A 56-year-old female with a history of adenocarcinoma of the gastric cardia status post Ivor-Lewis esophagectomy presented with a 10-month history of post-prandial chest pain. This occurred immediately after eating and was associated with an unintentional weight loss of 44 pounds. She denied typical reflux symptoms, vomiting, or gastrointestinal (GI) bleeding. Her symptoms started immediately after surgery and were not responsive to proton pump inhibitors. On examination, she appeared cachectic and physical examination was normal except for the post-surgical scar. Pertinent serology was consistent with iron deficiency anemia (hemoglobin of 9.7 g/dL, mean corpuscular volume of 76.5 fl, and ferritin of 4.7 ng/mL). An esophagogastroduodenoscopy was performed, which revealed exposed sutures (Fig. 1) at the gastro-esophageal anastomosis without ulcerations or stricture and a normal appearing remnant stomach. Random biopsies were performed at the anastomotic site, which were negative for malignancy and Helicobacter pylori. Computed tomography angiogram revealed patent vasculature and post-surgical changes and was otherwise unremarkable. Due to persistent symptoms, repeat esophagogastroduodenoscopy was performed with successful removal of the sutures at the anastomotic site (Fig. 2). This resulted in immediate relief of her post-prandial pain. At a 3-month follow-up visit, she continued to remain pain-free but endorsed reflux symptoms, which were controlled with proton pump inhibitors.

Retroflexed view during esophagogastroduodenoscopy (EGD) revealing exposed sutures at the gastroesophageal anastomosis following Ivor-Lewis esophagectomy (arrows). No stricture or ulceration is present. [Color figure can be viewed at wileyonlinelibrary.com] Retroflexed view during follow-up esophagogastroduodenoscopy demonstrating successful removal of sutures. [Color figure can be viewed at wileyonlinelibrary.com]

Esophageal resection and restoring GI continuity are technically challenging procedures, and complications can occur. Interestingly, a review of publications from 2005 to 2009 did not reveal a single short-term complication. The most common complications related to surgery include conduit complications, nerve injury, lymphatic leak, functional disorders, and diaphragmatic hernia. Normal digestive function is reported in less than 20% of patients after esophagectomy. Gastroenterologists may be called upon for evaluation of post-surgical patients with upper GI (UGI) symptoms, especially if the surgery involves any of the UGI tract (esophagus, stomach, and proximal small bowel). Symptom pursuit should include endoscopic evaluation of the anastomotic site for ulcerations, ischemia, and stenosis. In post-bariatric surgery patients, a case series reported that unraveled suture material was thought to be contributing to UGI symptoms in up to 10% of cases. This may be associated with marginal ulcerations or mechanical obstruction. Symptoms attributed to unraveled suture material include abdominal pain (65%), nausea (52%), dysphagia (22%), and melena (13%); 83% of patients had resolution or improvement of symptoms after therapeutic endoscopic suture removal. Although not reported in post-esophagectomy (Ivor-Lewis) procedure literature, consideration of anastomotic unraveled sutures as an etiology of UGI symptoms should be considered after ruling out other causes. Therapeutic endoscopic suture removal may resolve UGI symptoms as outlined in this case.