Abstract
Introduction
Endoscopic vacuum therapy (EVT) has been established in Germany for the treatment of anastomotic leakage after rectal resection. Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema promoting perfusion and granulation at the same time. However, data for use and long-term results of EVT in colorectal surgery are still scarce and are often limited by short-term follow-up.
Objectives
Here, we aimed at analyzing the treatment spectrum and long-term outcome of EVT for defects of the lower gastrointestinal tract.
Methods
This is a retrospective single-center analysis of EVT for defects of the lower gastrointestinal tract of different etiology in 41 patients over a time period of 8 years (2007–2015) with a mean follow-up of 36 (2–89) months.
Results
In total, 426 polyurethane sponges were placed in lower GI defects of 41 patients (31 male, 10 female) with a median age of 70 years (range, 29–91). Most frequent indications for EVT were anastomotic leakage after rectal resection (n = 20), Hartmann’s stump insufficiency (n = 12), and rectal perforation (n = 3). The median number of sponge insertions was six (range, 1–37) with a mean changing interval of 3 days (range, 1–5). Median time of therapy was 20 days. A successful vacuum therapy with local control of the septic focus was achieved in 18 of 20 patients (90 %) with anastomotic leakage after rectal resection and in nine of 12 patients with a Hartmann’s stump insufficiency. In 15 of 19 (79 %) patients with a diverting stoma, take-down after successful treatment was possible. Median time to closure was 244 days (range, 152–488 days).
Conclusion
To our knowledge, this retrospective observation of EVT application for rectal lesions represents the largest patient series in literature. EVT has earned its indication in complication management after colorectal surgery and can achieve a successful control of a local septic focus in the majority of patients.
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Primary Discussant
Pierpaolo Sileri, M.D., Ph. D (Rome, Italy): Anastomotic leakage after rectal surgery is serious complication and it is associated with important postoperative morbidity and mortality, thus with a great impact on economic burden.
Vacuum therapy has been used for many years for the treatment of surgical site infection, with excellent results, enhancing the formation of granulation tissue, increasing vascularity, and decreasing bacterial colonization. The device (Endo-Sponge) used in this clinical experience is intended for endoscopic use and can be introduced throughout the anastomotic dehiscence with promising results. The authors present a large series with the majority of the patients with an anastomotic leak treated with this approach “multiple sponge insertion” which leads a complete healing of the leak and the abscessual cavity. Few other papers are present in the literature despite with smaller number of patients. To date, no prospective data are available despite a shorter healing time seems to be evident using this approach compared to the standard conservative management. The endo-vacuum facilitates closure of the presacral space by the application of negative pressure into the sponge, ensuring continuous drainage and thereby infection control, thus avoids the risk of a sinus. Some questions for the authors are as follows:
—Timing for correct sponge placement. Obviously, the placement should be performed as soon as the leak is discovered, in my opinion even if peritonitis is present after abdominal lavage and fecal diversion.
—Limits of the procedure (size of the defect…). Small size leaks can be managed with conservative approach alone unless a large abscess cavity is present. No clear indications are evident.
—Costs of this approach. It is obviously dependant from the number of sponge insertions required but, reducing healing time, reduced compared to conservative approaches for anastomotic salvage.
The results of this manuscript indicate that this approach is safe and effective. A prospective randomized or case control study is required in the future to better convalide the use of this treatment.
Closing Discussant
Dr. Kuehn
Dear Dr. Sileri,
Thank you very much for the purposeful summary of our work and the important notes / questions you have addressed. Our opinion follows point by point:
1. Timing for correct sponge placement. Obviously the placement should be performed as soon as the leak is discovered, in my opinion even if peritonitis is present after abdominal lavage and fecal diversion.
Yes, this is correct. We initialized EVT as soon as the defect was detected. For patients with clinical signs of a generalized peritonitis operative revision was indicated. This case does not exclude EVT after operative revision and abdominal lavage.
2. Limits of the procedure (size of the defect…). Small size leaks can be managed with conservative approach alone unless a large abscess cavity is present. No clear indications are evident.
Exactly, small leaks with no evidence of abscess cavity can be treated with endoscopic rinsing and control. Here we do not initialize EVT because in these cases the vacuum therapy can even lead to an increase in size of the defect. However, an abscess cavity behind a small impressing defect represents an Indication for EVT and has to be exposed. In conclusion indication for EVT is based on clinical and endoscopic findings.
3. Costs of this approach. It is obviously dependent from the number of sponge insertions required but, reducing healing time, reduced compared to conservative approaches for anastomotic salvage.
The costs depend on the duration of therapy. In literature, there is no data that compare costs of the different treatment options. Only Nagell and Holte compared four patients treated with EVT for anastomotic leakage after rectal resection to a control group of ten patients undergoing conservative treatment. [1] The patients treated with EVT showed a significant shorter healing time and duration of therapy compared to the control group. We agree that a prospective randomized or case control study is needed for better validation of this important question.
Reference
1. Nagell CF, Holte K. Treatment of anastomotic leakage after rectal resection with transrectal vacuum-assisted drainage (VAC). A method for rapid control of pelvic sepsis and healing. Int J Colorectal Dis. 2006; 21: 657–60.
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Kuehn, F., Janisch, F., Schwandner, F. et al. Endoscopic Vacuum Therapy in Colorectal Surgery. J Gastrointest Surg 20, 328–334 (2016). https://doi.org/10.1007/s11605-015-3017-7
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DOI: https://doi.org/10.1007/s11605-015-3017-7