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Dell'Anna G, Fanti L, Fanizza J, Barà R, Barchi A, Fasulo E, Elmore U, Rosati R, Annese V, Laterza L, Fuccio L, Azzolini F, Danese S, Mandarino FV. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med 2024; 13:3805. [PMID: 38999371 PMCID: PMC11242239 DOI: 10.3390/jcm13133805] [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: 05/28/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.
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Affiliation(s)
- Giuseppe Dell'Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy
| | - Lorella Fanti
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Ugo Elmore
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Riccardo Rosati
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Liboria Laterza
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
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Pattynama LMD, Eshuis WJ, Seewald S, Pouw RE. Multi-modality management of defects in the gastrointestinal tract: Where the endoscope meets the scalpel: Endoscopic vacuum therapy in the upper gastrointestinal tract. Best Pract Res Clin Gastroenterol 2024; 70:101901. [PMID: 39053979 DOI: 10.1016/j.bpg.2024.101901] [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: 02/09/2024] [Accepted: 02/25/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Transmural defects in the upper gastrointestinal (GI) tract, such as anastomotic leakage and oesophageal perforations, are associated with significant morbidity and mortality risks. Endoscopic vacuum therapy (EVT) is an efficient and safe treatment option for these patients. With the growing use of EVT in the upper GI tract, it is important to share expertise on the topic. AIM This review explores the emerging role of endoscopic vacuum therapy (EVT) as treatment for transmural defects in the upper GI tract. An overview of the mechanism and procedures, outcomes in current literature and challenges of implementation and application are discussed. CONCLUSION EVT exhibits great efficacy and safety for the treatment of transmural defects in the upper GI tract. Current use of EVT is mostly experience-based, emphasizing the importance of sharing expertise and performing research to unlock its full potential.
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Affiliation(s)
- Lisanne M D Pattynama
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Wietse J Eshuis
- Amsterdam UMC Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Zürich, Switzerland.
| | - Roos E Pouw
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands.
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Ciuntu BM, Tanevski A, Buescu DO, Lutenco V, Mihailov R, Ciuntu MS, Zuzu MM, Vintila D, Zabara M, Trofin A, Cadar R, Nastase A, Lupascu Ursulescu C, Lupascu CD. Endoscopic Vacuum-Assisted Closure (E-VAC) in Septic Shock from Perforated Duodenal Ulcers with Abscess Formations. J Clin Med 2024; 13:470. [PMID: 38256604 PMCID: PMC10816729 DOI: 10.3390/jcm13020470] [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: 12/24/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
This case report underscores the importance of utilizing E-VAC (endoscopic vacuum-assisted closure) in the treatment of a perforated duodenal ulcer complicated by the formation of a subphrenic abscess and septic shock. It showcases how E-VAC can effectively mitigate the risk of further complications, such as leakage, bleeding, or rupture, which are more commonly associated with traditional methods like stents, clips, or sutures. As a result, there is a significant reduction in mortality rates. A perforated duodenal ulcer accompanied by abscess formation represents a critical medical condition that demands prompt surgical intervention. The choice of the method for abscess drainage and perforation closure plays a pivotal role in determining the patient's chances of survival. Notably, in patients with a high ASA (American Association of Anesthesiologists) score of IV-V, the mortality rate following conventional surgical intervention is considerably elevated. The management of perforated duodenal ulcers has evolved from open abdominal surgical procedures, which were associated with high mortality rates and risk of suture repair leakage, to minimally invasive techniques like laparoscopy and ingestible robots. Previously, complications arising from peptic ulcers, such as perforations, leaks, and fistulas, were primarily addressed through surgical and conservative treatments. However, over the past two decades, the medical community has shifted towards employing endoscopic closure techniques, including stents, clips, and E-VAC. E-VAC, in particular, has shown promising outcomes by promoting rapid and consistent healing. This case report presents the clinical scenario of a patient diagnosed with septic shock due to a perforated duodenal ulcer with abscess formation. Following an exploratory laparotomy that confirmed the presence of a subphrenic abscess, three drainage tubes were utilized to evacuate it. Subsequently, E-VAC therapy was initiated, with the kit being replaced three times during the recovery period. The patient exhibited favorable progress, including weight gain, and was ultimately discharged as fully recovered. In the treatment of patients with duodenal perforated ulcers and associated abscess formation, the successful and comprehensive drainage of the abscess, coupled with the closure of the perforation, emerges as a pivotal factor influencing the patient's healing process. The positive outcomes observed in these patients underscore the efficacy of employing a negative pressure E-VAC kit, resulting in thorough drainage, rapid patient recovery, and low mortality rates.
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Affiliation(s)
- Bogdan Mihnea Ciuntu
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Adelina Tanevski
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - David Ovidiu Buescu
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Valerii Lutenco
- Department of General Surgery, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800010 Galati, Romania; (V.L.); (R.M.)
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania
| | - Raul Mihailov
- Department of General Surgery, Faculty of Medicine, “Dunarea de Jos” University of Medicine and Pharmacy, 800010 Galati, Romania; (V.L.); (R.M.)
- General Surgery Clinic, “St. Apostol Andrei” County Emergency Clinical Hospital, Strada Brăilei 177, 800578 Galati, Romania
| | - Madalina Stefana Ciuntu
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
| | - Mihai Marius Zuzu
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Dan Vintila
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Mihai Zabara
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ana Trofin
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ramona Cadar
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Alexandru Nastase
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Corina Lupascu Ursulescu
- Department of Radiology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
| | - Cristian Dumitru Lupascu
- Department of General Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (D.O.B.); (M.M.Z.); (D.V.); (M.Z.); (A.T.); (R.C.); (A.N.); (C.D.L.)
- General Surgery Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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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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