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Barchi A, Massimino L, Mandarino FV, Vespa E, Sinagra E, Almolla O, Passaretti S, Fasulo E, Parigi TL, Cagliani S, Spanò S, Ungaro F, Danese S. Microbiota profiling in esophageal diseases: Novel insights into molecular staining and clinical outcomes. Comput Struct Biotechnol J 2024; 23:626-637. [PMID: 38274997 PMCID: PMC10808859 DOI: 10.1016/j.csbj.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024] Open
Abstract
Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luca Massimino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Omar Almolla
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Sandro Passaretti
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Stefania Cagliani
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Salvatore Spanò
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federica Ungaro
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
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de Moura DTH, Hirsch BS, Ribas PHBV, Silveira SQ, Guedes HG, Bestetti AM. Endoscopic vacuum therapy: pitfalls, tips and tricks, insights, and perspectives. Transl Gastroenterol Hepatol 2024; 9:50. [PMID: 39091653 PMCID: PMC11292076 DOI: 10.21037/tgh-23-86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 04/03/2024] [Indexed: 08/04/2024] Open
Abstract
This article provides a comprehensive review of the use of endoscopic vacuum therapy (EVT) in the management of transmural gastrointestinal (GI) defects (TGIDs) and its future perspectives, such as pre-emptive EVT and novel indications, including GI bleeding and large gastroduodenal ulcers management. This review is based on the available literature data and personal experience to demystify the mentioned limitations of EVT as technical difficulties related to the procedure, possible patients' complaints, and institutions' concerns, by sharing several tips and tricks to overcome EVT-related challenges that may discourage endoscopists from using this live-saving technique, and consequently, restricting patients to receive this therapy, which may lead to undesired outcomes. Several factors, such as placement techniques, EVT type selection, management during its use, EVT system exchanges, device removal, type of anesthesia, and how to avoid EVT-related adverse events are described in detail. Additionally, this review discusses good ways to promote effective communication with patients and relatives, surgeons, and multidisciplinary team. EVT possesses a unique mechanism of action including macro/micro deformation, changes in perfusion (stimulating angioneogenesis), exudate control, and bacterial clearance, promoting healing. EVT has an adequate safety profile and higher clinical success rate compared to any other endoscopic therapy for TGID. Additionally, pre-emptive EVT and its novel indications are promising due to its satisfactory effectiveness in initial studies. Therefore, detailing some practical solutions obtained by years of experience may collaborate to widespread EVT adoption, providing less-invasive treatment for several critical conditions to more patients worldwide.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Division, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Bruno Salomão Hirsch
- Deparment of Gastroenteroloy, Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Pedro Henrique Boraschi Vieira Ribas
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Saullo Queiroz Silveira
- Department of Anesthesiology-CMA Anesthesia Group, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
| | - Hugo Gonçalo Guedes
- Gastrointestinal Endoscopy Unit, Instituto D’Or de Pesquisa e Ensino-Hospital DF Star, Brasília, DF, Brazil
| | - Alexandre Moraes Bestetti
- Gastrointestinal Endoscopy Division, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Richter F, Conrad C, Hoffmann J, Reichert B, von Schoenfels W, Schafmayer C, Egberts JH, Becker T, Ellrichmann M. Endoluminal Vacuum Therapy Using a New "Fistula Sponge" in Treating Defects of the Upper Gastrointestinal Tract-A Comparative, Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1105. [PMID: 39064534 PMCID: PMC11279286 DOI: 10.3390/medicina60071105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/17/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT's duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.
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Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Claudio Conrad
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
| | - Julia Hoffmann
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Benedikt Reichert
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Witigo von Schoenfels
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Clemens Schafmayer
- Department of General Surgery, University Hospital Rostock, 18057 Rostock, Germany;
| | | | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Mark Ellrichmann
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
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Matteo MV, Birligea MM, Bove V, Pontecorvi V, De Siena M, Gualtieri L, Barbaro F, Spada C, Boškoski I. Management of fistulas in the upper gastrointestinal tract. Best Pract Res Clin Gastroenterol 2024; 70:101929. [PMID: 39053982 DOI: 10.1016/j.bpg.2024.101929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/08/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.
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Affiliation(s)
- Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy.
| | | | - Vincenzo Bove
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - Martina De Siena
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - Loredana Gualtieri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Sapienza University of Rome, 00161, Rome, Italy
| | - Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Roma, Italy; Università Cattolica del Sacro Cuore, 00168, Roma, Italy
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Hentschel F, Mollenhauer G, Siemssen B, Paasch C, Mantke R, Lüth S. Placing vacuum sponges in esophageal anastomotic leaks - how we do it. Langenbecks Arch Surg 2024; 409:86. [PMID: 38441680 PMCID: PMC10914858 DOI: 10.1007/s00423-024-03272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.
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Affiliation(s)
- Florian Hentschel
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany.
- Zentrum für Innere Medizin II, Hochschulklinikum Brandenburg der MHB, Hochstr. 29, 14770, Brandenburg an der Havel, Germany.
| | - Götz Mollenhauer
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | | | - Christoph Paasch
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
- Shouldice Hospital, Thornhill, ON, Canada
| | - René Mantke
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | - Stefan Lüth
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
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Felinska EA, Studier-Fischer A, Özdemir B, Willuth E, Wise PA, Müller-Stich B, Nickel F. Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy. Surg Endosc 2024; 38:1422-1431. [PMID: 38180542 PMCID: PMC10881612 DOI: 10.1007/s00464-023-10647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. MATERIAL AND METHODS A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). RESULTS Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg. CONCLUSIONS EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.
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Affiliation(s)
- Eleni Amelia Felinska
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Berkin Özdemir
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Estelle Willuth
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philipp Anthony Wise
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clara Hospital Basel, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany.
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Kim JY, Chung H. Endoscopic Intervention for Anastomotic Leakage After Gastrectomy. J Gastric Cancer 2024; 24:108-121. [PMID: 38225770 PMCID: PMC10774755 DOI: 10.5230/jgc.2024.24.e12] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/17/2024] Open
Abstract
Anastomotic leaks and fistulas are significant complications of gastric surgery that potentially lead to increased postoperative morbidity and mortality. Surgical intervention is reserved for cases with severe symptoms or hemodynamic instability; however, surgery carries a higher risk of complications. With advancements in endoscopic treatment options, endoscopic approaches have emerged as the primary choice for managing these complications. Endoscopic clipping is a traditional method comprising 2 main categories: through-the-scope clips and over-the-scope clips. Through-the-scope clips are user friendly and adaptable to various clinical scenarios, whereas over-the-scope clips can close larger defects. Another promising approach is endoscopic stent insertion, which has shown a high success rate for leak closure, although vigilant monitoring is required to monitor stent migration. Infection control is essential in post-surgical leakage cases, and endoscopic internal drainage provides a relatively safe and noninvasive means to manage fluids, contributing to infection control and wound healing promotion. Endoscopic suturing offers full-thickness wound closure, but requires additional training and endoscopic versatility. As a promising tool, endoscopic vacuum therapy potentially surpasses stent therapy by draining inflammatory materials and closing defects. Furthermore, the use of tissue sealants, such as fibrin glue and cyanoacrylate, has been reported to be effective in selected situations. The choice of endoscopic device should be tailored to individual cases and specific patient conditions, with careful consideration of the nature of the defect. Further extensive studies involving larger patient populations are required to provide more robust evidence on the efficacy of endoscopic approach in managing post-gastric anastomotic leaks.
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Affiliation(s)
- Ji Yoon Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Korea.
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Kouladouros K, Wichmann D, Loske G. The Role of Open-Pore Film Drainage Systems in Endoscopic Vacuum Therapy: Current Status and Review of the Literature. Visc Med 2024; 39:177-183. [PMID: 38205271 PMCID: PMC10775853 DOI: 10.1159/000535029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/02/2023] [Indexed: 01/12/2024] Open
Abstract
Background Endoscopic vacuum therapy (EVT) is an increasingly popular endoscopic technique used for the treatment of wall defects in the gastrointestinal tract. Open-pore film drainage (OFD) systems are a new addition to the armamentarium of EVT and have shown encouraging results in a wide spectrum of applications. The aim of this review is to summarize the current literature on the applications of OFD systems in the gastrointestinal tract. Summary Open-pore film drainage (OFD) systems have been used for the treatment of several defects of the gastrointestinal tract. The small size and easy placement of these devices make them very useful, particularly for the treatment of defects that are small in size or difficult to reach. OFDs have been successfully used for both perforations and anastomotic leaks in various locations, with most reports focusing on the treatment of duodenal defects, although successful applications in the esophagus, stomach, and colon have also been reported. Lately, the role of OFDs in preemptive EVT has also been explored. Key Messages OFD systems are easy to use, particularly for small defects and challenging localizations. The current literature, consisting mainly of small case series and case reports, shows encouraging results, but further prospective studies are needed to explore and verify the indications and technical aspects of this innovative method.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dörte Wichmann
- Interdisciplinary Endoscopy Unit, University Hospital Tübingen, Tübingen, Germany
| | - Gunnar Loske
- Department of General, Abdominal, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg gGmbH, Hamburg, Germany
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Wang H, Sun S, Wang G, Huang Q, Zhang Z. Analysis of Vacuum-Assisted Closure-Assisted Antibiotic Irrigation in Treatment of Severe Neurosurgical Central Nervous System Infections. Surg Infect (Larchmt) 2023; 24:803-810. [PMID: 37910866 DOI: 10.1089/sur.2023.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Objective: Severe neurosurgical central nervous system infections (sNCNSIs) are among the most serious complications of neurosurgical disease. Conventional methods have shown a poor prognosis. This study aims to analyze the clinical characteristics of vacuum-assisted closure (VAC) in sNCNSIs with the help of antibiotic irrigation treatment. Patients and Methods: A retrospective study was performed for patients diagnosed with sNCNSIs. A VAC device was placed on the incision after debridement and the surgical cavity was rinsed with antibiotic agents in the VAC group. Meanwhile the surgical cavity was drained after debridement in the control group. Medical data were reviewed and analyzed. Results: Twenty-eight patients met the inclusion criteria, including 18 cases in the VAC group and 10 cases in the control group. The basic medical data showed no differences. Bacteria was isolated from 24 (85.7%) patients. The cure rate was significantly higher in the VAC group (p < 0.05). The cure rate in patients with multi-drug-resistant (MDR) infections was significantly higher in patients treated with VAC therapy (p < 0.05). The prognosis evaluated by Glasgow Outcome Score (GOS) between the two groups showed significant difference (p < 0.05). No re-infection in the VAC group occurred in the follow-up period. Conclusions: It is suggested that VAC-assisted antibiotic irrigation is safe and effective for patients with severe NCNSIs and can improve the prognosis dramatically. The results can provide a new effective and reasonable therapeutic strategy for patients with sNCNSIs.
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Affiliation(s)
- Huaqing Wang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, Shandong Province, P.R. China
| | - Shengnan Sun
- Department of Nursing, Shandong Medical College, Jinan, Shandong Province, P.R. China
| | - Guanghui Wang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, Shandong Province, P.R. China
| | - Qibing Huang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, Shandong Province, P.R. China
| | - Zeli Zhang
- Department of Emergency Neurosurgical Intensive Care Unit, Qilu Hospital of Shandong University and Brain Science Research Institute of Shandong University, Jinan, Shandong Province, P.R. China
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Panneerselvam K, Jacob JS, Samuel RE, Tau A, Ketwaroo GA, Abidi WM, Sealock RJ. Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects. Clin Endosc 2023; 56:754-760. [PMID: 37157961 PMCID: PMC10665613 DOI: 10.5946/ce.2022.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 12/08/2022] [Accepted: 12/27/2022] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic vacuum therapy (EVT) can heal a variety of defects within the gastrointestinal (GI) tract via applying negative pressure, which reduces the defect size, aspirates the infected fluid, and promotes granulation tissue. Here we present our experience with EVT as it relates to both spontaneous and iatrogenic upper GI tract perforations, leaks, and fistulas. METHODS This retrospective study was conducted at four large hospital centers. All patients who underwent EVT between June 2018 and March 2021 were included. Data on multiple variables were collected, including demographics, defect size and location, number and intervals of EVT exchanges, technical success, and hospital length of stay. Student t-test and the chi-squared test were used to analyze the data. RESULTS Twenty patients underwent EVT. The most common defect cause was spontaneous esophageal perforation (50%). The most common defect location was the distal esophagus (55%). The success rate was 80%. Seven patients were treated with EVT as the primary closure method. The mean number of exchanges was five with a mean interval of 4.3 days between exchanges. The mean length of hospital stay was 55.8 days. CONCLUSION EVT is a safe and effective initial management option for esophageal leaks and perforations.
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Affiliation(s)
| | - Jake S. Jacob
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Ronald E. Samuel
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Andy Tau
- Austin Gastroenterology PA, Austin, TX, USA
| | | | - Wasif M. Abidi
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Robert J. Sealock
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
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11
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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12
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Momblan D, Gimeno Garcia AZ, Busquets D, Juzgado D, García Lledó J, Ferrero E, Tejedor-Tejada J, Junquera F, Díaz-Tasende J, Moris M, Rodriguez de Santiago E, Gornals J, Garrido C, Gonzalez-Vazquez S, Guarner-Argente C, Repiso A, Esteban JM, Loras C, Seoane A, Fernández-Simon A, Guevara HC, Ibarzabal A, Morales X, Curell A, Cardenas A, Ríos J, de Lacy AM, Sendino O. Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry. Am J Gastroenterol 2023; 118:1797-1806. [PMID: 37606066 DOI: 10.14309/ajg.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.
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Affiliation(s)
- Dulce Momblan
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antonio Z Gimeno Garcia
- Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - David Busquets
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Diego Juzgado
- Department of Gastroenterology, Hospital Quirón Madrid, Madrid, Spain
| | - Javier García Lledó
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Esther Ferrero
- Department of General and Digestive Surgery, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | | | - Félix Junquera
- Department of Gastroenterology, Hospital de Sabadell, Institut d´Investigació i Innovació Parc Taulí I3PT, CIBERehd, Sabadell, Spain
| | - José Díaz-Tasende
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Moris
- Department of Gastroenterology and Hepatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, IRYCIS, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Joan Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carmen Garrido
- Endoscopy Unit, Department of Gastroenterology, Son Espases University Hospital, Illes Balears, Spain
| | | | | | - Alejandro Repiso
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Jose Miguel Esteban
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Agustín Seoane
- Department of Gastroenterology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Henry Cordova Guevara
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ainitze Ibarzabal
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Xavier Morales
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Curell
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrés Cardenas
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Ríos
- Department of Clinical Farmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Maria de Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
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13
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Mandarino FV, Barchi A, Leone L, Fanti L, Azzolini F, Viale E, Esposito D, Salmeri N, Puccetti F, Barbieri L, Cossu A, Treppiedi E, Elmore U, Rosati R, Danese S. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc 2023; 37:7039-7050. [PMID: 37353654 DOI: 10.1007/s00464-023-10213-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Management of anastomotic leaks after Ivor-Lewis esophagectomy remains a challenge. Although intracavitary endoscopic vacuum therapy (EVT) has shown great efficacy for large dehiscences, the optimal management of smaller leaks has not been standardized. This study aims to compare EVT versus self-expandable metal stent (SEMS) in the treatment of leaks < 30 mm in size, due to the lack of current data on this topic. METHODS Patients undergoing EVT (cases) or SEMS (controls) between May 2017 and July 2022 for anastomotic leaks < 3 cm following oncologic Ivor-Lewis esophagectomy were enrolled. Controls were matched in a 1:1 ratio based on age (± 3 years), BMI (± 3 kg/m2) and leak size (± 4 mm). RESULTS Cases (n = 22) and controls (n = 22) showed no difference in baseline characteristics and leak size, as per matching at enrollment. No differences were detected between the two groups in terms of time from surgery to endoscopic treatment (p = 0.11) or total number of procedures per patient (p = 0.05). Remarkably, the two groups showed comparable results in terms of leaks resolution (90.9% vs. 72.7%, p = 0.11). The number of procedures per patient was not significant between the two cohorts (p = 0.05). The most frequent complication in the SEMS group was migration (15.3% of procedures). CONCLUSION EVT and SEMS seem to have similar efficacy outcomes in the treatment of anastomotic defects < 30 mm after Ivor-Lewis esophagectomy. However, larger studies are needed to corroborate these findings.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy.
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorenzo Leone
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorella Fanti
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Edi Viale
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Dario Esposito
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Noemi Salmeri
- Department of Gynecology/Obstetrics Unit, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Puccetti
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lavinia Barbieri
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Andrea Cossu
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Elio Treppiedi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
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14
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Fuentes KMI, Seastedt KP, Kidane B, Servais EL. Advanced Endoscopy for Thoracic Surgeons. Thorac Surg Clin 2023; 33:251-263. [PMID: 37414481 DOI: 10.1016/j.thorsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.
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Affiliation(s)
- Kathleen M I Fuentes
- Department of General Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Kenneth P Seastedt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Room GE-611, 820 Sherbook Street, Winnipeg, Manitoba R3A 1R9, Canada
| | - Elliot L Servais
- Division of Thoracic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
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15
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Monino L, Moreels TG. Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks: How to Deal with the Challenges (with Video). Life (Basel) 2023; 13:1412. [PMID: 37374194 DOI: 10.3390/life13061412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/19/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Anastomotic leaks after gastrointestinal surgery have an important impact on surgical outcomes because of the high morbidity and mortality rates. Multiple treatment options exist requiring an individualized patient-tailored treatment plan after multidisciplinary discussion. Endoscopic vacuum therapy (EVT) is a novel treatment option that is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. EVT has a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient. To the unexperienced, the EVT technique may be prone to several hurdles which may deter endoscopists from using it and depriving patients from a potentially life-saving therapeutic option. The current review highlights the possible difficulties of the EVT procedure and aims to provide some practical solutions to facilitate its use in daily clinical practice. Personal tips and tricks are shared to overcome the pre-, intra- and post-procedural hurdles. An instructive video of the procedure helps to illustrate the technique of EVT.
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Affiliation(s)
- Laurent Monino
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Tom G Moreels
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
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16
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Kouladouros K. Applications of endoscopic vacuum therapy in the upper gastrointestinal tract. World J Gastrointest Endosc 2023; 15:420-433. [PMID: 37397978 PMCID: PMC10308278 DOI: 10.4253/wjge.v15.i6.420] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Surgical Clinic, Mannheim University Hospital, University of Heidelberg, Mannheim 68167, Baden-Wuerttemberg, Germany
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17
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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18
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Simas de Lima M, Uemura RS, Gusmon-Oliveira CC, Pombo AADM, Martins BC, Lenz L, Kawaguti FS, De Paulo GA, Baba ER, Safatle-Ribeiro AV, Ribeiro U, Monkemüller K, Maluf-Filho F. Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations. Endoscopy 2022; 54:980-986. [PMID: 35378562 DOI: 10.1055/a-1774-4630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND : Although endoscopic vacuum therapy (EVT) has been successfully used to treat postoperative upper gastrointestinal (UGI) wall defects, its use demands special materials and several endoscopic treatment sessions. Herein, we propose a technical modification of EVT using a double tube (tube-in-tube drain) without polyurethane sponges for the drainage element. The tube-in-tube drainage device enables irrigation and application of suction. A flowchart for standardizing the management of postoperative UGI wall defects with this device is presented. METHODS : An EVT modification was made to achieve frequent fistula cleansing, with 3 % hydrogen peroxide rinsing, and the application of negative pressure. A tube-in-tube drain without polyurethane sponges can be inserted like a nasogastric tube or passed through a previously positioned surgical drain. This was a retrospective two-center observational study, with data collected from 30 consecutive patients. Technical success, clinical success, adverse events, time under therapy, interval time from procedure to fistula diagnosis and treatment start, size of transmural defect, volume of cavity, number of endoscopic treatment sessions, and mortality were reviewed. RESULTS : 30 patients with UGI wall defects were treated. The technical and clinical success rates were 100 % and 86.7 %, respectively. Three patients (10 %) had adverse events and three patients (10 %) died. The median time under therapy was of 19 days (range 1-70) and the median number of endoscopic sessions was 3 (range 1-9). CONCLUSIONS : This standardized approach and EVT modification using a tube-in-tube drain, with frequent fistula cleansing, were successful and safe in a wide variety of UGI wall defects.
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Affiliation(s)
- Marcelo Simas de Lima
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ricardo Sato Uemura
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carla Cristina Gusmon-Oliveira
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Amanda Aquino de Miranda Pombo
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruno Costa Martins
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luciano Lenz
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fabio Shiguehissa Kawaguti
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gustavo Andrade De Paulo
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Elisa Ryoka Baba
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Adriana V Safatle-Ribeiro
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Klaus Monkemüller
- Division of Gastroenterology, University Teaching Hospital Ameos Klinikum, Halberstadt, Germany
| | - Fauze Maluf-Filho
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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19
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Scognamiglio P, Reeh M, Melling N, Kantowski M, Eichelmann AK, Chon SH, El-Sourani N, Schön G, Höller A, Izbicki JR, Tachezy M. Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting. BMC Surg 2022; 22:309. [PMID: 35953796 PMCID: PMC9367146 DOI: 10.1186/s12893-022-01764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.
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Affiliation(s)
- Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marcus Kantowski
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Eichelmann
- General, Visceral and Transplantation Surgery, University Hospital Münster, Münster, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Nader El-Sourani
- Department for General and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Höller
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus 2022; 19:417-425. [PMID: 35347509 DOI: 10.1007/s10388-022-00912-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) represents an effective endoscopic technique for the treatment of post-esophagectomy leaks and can be used after failure of primary treatment. We aimed to investigate endoscopic data and success rate of EVT for post-esophagectomy anastomotic leaks, after failed redo surgery or previous endoscopic treatment. METHODS We retrospectively recruited 12 patients from January 2018 to October 2020. Success was defined as dehiscence closure at radiological and/or endoscopic evaluation. Ethical Committee of our institution approved the study. RESULTS Twelve patients (66.7% male, mean age 65.08 ± 16.7 years) affected by esophago-gastric (n = 10) or esophago-jejunal (n = 2) anastomosis dehiscences after oncologic surgery were treated with EVT, after failure of previous redo-surgical (n = 3, 25%) or endoscopic management (n = 9, 75%). Technical success rate was 100% (60/60 procedures) and dehiscence closure was achieved in three quarters of patients (9/12, 75%). Regarding complications, one case of sponge dislocation (1/60 = 1.7%) and another case of delayed stricture after post-EVT stent placement (1/60 = 1.7%) were recorded, during a mean follow up of 182.3 days. CONCLUSIONS EVT is a promising option in the treatment of the most complicated anastomotic dehiscences. Its use could be also considered after failure of previous endoscopic or surgical management.
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21
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Jiang ZY, Tao GQ, Zhu YF. Computer tomography-guided negative pressure drainage treatment of intrathoracic esophagojejunal anastomotic leakage: A case report. World J Clin Cases 2022; 10:4580-4585. [PMID: 35663059 PMCID: PMC9125289 DOI: 10.12998/wjcc.v10.i14.4580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/16/2022] [Accepted: 03/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Esophagojejunal anastomotic leakage (EJAL) is a serious and potentially crucial complication of total gastrectomy and represents the major cause of postoperative death, with a mortality rate of up to 50%. However, treatment remains challenging and controversial. We report here the case of a patient whose intrathoracic EJAL was successfully treated with computer tomography (CT)-guided negative pressure drainage treatment. CASE SUMMARY A 69-year-old male patient complained of difficulty swallowing within the last six months. He was diagnosed with esophagogastric junction carcinoma, Siewert II, cT3N0M0 stage II. Total gastrectomy and Roux-en-Y esophagojejunostomy were performed. High fever, left chest pain and dyspnea appeared on postoperative day 5, and EJAL was confirmed by CT, gastroscopy and oral blue-dimethylene tests. Conservative treatment measures were applied immediately, including antibiotics, nasojejunal tubes, and repeated thoracic puncture and drainage under ultrasound guidance. However, without sufficient and effective drainage, the thoracic infection and systemic condition continued to deteriorate. With the cooperation of multiple departments, percutaneous CT-guided drainage (24 Fr 7 mm) in the thoracic cavity was successfully placed near the anastomotic leakage. Because of continuous negative pressure suction, the infection symptoms were effectively controlled and the general situation gradually recovered. Subsequent follow-up examination showed that the patient was in good condition. CONCLUSION Negative pressure drainage via CT may represent an effective minimally invasive approach to treating intrathoracic EJAL.
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Affiliation(s)
- Zhi-Yang Jiang
- Department of General Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, Jiangsu Province, China
| | - Guo-Qing Tao
- Department of General Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, Jiangsu Province, China
| | - Yan-Fei Zhu
- Department of General Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, Jiangsu Province, China
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22
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Gutschow CA, Schlag C, Vetter D. Endoscopic vacuum therapy in the upper gastrointestinal tract: when and how to use it. Langenbecks Arch Surg 2022; 407:957-964. [PMID: 35041047 PMCID: PMC9151563 DOI: 10.1007/s00423-022-02436-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) has emerged as a novel treatment option for upper gastrointestinal wall defects. The basic principle of action of EVT entails evacuation of secretions, removal of wound debris, and containment of the defect. Furthermore, there is increasing evidence that EVT reduces interstitial edema, increases oxygen saturation, and promotes tissue granulation and microcirculation. Various devices, such as macroporous polyurethane sponge systems or open-pore film drains, have been developed for specific indications. Depending on the individual situation, EVT devices can be placed in- or outside the intestinal lumen, as a stand-alone procedure, or in combination with surgical, radiological, and other endoscopic interventions. PURPOSE The aim of this narrative review is to describe the current spectrum of EVT in the upper gastrointestinal tract and to assess and summarize the related scientific literature. CONCLUSIONS There is growing evidence that the efficacy of EVT for upper GI leakages exceeds that of other interventional treatment modalities such as self-expanding metal stents, clips, or simple drainages. Owing to the promising results and the excellent risk profile, EVT has become the therapy of choice for perforations and anastomotic leakages of the upper gastrointestinal tract in many centers of expertise. In addition, recent clinical research suggests that preemptive use of EVT after high-risk upper gastrointestinal resections may play an important role in reducing postoperative morbidity.
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Affiliation(s)
- Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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23
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Stathopoulos P, Zumblick M, Wächter S, Schiffmann L, Gress TM, Bartsch D, Seitz G, Denzer UW. Endoscopic vacuum therapy (EVT) for acute esophageal perforation: Could it replace surgery? Endosc Int Open 2022; 10:E686-E693. [PMID: 35571474 PMCID: PMC9106444 DOI: 10.1055/a-1781-0827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background and study aims Acute esophageal perforation is a potentially life-threating condition that demands a multidisciplinary approach. Based on recently published data indicating that EVT may be effective in managing esophageal perforation, we report our institution's experience with EVT in this clinical setting. Patients and methods We retrospectively analyzed all 10 patients with acute esophageal perforation from May 2018 to January 2021, using descriptive statistics. The primary outcome was successful closure of the perforation. Secondary outcomes included the length of treatment, number of endoscopic procedures required, and complication rate. Results All patients (site of perforation: 4 upper, 2 middle, 4 lower esophagus; etiology: 8 iatrogenic, 2 foreign body ingestion) were treated with EVT successfully. In eight cases, EVT was started immediately after the perforation, in the other two cases 1 and 2 days later. The median (interquartile range) number of endoscopic procedures was 2.5 (range, 2-3) and the median duration of treatment was 7.5 days (range, 7-11.5). The sponge was placed in eight cases intraluminally, in the other two cases initially intracavitary. No complication occurred. Conclusions EVT is highly effective for managing acute esophageal perforation within 1 to 3 weeks. Immediate start of EVT to prevent abscess formation and induce defect closure is crucial.
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Affiliation(s)
- Petros Stathopoulos
- Division of Interdisciplinary Endoscopy, Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
| | - Malte Zumblick
- Division of Interdisciplinary Endoscopy, Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
| | - Sabine Wächter
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Marburg, Marburg, Germany
| | - Leif Schiffmann
- Department of General, Visceral and Thoracic Surgery, Helios Hospital Aue, Aue, Germany
| | - Thomas M. Gress
- Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
| | - Detlef Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Marburg, Marburg, Germany
| | - Guido Seitz
- Department of Pediatric Surgery, University Hospital Marburg, Marburg, Germany
| | - Ulrike W. Denzer
- Division of Interdisciplinary Endoscopy, Department of Gastroenterology, University Hospital Marburg, Marburg, Germany
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24
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Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14040980. [PMID: 35205730 PMCID: PMC8870330 DOI: 10.3390/cancers14040980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments. Abstract Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.
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25
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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26
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Kim Y, Kang S, Ahn JY. Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.
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27
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Livingstone I, Pollock L, Sgromo B, Mastoridis S. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc 2021; 54:787-797. [PMID: 34781418 PMCID: PMC8652150 DOI: 10.5946/ce.2021.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022] Open
Abstract
Esophageal wall defects, including perforations and postoperative leaks, are associated with high morbidity and mortality and pose a significant management challenge. In light of the high morbidity of surgical management or revision, in recent years, endoscopic vacuum therapy (EVT) has emerged as a novel alternative treatment strategy. EVT involves transoral endoscopic placement of a polyurethane sponge connected to an externalized nasogastric tube to provide continuous negative pressure with the intention of promoting defect healing, facilitating cavity drainage, and ameliorating sepsis. In the last decade, EVT has become increasingly adopted in the management of a diverse spectrum of esophageal defects. Its popularity has been attributed in part to the growing body of evidence suggesting superior outcomes and defect closure rates in excess of 80%. This growing body of evidence, coupled with the ongoing evolution of the technology and techniques of deployment, suggests that the utilization of EVT has become increasingly widespread. Here, we aimed to review the current status of the field, addressing the mechanism of action, indications, technique methodology, efficacy, safety, and practical considerations of EVT implementation. We also sought to highlight future directions for the use of EVT in esophageal wall defects.
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Affiliation(s)
| | | | - Bruno Sgromo
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sotiris Mastoridis
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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28
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Abbitt D, Barnes AL, Hammad HT, Reveille RM, Jones EL. Endoluminal vacuum closure of a duodenal perforation. J Surg Case Rep 2021; 2021:rjab479. [PMID: 34754414 DOI: 10.1093/jscr/rjab479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Perforation is a known complication of endoscopic resection and has been managed with endoscopic defect closure, antibiotics and close observation. Closure of duodenal perforations are more challenging due to the presence of gastric and pancreaticobiliary secretions. The use of endoluminal vacuum therapy (EVT) to divert flow and aid closure is increasingly prevalent and may avoid high-risk surgery. We describe the use of endoluminal vacuum closure to salvage an iatrogenic duodenal perforation in a 57-year-old male who underwent an endoscopic mucosal resection of a 35-mm polypoid lesion on the posterior wall of the second portion of the duodenum. The endoluminal wound vac successfully controlled leakage and allowed defect closure. EVT is an emerging technique that can effectively manage complicated injuries throughout the GI tract and may allow enhanced recovery by avoiding surgical salvage and its associated morbidity and mortality.
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Affiliation(s)
- Danielle Abbitt
- Department of GI, Trauma and Endocrine Surgery, The University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Hazem T Hammad
- Division of Gastroenterology, Department of Medicine, The University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - R Matthew Reveille
- Division of Gastroenterology, Department of Medicine, The University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Edward L Jones
- Department of GI, Trauma and Endocrine Surgery, The University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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29
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Hayami M, Klevebro F, Tsekrekos A, Samola Winnberg J, Kamiya S, Rouvelas I, Nilsson M, Lindblad M. Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience. Dis Esophagus 2021; 34:6046267. [PMID: 33367786 DOI: 10.1093/dote/doaa122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.
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Affiliation(s)
- Masaru Hayami
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Johanna Samola Winnberg
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Kamiya
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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30
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do Monte Junior ES, de Moura DTH, Ribeiro IB, Hathorn KE, Farias GFA, Turiani CV, Medeiros FS, Bernardo WM, de Moura EGH. Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis. Dig Endosc 2021; 33:892-902. [PMID: 33300634 DOI: 10.1111/den.13813] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/30/2020] [Accepted: 08/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Upper gastrointestinal fistulas, leaks, and perforations represent a high cost burden to health systems worldwide, with high morbidity and mortality rates for affected patients. Management of these transmural defects remains therapeutically challenging. OBJECTIVES The aim of this study is to perform a systematic review and meta-analysis to investigate the efficacy and safety of self-expanding metal stents (SEMS) versus endoscopic vacuum therapy (EVT) for treatment of upper gastrointestinal transmural defects. METHODS Searches were performed on MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events. RESULTS Five studies with a total of 274 patients were included. There was a 21% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.21, CI 0.10-0.32; P = 0.0003). EVT demonstrated a 12% reduction in mortality compared to stenting (RD 0.12, CI 0.03-0.21; P = 0.006) and an average reduction of 14.22 days in duration of treatment (CI 8.38-20.07; P < 0.00001). There was a 24% reduction in adverse events (RD 0.24, CI 0.13-0.35; P = 0.0001. There were no statistical differences between the studied therapies regarding the length of hospital stay. CONCLUSION Endoscopic vacuum therapy proves to be superior in successful defect closure, mortality, adverse events and duration of treatment.
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Affiliation(s)
- Epifanio Silvino do Monte Junior
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Sao Paulo, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Sao Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Sao Paulo, Brazil
| | - Kelly Elizabeth Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy - Harvard Medical School, Brigham and Women's Hospital, Boston, USA
| | - Galileu Ferreira Ayala Farias
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Sao Paulo, Brazil
| | | | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Sao Paulo, Brazil
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31
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Glait M, Wong J, Krasaelap A, Wagner A, Lal D, Schneider J, Lerner D. Esophageal Wound Vacuum Placement for Anastomotic Leak: Lessons Learned From First Time Use at a Tertiary Care Center. JPGN REPORTS 2021; 2:e114. [PMID: 37205950 PMCID: PMC10191559 DOI: 10.1097/pg9.0000000000000114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/15/2021] [Indexed: 05/21/2023]
Abstract
Esophageal atresia and tracheoesophageal fistula (TEF) are rare birth anomalies typically requiring corrective surgery over the first few months of life. Esophageal surgery can lead to a life-threatening anastomotic leak. Esophageal wound vacuums have seen increased use in adults and one cohort of children as a therapeutic modality. This case study explores a tertiary care pediatric hospital's introductory experience in utilizing this technique. A 19-month-old male underwent staged repair for esophageal atresia/tracheoesophageal fistula requiring an esophageal stricture resection with primary anastomosis. An anastomotic leak was successfully managed with wound vacuums. Our experiences highlighted the need for individualized treatment plans with this therapy based on feeding capabilities, side effects of the vacuum, placement method, and replacement strategies.
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Affiliation(s)
- Megan Glait
- From the Medical College of Wisconsin, Wauwatosa, WI
| | - Jonathan Wong
- From the Medical College of Wisconsin, Wauwatosa, WI
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Wisconsin, Milwaukee, WI
| | | | - Amy Wagner
- From the Medical College of Wisconsin, Wauwatosa, WI
- Division of Pediatric Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI
| | - Dave Lal
- From the Medical College of Wisconsin, Wauwatosa, WI
- Division of Pediatric Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI
| | - John Schneider
- From the Medical College of Wisconsin, Wauwatosa, WI
- Division of Pediatric Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI
| | - Diana Lerner
- From the Medical College of Wisconsin, Wauwatosa, WI
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Wisconsin, Milwaukee, WI
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32
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Preemptive Endoluminal Vacuum Therapy to Reduce Morbidity after Minimally Invasive Ivor Lewis Esophagectomy: Including a Novel Grading System For Postoperative Endoscopic Assessment of GI-Anastomoses. Ann Surg 2021; 274:751-757. [PMID: 34334639 DOI: 10.1097/sla.0000000000005125] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Preemptive endoluminal vacuum therapy (pEVT) is a novel concept to reduce postoperative morbidity and has the potential to disrupt current treatment paradigms for patients undergoing esophagectomy. SUMMARY BACKGROUND DATA Endoluminal vacuum therapy is an accepted treatment for anastomotic leakage (AL) after esophagectomy. METHODS Retrospective analysis of patients undergoing minimally invasive Ivor Lewis esophagectomy (MILE) with pEVT between 11/2017 and 10/2020. The sponge was removed endoscopically after 4-6 days, and anastomosis and gastric conduit were assessed according to a novel endoscopic grading system. Further management was customized according to endoscopic appearance and clinical course. Endpoints were postoperative morbidity and AL rate, defined according to the Clavien-Dindo (CD) and International Esodata Study Group classifications. RESULTS PEVT was performed in 67 consecutive patients, 57 (85%) were high-risk patients with an ASA score >2, WHO/ECOG score >1, age >65 years, or BMI >29 kg/m2. Thirty patients experienced textbook outcome, and overall minor (≤CD IIIa) and major (≥CD IIIb) morbidity was 40.3% and 14.9% respectively. 30-day-mortality was 0%. Forty-nine patients (73%) had uneventful anastomotic healing after pEVT without further endoscopic treatment. The remaining 18 patients (27%) underwent prolonged EVT with uneventful anastomotic healing in 13 patients (19%), contained AL in 4 patients (6%), and one uncontained leakage (1.5%) in a case with proximal gastric conduit necrosis, resulting in an overall AL rate of 7.5%. CONCLUSIONS PEVT is an innovative and safe procedure with a promising potential to reduce postoperative morbidity after MILE and may be particularly valuable in highly comorbid cases.
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Hatamori H, Yoshio T, Tokai Y, Namikawa K, Yoshimizu S, Horiuchi Y, Tsuchida T, Ishiyama A, Hirasawa T, Kanamori J, Okamura A, Imamura Y, Watanabe M, Fujisaki J. Efficacy of endoscopic filling with polyglycolic acid sheets and fibrin glue for anastomotic leak after esophageal cancer surgery: identification of an optimal technique. Esophagus 2021; 18:529-536. [PMID: 33420532 DOI: 10.1007/s10388-020-00808-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/18/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Anastomotic leak is a potentially life-threatening complication following esophageal cancer surgery. In this study, we aimed to clarify the efficacy of endoscopic filling with polyglycolic acid (PGA) sheets and fibrin glue for anastomotic leak after esophageal cancer surgery. METHODS Consecutive patients who underwent endoscopic filling with PGA sheets and fibrin glue for anastomotic leak after esophageal cancer surgery between August 2014 and January 2020 were included in the study, with its efficacy retrospectively reviewed. We performed endoscopic filling using two methods: (1) filling the fistula with PGA sheets, followed by the application of a fibrinogen and thrombin solution (conventional method) and (2) filling the fistula with PGA sheets pre-soaked in a fibrinogen solution, followed by the application of a thrombin solution (pre-soak method). RESULTS A total of 14 patients underwent endoscopic filling procedures within the study period. The endoscopic filling procedures were successfully performed in all cases and no adverse events associated with the procedures were observed. Fistula closure was obtained in 10 (71%) cases. In the 10 successful cases, the median number of procedures was 1 (range 1-3) and the median time from the first procedure to oral intake was 7.5 days (range 4-36 days). The success rate of the pre-soak method was significantly higher than that of the conventional method (90% vs. 25%, P = 0.041). CONCLUSIONS Endoscopic filling with PGA sheets and fibrin glue is a safe and effective treatment for the closure of an anastomotic leak. The pre-soak method can achieve successful endoscopic filling.
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Affiliation(s)
- Hiroyuki Hatamori
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Yoshitaka Tokai
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Ken Namikawa
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shoichi Yoshimizu
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yusuke Horiuchi
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tomohiro Tsuchida
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akiyoshi Ishiyama
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis. J Clin Med 2021; 10:jcm10112346. [PMID: 34071877 PMCID: PMC8197794 DOI: 10.3390/jcm10112346] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022] Open
Abstract
A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle-Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81-0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45-4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24-2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17-5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12-4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23-7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.
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Loeck J, von Lücken HJ, Münscher A, Müller CT, Loske G. Endoscopic negative pressure therapy (ENPT) in head and neck surgery: first experiences in treatment of postoperative salivary fistulas and cervical esophageal perforations. Eur Arch Otorhinolaryngol 2021; 278:4525-4534. [PMID: 33715018 DOI: 10.1007/s00405-021-06709-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/18/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Iatrogenic cervical esophageal perforations (CEP) and postoperative salivary fistulas (PSF) are some of the complications requiring treatment in head and neck surgery. Conservative, surgical and endoscopic therapeutic techniques are used. Both CEP and PSF are potentially life-threatening complications and require intensive treatment. Endoscopic negative pressure therapy (ENPT) is an innovative endoscopic surgical procedure for the treatment of transmural intestinal defects throughout the gastrointestinal tract (GIT). In this retrospective study, we demonstrate its application in head and neck surgery. MATERIALS AND METHODS In ENPT, open-pore drains are placed endoscopically in the wound area. The drains can be inserted in an intraluminal position spanning the length of the defect (intraluminal ENPT), or through the defect into the extraluminal wound cavity (intracavitary ENPT). An electronic suction pump applies and maintains a continuous negative pressure of - 125 mmHg over a period of several days. The endoscopic drains are changed at regular intervals every few days until stable intracorporeal wound healing by secondary intention or defect closure is achieved. Between 06/2008 and 05/2019 ten patients (f = 3, m = 7; 46-78 years old) were treated with ENPT for CEP or PSF. Five patients had postoperative wound defects with consecutive PSF after total laryngectomy or floor of mouth resection. In five patients iatrogenic CEP was found following endoscopic procedures. RESULTS In all patients treated with ENPT, healing of the perforation defect or fistula was achieved (cure rate 100%). The median treatment duration was 13.7 days (range 4-42 days). No relevant treatment-associated complications were observed. CONCLUSION ENPT is a new, minimally invasive method for treating PSF and CEP.
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Affiliation(s)
- Jonathan Loeck
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany.
| | - Hans-Jürgen von Lücken
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany
| | - Adrian Münscher
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany
| | - Christian Theodor Müller
- Department of General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| | - Gunnar Loske
- Department of General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
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Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A. Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 2021; 21:72. [PMID: 33593301 PMCID: PMC7885467 DOI: 10.1186/s12876-021-01651-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).
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Affiliation(s)
- Chengcheng Christine Zhang
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Lukas Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Kouladouros K, Belle S, Reissfelder C, Kähler G. Endoscopic negative pressure therapy for leaks with large cavities in the upper gastrointestinal tract: is it a feasible therapeutic option? Scand J Gastroenterol 2021; 56:193-198. [PMID: 33332197 DOI: 10.1080/00365521.2020.1861645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic negative pressure therapy (ENPT) is an increasingly popular method for the treatment of various defects of the upper and lower gastrointestinal (GI) tract and has been associated with high success rates. The largest reported series focus on intraluminal therapy of local defects, whereas larger defects connected to the abdominal or pleural cavity are still regarded as indications for surgical revision in many units. The aim of our study is to assess the efficacy and the periinterventional characteristics of ENPT applications in patients with defects with large cavities in the upper GI tract. METHODS We retrospectively analysed all cases of ENPT applications in the upper gastrointestinal tract performed in our clinic between 1 January 2010 and 31 December 2019 and identified the patients with defects leading to large cavities with a length of at least 7 cm. The procedural characteristics, intraprocedural and late complications and overall clinical success were analysed. RESULTS We identified 14 cases meeting our inclusion criteria. In all cases, an intracavitary or combined intracavitary and intraluminal ENPT was applied. The average duration of therapy was 47.5 days and included an average of 10.4 changes per patient in an interval of 4.5 days. Clinical success rate was 92.9%, average hospital stay was 74.5 days. In three cases, a late stenosis occurred, which could be treated endoscopically. CONCLUSION Based on the data of our case series, we conclude that ENPT is a feasible and promising therapeutic option for upper GI defects with contact to large cavities.
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Affiliation(s)
- Konstantinos Kouladouros
- Department of Surgery, Medical Faculty Mannheim, Central Interdisciplinary Endoscopy, University of Heidelberg, Mannheim, Germany
| | - Sebastian Belle
- Department of Gastroenterology, Medical Faculty Mannheim, Central Interdisciplinary Endoscopy, University of Heidelberg, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Georg Kähler
- Department of Surgery, Medical Faculty Mannheim, Central Interdisciplinary Endoscopy, University of Heidelberg, Mannheim, Germany
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Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus 2021; 34:doaa039. [PMID: 32476017 PMCID: PMC7801633 DOI: 10.1093/dote/doaa039] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.
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Affiliation(s)
- M Fabbi
- Fondazione IRCCS Cà Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - E R C Hagens
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Mastoridis S, Chana P, Singh M, Akbari K, Shalaby S, Maynard ND, Sgromo B. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. MINIM INVASIV THER 2020; 31:380-388. [DOI: 10.1080/13645706.2020.1801753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sotiris Mastoridis
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Prem Chana
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mohan Singh
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Khalid Akbari
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Samar Shalaby
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas D. Maynard
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bruno Sgromo
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Sendino O, Loras C, Mata A, Momblán D, Andujar X, Cruz M, Cárdenas A, Marquez I, Uchima H, Cordova H, de Lacy AM, Espinós J. Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:431-438. [PMID: 32680732 DOI: 10.1016/j.gastrohep.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract. PATIENTS AND METHODS This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany). RESULTS 11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak. CONCLUSION EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.
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Affiliation(s)
- O Sendino
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
| | - C Loras
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - A Mata
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - D Momblán
- Servicio de Cirugía Gastrointestinal, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - X Andujar
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - M Cruz
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - A Cárdenas
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - I Marquez
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - H Uchima
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - H Cordova
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - A M de Lacy
- Servicio de Cirugía Gastrointestinal, ICMDiM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - J Espinós
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España; Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
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Pines G, Malka Yosef L, Lazar LO, Bar I, Schindel D. Negative-Pressure Vacuum Therapy for High-Output Chyle Leak Following Neck Dissection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:481-483. [PMID: 32628079 DOI: 10.1177/1556984520935535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chyle fistula is a challenging complication following neck dissection carrying a high morbidity and mortality rate. Herein we present a challenging case of successful management of high-output left-sided cervical chyle fistula with negative-pressure vacuum (VAC) therapy in a case where all conservative treatments failed. A 40-year-old man with lymphoma and supraglottic carcinoma underwent endoscopic resection and bilateral neck dissections. He developed high-output chyle fistula, nonresponsive to conservative treatments. Double-layered Vicryl mesh was placed between the sponge and the jugular vein to prevent vascular injury. Immediately after initiation of the VAC therapy, the output decreased, and completely stopped after 3 days. The VAC therapy was continued for additional 5 days to ensure complete seal of the fistula by granulation tissue, by which time the wound was primarily closed. VAC therapy seems to be a safe and effective treatment for high-output cervical chyle fistula following neck dissection, avoiding complex surgical interventions. Thoracic surgeons should be aware of this low-morbidity and potentially effective treatment modality for this challenging complication.
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Affiliation(s)
- Guy Pines
- 37601 Department of Thoracic Surgery, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University Medical School, Jerusalem, Israel
| | - Liron Malka Yosef
- The Hebrew University Medical School, Jerusalem, Israel.,37601 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Li Or Lazar
- 37601 Department of Thoracic Surgery, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University Medical School, Jerusalem, Israel
| | - Ilan Bar
- 37601 Department of Thoracic Surgery, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University Medical School, Jerusalem, Israel
| | - Doron Schindel
- The Hebrew University Medical School, Jerusalem, Israel.,37601 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
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Loske G, Rucktaeschel F, Schorsch T, Moenkemueller K, Mueller CT. Endoscopic negative pressure therapy (ENPT) for duodenal leakage - novel repair technique using open-pore film (OFD) and polyurethane-foam drainages (OPD). Endosc Int Open 2019; 7:E1424-E1431. [PMID: 31673614 PMCID: PMC6805203 DOI: 10.1055/a-0972-9660] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/21/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic negative pressure therapy (ENPT) is used to close transmural defects in the rectum and esophagus. Very few reports have described ENPT to manage duodenal defects. This study was designed to demonstrate ENPT in a population of 11 patients with transmural duodenal leakages. Patients and methods The method of ENPT was adapted for duodenal use. Open-pore polyurethane-foam or a thin, open-pore double-layered film was wrapped around the distal end of a gastroduodenal tube. First, this open-pore element was placed on the inner wound in the duodenum with endoscopy. Second, continuous negative pressure of -125 mmHg was applied with an electronic pump. Drains were changed after 2 to 7 days. Results Eleven patients were treated with duodenal leaks. Eight defects occurred after operative closure of perforated duodenal ulcers, papillectomy or stricturoplasty, one anastomotic leakage after Billroth - 1 distal gastric resection, one iatrogenic perforation in endoscopic retrograde cholangiopancreatography, and one by a surgical drain. Median duration of therapy was 11 days (range 7 - 24 days). Complete healing of defects was achieved in all patients. Conclusion ENPT is an innovative endoscopic alternative for treatment of transmural duodenal defects.
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Affiliation(s)
- Gunnar Loske
- Marienkrankenhaus - Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany, Hamburg,Corresponding author Gunnar Loske Katholisches Marienkrankenhaus Hamburg gGmbHDepartment for General, Abdominal, Thoracic and Vascular SurgeryAlfredstrasse 9, Hamburg 22087Germany+0049 40 2546 1400
| | - Frank Rucktaeschel
- Westküstenklinikum Heide - Department for Internal Medicine, Gastroenterology, Hemato-Oncology, Nephrology and Endocrinology, Heide, Schleswig-Holstein, Germany
| | - Tobias Schorsch
- Marienkrankenhaus - Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany, Hamburg
| | - Klaus Moenkemueller
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HELIOS Frankenwaldklinik Kronach - Department of Gastroenterology
Kronach, Bayern, Germany
| | - Christian Theodor Mueller
- Marienkrankenhaus - Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany, Hamburg
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Endoscopic Vacuum Therapy in the Management of Postoperative Leakage After Esophagectomy. World J Surg 2019; 44:179-185. [DOI: 10.1007/s00268-019-05228-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
INTRODUCTION The vacuum-assisted drainage has many applications in managing complex wound healing. It quickens the recovery period by its hyperemic effect on the exposed zone, decreasing bacterial colonization, preventing tissue edema, and promoting granulation of the wound. However, its use in anastomotic leak after IPAA is scarcely studied, especially because a proprietary endoluminal vacuum-assisted closure system was removed from the US market. TECHNIQUE We applied a hand-crafted endoluminal vacuum-assisted closure system using the existing standard wound vacuum-assisted closure supplies to 2 patients who developed an anastomotic leak with a presacral abscess after completion proctectomy with J-pouch construction. RESULTS We changed the endoluminal vacuum-assisted closure drain every 2 to 3 days, and both patients had substantial improvements in their abscess cavity after the seventh and ninth applications. CONCLUSIONS Anastomotic leak at the IPAA traditionally takes up to a year to heal, which causes a significant toll on the psychosocial life of the patient and delayed stoma closure. Therefore, we believe that facilitating the healing process by using our hand-crafted endoluminal vacuum-assisted closure drain might provide a great value to patients' quality of life.
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Barchi LC, Ramos MFKP, Pereira MA, Dias AR, Ribeiro-Júnior U, Zilberstein B, Cecconello I. Esophagojejunal anastomotic fistula: a major issue after radical total gastrectomy. Updates Surg 2019; 71:429-438. [PMID: 31161587 DOI: 10.1007/s13304-019-00659-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Abstract
Gastric cancer surgery has evolved considerably over the past years, with substantial improvement on outcomes. Meanwhile, esophagojejunal anastomotic fistula (EJF) continues to impair postoperative results. This study aimed to assess EJF regarding its incidence, risk factors, management and the impact on overall survival. We retrospectively analyzed 258 consecutive patients who underwent total or completion gastrectomy for GC from 2009 and 2017. Clinicopathological characteristics analysis was performed comparing patients who developed EJF with patients with other clinical or surgical complications, as well as patients without any postoperative complications. Fifteen (5.8%) patients had EJF and 81 (31.4%) had other complications (including other surgical fistulas). The median time of EJF diagnosis was on the eighth postoperative day (range 3-76). Completion gastrectomy (p = 0.048) and longer hospital stay (p < 0.001) were associated with the occurrence of EJF. The surgical mortality of patients with EJF was higher than in non-EJF patients (26.7% vs. 4.5%; p < 0.001). Nine patients were treated conservatively and six required surgery. The mortality rate of EJF was 11.1% and 50% in patients who underwent conservative and surgical treatment, respectively. Patients with other complications and patients with EJF had worse survival compared to patients without any complication (p = 0.004 and p = 0.013, respectively). Completion gastrectomy is the main risk factor for EJF occurrence. Still, EJF is associated with high postoperative mortality, longer hospital stay and has a negative impact on long-term survival.
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Affiliation(s)
- Leandro Cardoso Barchi
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil.
| | | | - Marina Alessandra Pereira
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - André Roncon Dias
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ulysses Ribeiro-Júnior
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Bruno Zilberstein
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ivan Cecconello
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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Abstract
Endoscopic negative-pressure therapy (ENPT) is becoming a valuable tool in surgical complication management of transmural intestinal defects and wounds in the upper and lower gastrointestinal tract. Innovative materials for drains have been developed, endoscopic techniques adapted, and new indications for ENPT have been found. Based on our broad clinical experience, numerous tips and tricks are described, which contribute to the safety of dealing with the new therapy. The aim of this work is to present these methods. The focus is on describing the treatment in the esophagus.
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Affiliation(s)
- G Loske
- Klinik für Allgemein‑, Viszeral‑, Thorax und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg gGmbH, Alfredstr. 9, 22087, Hamburg, Germany.
| | - C T Müller
- Klinik für Allgemein‑, Viszeral‑, Thorax und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg gGmbH, Alfredstr. 9, 22087, Hamburg, Germany
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de Moura DTH, de Moura BFBH, Manfredi MA, Hathorn KE, Bazarbashi AN, Ribeiro IB, de Moura EGH, Thompson CC. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11:329-344. [PMID: 31205594 PMCID: PMC6556487 DOI: 10.4253/wjge.v11.i5.329] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Ahmad N Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
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Novel endoscopic modalities for closure of perforations, leaks, and fistula in the gastrointestinal tract. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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