Choosing the Appropriate Endoscopic Armamentarium for Treatment of Anastomotic Leaks

Endoscopic Treatment of Acute and Chronic Anastomotic Leaks from Inflammatory Bowel Disease Surgery

Acute or chronic anastomotic leak is a common complication after any gastrointestinal surgery in inflammatory bowel disease (IBD). The underlying disease of the bowel, comorbidities, malnutrition, anemia, and concurrent use of corticosteroids increase the risk for the development of anastomotic leaks. Anastomotic leak is traditionally managed with surgery. However, recent innovation has allowed the use of endoscopic methods in the management of some anastomotic leaks and their consequences. This article discusses a variety of endoscopic techniques that have either been established or are under current evaluation, for the management of anastomotic leaks in patients with IBD.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

Endoscopic internal drainage and low negative-pressure endoscopic vacuum therapy for anastomotic leaks after oncologic upper gastrointestinal surgery

BACKGROUND

Endoscopic internal drainage (EID) with double-pigtail stents or low negative-pressure endoscopic vacuum therapy (EVT) are treatment options for leakage after upper gastrointestinal oncologic surgery. We aimed to compare the effectiveness of these techniques.

METHODS

Between 2016 and 2019, patients treated with EID in five centers in France and with EVT in Göttingen, Germany were included and retrospectively analyzed using univariate analysis. Pigtail stents were changed every 4 weeks; EVT was repeated every 3-4 days until leak closure.

RESULTS

35 EID and 27 EVT patients were included, with a median (interquartile range [IQR]) leak size of 0.75 cm (0.5-1.5). Overall treatment success was 100 % (95 % confidence interval [CI] 90 %-100 %) for EID vs. 85.2 % (95 %CI 66.3 %-95.8 %) for EVT (P = 0.03). The median (IQR) number of endoscopic procedures was 2 (2-3) vs. 3 (2-6.5; P = 0.003) and the median (IQR) treatment duration was 42 days (28-60) vs. 17 days (7.5-28; P < 0.001), for EID vs. EVT, respectively.

CONCLUSION

EID and EVT provide high closure rates for upper gastrointestinal anastomotic leaks. EVT provides a shorter treatment duration, at the cost of a higher number of procedures.

Endoscopy in Patients With Surgically Altered Anatomy

A comprehensive understanding of gastrointestinal anatomy is essential for performance of any endoscopic procedure. Surgical approaches to therapy have become increasingly common in the past decade, which has resulted in a substantial proportion of patients with surgically altered anatomy who require endoscopy. In parallel with the obesity epidemic, bariatric surgery for obesity management has been widely adopted. In response to these trends, gastroenterologists must become familiar with patient anatomy after these surgical interventions and understand the implications of this altered anatomy on the current array of available endoscopic modalities for diagnosis and therapy. This review describes the range of surgically altered anatomy commonly encountered in the upper gastrointestinal tract. For each foregut location-esophagus, stomach, and small bowel-we describe indications for and specific details of the range of common surgical approaches affecting this regional anatomy. We then provide an endoscopic roadmap through the altered anatomy resulting from these surgical interventions. Finally, we address the impact of postsurgical anatomy on performance of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, with guidance surrounding how to successfully execute these procedures. Evolution of endoscopic approaches over time might be expected to enhance the safety and efficacy of these interventions in patients with surgically altered anatomy.

Gastric conduit perforation after Ivor Lewis esophagectomy successfully treated with endoscopic vacuum therapy (E-VAC): a case report

Gastric conduit perforation is a life-threatening complication after esophagectomy and currently there is no consensus about its optimal management. Endoscopic vacuum therapy (E-VAC) is a promising technique for the treatment of leaks and perforations after upper gastro-intestinal surgery. We report the case of a 65 years-old male patient who underwent an Ivor Lewis esophagectomy for esophago-gastric junction adenocarcinoma. He referred to our Emergency Department for septic shock and right hydropneumothorax. We performed an emergency thoracoscopy with intraoperative esophagogastroduodenoscopy which showed a pre-pyloric perforation of the gastric conduit. The perforation was initially treated with unsuccessful primary surgical closure and subsequently by means of E-VAC, firstly placed intraluminal and then intracavitary. With the latter technique, we assisted to a progressive clinical improvement until the definitive healing of the perforation. To our knowledge, this is the first case of a gastric tube perforation after esophagectomy successfully treated with E-VAC.

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Background and study aims  A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods  A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results  A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions  There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

Role of endoscopic vacuum therapy, internal drainage, and stents for postbariatric leaks

Background and Aims

Therapeutic endoscopy plays a major role in the management of postbariatric anastomotic leaks, offering an effective treatment alternative to repeated surgery. In recent years, management has been moving from bridging and closing the leak’s orifice toward an approach that uses vacuum therapy or internal drainage. Our aim was to demonstrate different treatment options for the management of postbariatric leaks.

Methods

We describe 3 different endoscopic techniques for postbariatric leaks in 2 patients who had undergone Roux-en-Y gastric bypass (RYGB) and 1 patient who had undergone sleeve gastrectomy.

Results

The first patient had a 20-mm early post-RYGB leak with an intra-abdominal associated collection treated with 5 sessions of endoscopic vacuum therapy (EVT). The second patient had a 12-mm acute postgastric sleeve leak with an associated collection, in whom therapy with EVT had failed, and who was then treated with endoscopic internal drainage (EID). The last patient had a chronic intra-abdominal collection after RYGB, despite reoperation, in whom therapy with EID and esophageal stent had failed, and who was treated with a diabolo-shaped lumen-apposing metal stent placed between the gastric pouch and the gastric remnant. Weight-loss intention was not compromised in any patient. All patients remain well.

Conclusions

Staple-line or anastomotic leaks are an important cause of morbidity and mortality after surgery. There are myriad endoscopic techniques, with varying reported efficacy. Often, more than one endoscopic approach can be used concomitantly, whereas in other cases, therapies are applied sequentially depending on the initial clinical response. Multiple therapeutic options should be considered before endoscopic failure.