODUCTION
CASE REPORT
DISCUSSION