Abstract
Introduction
Intraluminal therapy used in the gastrointestinal (GI) tract was first shown for anastomotic leaks after rectal resection. Since a few years vacuum sponge therapy is increasingly being recognized as a new promising method for repairing upper GI defects of different etiology. The principles of vacuum-assisted closure (VAC) therapy remain the same no matter of localization: Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema. At the same time, perfusion and granulation is promoted. However, data for endoscopic vacuum therapy (EVT) of the upper intestinal tract are still scarce and consist of only a few case reports and small series with low number of patients.
Objectives
Here, we present a single center experience of EVT for substantial wall defects in the upper GI tract.
Methods
Retrospective single-center analysis of EVT for various defects of the upper GI tract over a time period of 4 years (2011–2015) with a mean follow-up of 17 (2–45) months was used. If necessary, initial endoscopic sponge placement was performed in combination with open surgical revision.
Results
In total, 126 polyurethane sponges were placed in upper gastrointestinal defects of 21 patients with a median age of 72 years (range, 49–80). Most frequent indication for EVT was anastomotic leakage after esophageal or gastric resection (n = 11) and iatrogenic esophageal perforation (n = 8). The median number of sponge insertions was five (range, 1–14) with a mean changing interval of 3 days (range, 2–4). Median time of therapy was 15 days (range, 3–46). EVT in combination with surgery took place in nine of 21 patients (43 %). A successful vacuum therapy for upper intestinal defects with local control of the septic focus was achieved in 19 of 21 patients (90.5 %).
Conclusion
EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. In this series, EVT was combined with operative revision in a relevant proportion of patients.
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The study was reviewed and registered as official treatment option at the ethics board of the University of Rostock. All patients or authorized persons, respectively, agreed to the treatment with written informed consent.
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Primary Discussant
Vic Velanovich, MD (Tampa, FL)
Perforations and anastomotic leaks of the foregut are vexing problems. Up until recently, our only options were either external drainage and wait for the perforation to heal or surgery for an attempt at primary repair. Both have not always had satisfactory results. The conservative approach, if it worked, would take a long time, and if it did not, sepsis would continue. Surgery, if it worked, still required an operation with a high complication rate, and if it did not, the repair would fall apart.
Recently, endoluminal approaches have increased our armamentarium in treating leaks and perforations. These include stents, clips, glues, and endoscopic suturing devices. One of these new approaches is endoscopic vacuum therapy, what I like to call endo-vacuum-assisted closure (VAC) therapy. The authors present a series of 21 patients treated over 4 years with excellent results. I have personally used this therapy on a few of my own patients and have been very impressed. I think that this therapy can be a game-changer. Combining endo-VAC therapies with and without external percutaneous drainage may become the standard of care for esophageal perforations and leaks.
I have three questions:
1. Are there any perforations or disruptions which are too big for endo-VAC therapy?
2. How do you decided when endo-VAC therapy has failed and another approach is needed?
3. There are reports of combining endo-VAC therapy with stenting. Do you have any experience or opinion with this approach?
Congratulations on an excellent study. I look forward to future work from your group.
Closing Discussant
Dr. Kuehn
Dear Dr. Velanovich,
Thank you very much for the purposeful summary of our work and the important questions that you have addressed. Our opinions follow point by point:
1. Are there any perforations or disruptions which are too big for endo-VAC therapy?
From our experience, we cannot say that there are any limitations for EVT concerning size of defect.
For example, a 55-year-old developed a coagulative necrosis after ingestion of an alkaline solution. After 1 week of conservative treatment, the patient was experiencing increasing dysphagia. Endoscopic dilation was performed but led to a large esophageal perforation 23–40 cm from the dental arch. We immediately commenced EVT with extraluminal and intraluminal sponge placement. Up to four sponges were placed at the same time. Following this, the patient underwent ongoing therapy with both esophageal bougienage and the use of intraluminal and extraluminal sponge placement. EVT was continued for 18 days with changes being made at intervals of 3 days. The 17-cm long perforation in a highly infectious environment was successfully healed with EVT.
2. How do you decided when endo-VAC therapy has failed and another approach is needed?
We think that EVT cannot really fail if the indication is right. However, in some cases, therapy has to be extended. In contrast to other published series, we combined EVT with surgery in a relevant proportion of our patients. Nine of 21 (43 %) patients received EVT to control esophageal defects that could not be closed by suture due to extent or late presentation. In these cases, the esophageal wall defect was controlled by an intraluminal sponge whereas the concomitant mediastinitis was dealt with by established surgical concepts. In these cases, the sponge therapy resulted in salvage of the esophagus in seven of nine (78 %) patients. From our experience, EVT and surgery should be seen as complementary procedures. Mediastinitis and pleural empyema were the main indications for operative therapy as inevitable adjunct procedure to sponge therapy in these individual cases. EVT can serve as an isolated therapy or as part of a more complex concept of esophageal salvage combined with conventional surgery for the control of mediastinal or pleural sepsis.
3. There are reports of combining endo-VAC therapy with stenting. Do you have any experience or opinion with this approach?
Yes, there is one report in which two patients were treated successfully with EVT after stent placementx.20 Here, EVT was used as a rescue strategy for leakages that were refractory to stent therapy. They concluded that “If stent therapy fails or the perianastomotic abscess cavity is large and complex to drain from outside, the endoscopic two-modality approach can be considered.” However, since we do not stent these defects in the first place anymore, we do not have any experience with this approach.
References:
1. Gubler C, Schneider PM, Bauerfeind P. Complex anastomotic leaks following esophageal resections: the new stent over sponge (SOS) approach. Dis Esophagus. 2013; 26: 598–602.
Florian Kuehn and Leif Schiffmann contributed equally to this work.
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Kuehn, F., Schiffmann, L., Janisch, F. et al. Surgical Endoscopic Vacuum Therapy for Defects of the Upper Gastrointestinal Tract. J Gastrointest Surg 20, 237–243 (2016). https://doi.org/10.1007/s11605-015-3044-4
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DOI: https://doi.org/10.1007/s11605-015-3044-4