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Strobel RM, Wellner JE, Neumann K, Otto SD, Eschlboeck SM, Seifarth C, Schineis CHW, Beyer K, Kreis ME, Lauscher JC. Influence of Neoadjuvant Therapy on Success of Endoscopic Vacuum Therapy in Anastomotic Leakage after Rectal Resection Because of Rectal Cancer. J Clin Med 2024; 13:3982. [PMID: 38999546 PMCID: PMC11242140 DOI: 10.3390/jcm13133982] [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: 05/30/2024] [Revised: 06/21/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024] Open
Abstract
Background: For locally advanced rectal cancer, neoadjuvant therapy (NT) is an established element of therapy. Endoscopic vacuum therapy (EVT) has been a relevant treatment option for anastomotic leakage after rectal resection since 2008. The aim was to evaluate the influence of NT on the duration and success of EVT in anastomotic leakage after rectal resection for rectal cancer. Methods: This was a monocentric, retrospective cohort study including patients who underwent rectal resection with primary anastomosis because of histologically proven carcinoma of the rectum in the Department for General and Visceral Surgery of Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin over a period of ten years (2012 to 2022). Results: Overall, 243 patients were included, of which 47 patients (19.3%) suffered from anastomotic leakage grade B with consecutive EVT. A total of 29 (61.7%) patients received NT and 18 patients (38.3%) did not. The median duration of EVT until the removal of the sponge did not differ between patients with and without NT: 24.0 days (95% CI 6.44-41.56) versus 20.0 days (95% CI 17.03-22.97); p = 0.273. The median duration from insertion of EVT until complete healing was 74.0 days with NT (95% CI 10.07-137.93) versus 62.0 days without NT (95% CI 45.99-78.01); p = 0.490. Treatment failure-including early persistence and late onset of recurrent anastomotic leakage-was evident in 27.6% of patients with NT versus 27.8% without NT; p = 0.989. Ostomy was reversed in 19 patients (79.2%) with NT compared to 11 patients (68.8%) without NT; p = 0.456. Overall, continuity was restored in 75% of patients in the long term after EVT. Conclusion: This trial comprised-to our knowledge-the largest study cohort to analyze the outcome of EVT in anastomotic leakage after rectal resection for rectal cancer. We conclude that neoadjuvant therapy neither prolongs EVT nor the time to healing from anastomotic leakage. The rates of treatment failure of EVT and permanent ostomy were not higher when neoadjuvant therapy was used.
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Affiliation(s)
- Rahel M Strobel
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Julia E Wellner
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Konrad Neumann
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Susanne D Otto
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sophie M Eschlboeck
- Department of General and Visceral Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Claudia Seifarth
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christian H W Schineis
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Martin E Kreis
- Executive Board, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Johannes C Lauscher
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
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Keshvari A, Mollamohammadi L, Keramati MR, Behboudi B, Fazeli MS, Kazemeini A, Naseri A, Shahmohammadi E, Foroutani L, Ayati A, Tayebi A, Sajjadian Z, Hadizadeh A, Ahmadi-Tafti SM. Assessment of the efficacy of Handmade Vacuum-Assisted Sponge Drain for Treatment of Anastomotic leakage after Low Anterior Rectal Resection. Updates Surg 2023:10.1007/s13304-023-01518-3. [PMID: 37086350 DOI: 10.1007/s13304-023-01518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/17/2023] [Indexed: 04/23/2023]
Abstract
Anastomotic leakage is one of the major complications of colorectal surgery, which might lead to reoperation, increased hospital stays, further intervention and mortality. Vacuum-assisted closure by devices such as Endo-SPONGE® produced by (B-Braun Medical B.V.) is currently being used to treat leakage and fistula. In this study, we aimed to assess the handmade vacuum-assisted sponge drain for anastomotic leakage following low anterior resection. This prospective study included 22 patients who had undergone sponge drain placement to treat anastomotic leakage. All patients had anastomotic leaks or defects after left anterior rectal resection (LAR) without ileostomy. They were treated with neo-adjuvant chemotherapy before the surgery and then subjected to rigid recto-sigmoidoscopy for 30 days following the operation. Any sign of leakage, such as perianal and pelvic pain, was immediately identified and followed up with a CT scan and another recto-sigmoidoscopy. Twenty-two patients were enrolled in this study, 12 men (54.5%) and 10 women (47.4%). All patients had received neo-adjuvant chemotherapy with an average follow-up of 22.30 ± 3.81. 75% of patients (15 cases) were successfully treated, and 17 patients (85%) underwent successful ostomy closure. Treatment failed in 5 patients (25%), including three men and two women. This study shows that handmade vacuum-assisted sponge drain is a cost-effective method of anastomotic leakage management with efficacy similar to that of Endo-SPONGE®.
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Affiliation(s)
- Amir Keshvari
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Leila Mollamohammadi
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Mohammad Reza Keramati
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Behnam Behboudi
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Mohammad Sadegh Fazeli
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Alireza Kazemeini
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Amirhossein Naseri
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran
| | - Elnaz Shahmohammadi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Laleh Foroutani
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Tayebi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Sajjadian
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Alireza Hadizadeh
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyed-Mohsen Ahmadi-Tafti
- Colorectal Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, 1419733141, Iran.
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Gowthaman D, Gabor LR, Lin KY, Yang J, Dellacerra GA, Isani SS, Kuo DY. Use of endoluminal vacuum therapy after anastomotic leak in a gynecologic oncology patient with rectosigmoid resection: A case report. Gynecol Oncol Rep 2022; 44:101113. [PMID: 36579181 PMCID: PMC9791311 DOI: 10.1016/j.gore.2022.101113] [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: 09/13/2022] [Revised: 11/30/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
•Anastomotic leak is an infrequent complication after colon resection and is associated with high morbidity and mortality.•Endoluminal vacuum therapy (EVAT) promotes wound closure by covering anastomotic leaks intraluminally and applying vacuum.•EVAT has been shown to be safe with mild adverse events.•EVAT should be considered in hemodynamically stable gynecologic oncology patients with a confined anastomotic leak.
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Drefs M, Schardey J, von Ehrlich-Treuenstätt V, Wirth U, Burian M, Zimmermann P, Werner J, Kühn F. Endoscopic Treatment Options for Gastrointestinal Leaks. Visc Med 2022; 38:311-321. [PMID: 37970585 PMCID: PMC10642546 DOI: 10.1159/000526759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients. Methods We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
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5
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Vignali A, De Nardi P. Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis. World J Gastroenterol 2022; 28:1394-1404. [PMID: 35582677 PMCID: PMC9048477 DOI: 10.3748/wjg.v28.i14.1394] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/07/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.
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Affiliation(s)
- Andrea Vignali
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
- Department of Surgery, Vita-Salute University, Milano 20132, Italy
| | - Paola De Nardi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
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6
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Jagielski M, Piątkowski J, Jarczyk G, Jackowski M. Transrectal endoscopic drainage with vacuum-assisted therapy in patients with anastomotic leaks following rectal cancer resection. Surg Endosc 2022; 36:959-967. [PMID: 33650007 PMCID: PMC8758650 DOI: 10.1007/s00464-021-08359-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgery is the gold standard for the treatment of malignant tumors of the rectum. Intestinal anastomotic leakage remains a serious complication of colorectal surgery. The efficacy and safety of transrectal endoscopic drainage by vacuum therapy in patients with intestinal anastomotic leakage after surgical treatment of middle and distal rectal tumors were assessed. METHODS Prospective analysis of treatment outcomes among patients undergoing surgery for middle and distal rectal tumors at the Department of General, Gastroenterological, and Oncological Surgery of the Ludwik Rydygier Collegium Medicum in Bydgoszcz and Nicolaus Copernicus University in Torun from 2016 to 2019 was conducted. RESULTS Seventy-nine patients with middle and distal rectal tumors underwent laparoscopic resection. Intestinal anastomotic leak was identified in 18 (22.79%) patients [all men, mean age 61.39 (43-86) years] during the postoperative period. Primary protective ileostomy was performed in 8/18 (44.44%) patients. All 18 patients were treated with endoluminal vacuum therapy via transrectal endoscopic drainage. The mean time from surgery to the diagnosis of leakage and initiation of endoscopic treatment was 16 (3-728) days. The mean number of endoscopic procedures per patient was 6 (1-11). The mean duration of endoscopic treatment was 22 (4-43) days. Complications of endotherapy occurred in 2/18 (11.11%) patients treated endoscopically for bleeding from the abscess cavity. Success of endoluminal vacuum therapy was achieved in 17/18 (94.44%) patients. Moreover, 5/18 (27.78%) patients required ileostomy during the endoscopic treatment. The mean follow-up period was 368 (118-724) days. Long-term success of transrectal endoscopic drainage using vacuum-assisted therapy was achieved in 15/18 (83.33%) patients. CONCLUSIONS Endoscopic rectal drainage using vacuum-assisted therapy is an effective and safe minimally invasive treatment in patients with intestinal anastomotic leaks following resection procedures within the middle and distal rectum.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland.
| | - Jacek Piątkowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
| | - Grzegorz Jarczyk
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
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7
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Endoscopic vacuum therapy for the treatment of colorectal leaks - a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:283-292. [PMID: 34817647 PMCID: PMC8803669 DOI: 10.1007/s00384-021-04066-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND During the last two decades, vacuum-assisted wound therapy has been successfully transferred to an endoscopic treatment approach of various upper and lower gastrointestinal leaks called endoscopic vacuum therapy (EVT). As mostly small case series are published in this field, the aim of our systematic review and meta-analysis was to evaluate the efficacy and safety of EVT in the treatment of colorectal leaks. METHODS A systematic search of MEDLINE/PubMed and Cochrane databases was performed using search terms related to EVT and colorectal defects (anastomotic leakage, rectal stump insufficiency) according to the PRISMA guidelines. Randomized controlled trials (RCTs), observational studies, and case series published by December 2020 were eligible for inclusion. A meta-analysis was conducted on the success of EVT, stoma reversal rate after EVT as well as procedure-related complications. Statistical interferences were based on pooled estimates from random effects models using DerSimonian-Laird estimator. RESULTS Only data from observational studies and case series were available. Twenty-four studies reporting on 690 patients with colorectal defects undergoing EVT were included. The mean rate of success was 81.4% (95% CI: 74.0%-87.1%). The proportion of diverted patients was 76.4% (95% CI: 64.9%-85.0%). The mean rate of ostomy reversal across the studies was 66.7% (95% CI: 58.0%-74.4%). Sixty-four patients were reported with EVT-associated complications, the weighted mean complication rate across the studies was 12.1% (95% CI: 9.7%-15.2%). CONCLUSIONS Current medical evidence on EVT in patients with colorectal leaks lacks high quality data from RCTs. Based on the data available, EVT can be seen as a feasible treatment option with manageable risks for selected patients with colorectal leaks.
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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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Dhindsa BS, Naga Y, Saghir SM, Daid SGS, Chandan S, Mashiana H, Dhaliwal A, Sidhu A, Sayles H, Ramai D, Bhat I, Singh S, McDonough S, Adler DG. Endo-sponge in management of anastomotic colorectal leaks: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1342-E1349. [PMID: 34466357 PMCID: PMC8367445 DOI: 10.1055/a-1490-8783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Following colorectal surgery, anastomotic dehiscence and leak formation has an incidence of 2 % to 7 %. Endo-SPONGE has been applied in the management of anastomatic leaks (ALs) after colorectal surgery. This is the first systematic review and meta analysis to evaluate the efficacy and safety of Endo-SPONGE in the management of colorectal ALs. Patients and methods The primary outcomes assessed were the technical and clinical success of Endo-SPONGE placement in colorectal ALs. The secondary outcomes assessed were the overall adverse events (AEs) and the AE subtypes. Pooled estimates were calculated using random-effects models with 95 % confidence interval (C. I.). The statistical analysis was done using STATA v16.1 software (StataCorp, LLC College Station, Texas, United States). Results The analysis included 17 independent cohort studies with a total of 384 patients. The rate of technical success was 99.86 % (95 % CI: 99.2 %, 100 %; P = 0.00; I 2 = 70.69 %) and the calculated pooled rate of clinical success was 84.99 % (95 % CI: 77.4 %, 91.41 %; P = 0.00; I 2 = 68.02 %). The calculated pooled rate of adverse events was 7.6 % (95 % CI: 3.99 %, 12.21 %; P = 0.03; I 2 = 42.5 %) with recurrent abscess formation and bleeding being the most common AEs. Moderate to substantial heterogeneity was noted in our meta-analysis. Conclusions Endoscopic vacuum therapy appears to be a minimally invasive, safe, and effective treatment modality for patients with a significant colorectal leak without any generalized peritonitis with high clinical and technical success rates and a low rate of adverse events. Further prospective or randomized controlled trials are needed to validate our findings.
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Affiliation(s)
- Banreet S. Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Yassin Naga
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, United States
| | - Syed M. Saghir
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, United States
| | | | - Saurabh Chandan
- Creighton University Medical Center, Omaha, Nebraska, United States
| | - Harmeet Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Abhitej Sidhu
- Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Daryl Ramai
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
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Keshvari A, Badripour A, Keramati MR, Kazemeini A, Behboudi B, Fazeli MS, Rahimpour E, Ghaffari P, Tafti SMA. Introduction of a Handmade Vacuum-Assisted Sponge Drain for the Treatment of Anastomotic Leakage After Low Anterior Rectal Resection. Ann Coloproctol 2021; 38:230-234. [PMID: 34111349 PMCID: PMC9263312 DOI: 10.3393/ac.2021.00059.0008] [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: 01/18/2021] [Accepted: 03/15/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Anastomotic leakage, a known major postoperative complication, potentially leads to readmission, reoperation, and increased mortality rates in patients, such as rectal cancer patients following a low anterior resection (LAR). Currently, vacuum-assisted closure, as featured by B-Braun (B-Braun Medical B.V.), is already being used for the treatment of gastrointestinal leakages and fistulas. The main aim of this study was to introduce a novel method for creating a vacuum-assisted drain for the treatment of anastomotic leakage after LAR. Methods All 10 patients, who underwent LAR surgery from 2018 to 2019, were diagnosed with anastomotic leakage and had received neoadjuvant chemotherapy prior to surgery. Therefore, patients were treated with a handmade vacuum-assisted drain and were revisited every 5 to 7 days for further evaluations and drain replacement until leakage resolution. Physical features of cavity, time of diagnose, and duration of treatment were analyzed correspondingly. The handmade vacuum-assisted sponge drain was prepared for each patient in each session of follow-up. Results Eight out of 10 patients experienced complete closure of the defect. The mean delay time from the day of operation to the diagnosis of anastomotic leakage was 61.0±80.4 days while the mean time for leakage closure was 117.6±68.3 days. Eventually, 7 cases underwent ileostomy reversal with no complications during a 3-month follow-up. Conclusion In this study, we evaluated the healing process of anastomotic leakage after the usage of a handmade vacuum-assisted sponge drain in a case series method. In our trial, we provided an innovative cost-benefit method easily applicable in the operating room.
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Affiliation(s)
- Amir Keshvari
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Badripour
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Keramati
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Fazeli
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Rahimpour
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Ghaffari
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital affiliated with Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Disivion of Colorectal Surgery, Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Weréen A, Dahlberg M, Heinius G, Pieniowski E, Saraste D, Eklöv K, Nygren J, Pekkari K, Everhov ÅH. Long-Term Results after Anastomotic Leakage following Rectal Cancer Surgery: A Comparison of Treatment with Endo-Sponge and Transanal Irrigation. Dig Surg 2020; 37:456-462. [PMID: 32829324 DOI: 10.1159/000508935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/19/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE We aimed to evaluate long-term results in patients from regular health care treated with endoscopic transanal closure system, that is, endoscopic vacuum-assisted closure system (EVAC) compared to transanal irrigation. METHODS In this retrospective, medical chart-based, observational study, we included patients with anastomotic leakage after low anterior resection for rectal cancer from 3 Stockholm hospitals 2006-2016 and compared time to first stoma closure in a Kaplan-Meier model and the proportion of patients who were stoma-free at end of follow-up. RESULTS Anastomotic leakage was found in 81 patients who were followed up in median 5.9 years (min-max: 0.53-13). EVAC was used on 14 (17%) patients and transanal irrigation on 34 (42%) patients. The remaining 33 (41%) patients either got a permanent colostomy or were treated only with antibiotics and percutaneous drainage. Treatment with EVAC or transanal irrigation led to similar rates of stoma closure, both when comparing all patients, and when comparing patients with similar defects. At the end of follow-up, 43% of patients treated with EVAC and 50% of patients treated with repeated irrigation were stoma-free (p = 0.75). CONCLUSIONS We found no evidence of better outcomes in patients treated with EVAC. The study was, however, limited by small sample size.
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Affiliation(s)
- Alice Weréen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Göran Heinius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Emil Pieniowski
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Deborah Saraste
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Karolina Eklöv
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, .,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,
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Mahendran B, Rossi B, Coleman M, Smolarek S. The use of Endo-SPONGE ® in rectal anastomotic leaks: a systematic review. Tech Coloproctol 2020; 24:685-694. [PMID: 32377984 DOI: 10.1007/s10151-020-02200-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. METHODS All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. CONCLUSIONS Endo-SPONGE® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.
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Affiliation(s)
- B Mahendran
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK.
| | - B Rossi
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - M Coleman
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - S Smolarek
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
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13
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Popivanov GI, Mutafchiyski VM, Cirocchi R, Chipeva SD, Vasilev VV, Kjossev KT, Tabakov MS. Endoluminal negative pressure therapy in colorectal anastomotic leaks. Colorectal Dis 2020; 22:243-253. [PMID: 31274227 DOI: 10.1111/codi.14754] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
AIM The aim of the present work was to perform an up-to-date review of the literature on endoluminal negative pressure therapy for colorectal anastomotic leak. METHOD An electronic search in PubMed and Google Scholar and a manual search without language restrictions were performed on 25 January 2019. Only original series reporting endoluminal negative pressure therapy in colorectal anastomotic leaks were included. The primary outcome was the success rate (complete closure of the abscess cavity). The secondary outcomes were the rates of complications and stoma closure. RESULTS Nineteen series with a total of 295 cases were analysed. The median distance of the anastomosis from the anal verge and the size of the abscess were 5.65 cm (4.9-10) and 6.0 cm (5-8.1) respectively. In 84.5% (78%-91%) the stoma was created at the first intervention. Neoadjuvant therapy was performed in 48.6% (3%-60%). Median 7 sponges (2-34) were used with median negative pressure 150 mmHg (125-700) for a median of 31 days (14-127). The success rate was 85.4% (80%-91%) with ileostomy closure in 72.6%. Complications were observed in 19% (13%-25%): abscesses 11.5% and anastomotic stenosis 4.4%. Laparotomy was required in 15% of the complications. The stoma was the only significant predictor for the success of the therapy (0.007, SE 0.004, P = 0.040). CONCLUSIONS The initial experience looks promising with an 85% success rate, which precludes risky re-resections with redo anastomosis or Hartmann's procedure. Despite the good initial results, definitive conclusions cannot be drawn because of the small sample size and the lack of high-quality comparative studies.
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Affiliation(s)
- G I Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - V M Mutafchiyski
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - R Cirocchi
- Department of Surgery and Surgical Science, University of Perugia, Perugia, Italy
| | - S D Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
| | - V V Vasilev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - K Ts Kjossev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - M S Tabakov
- Clinic of Abdominal Surgery, MHAT 'Sv. Ivan Rilski', Sofia, Bulgaria
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Improved colorectal anastomotic leakage healing by transanal rinsing treatment after endoscopic vacuum therapy using a novel patient-applied rinsing catheter. Int J Colorectal Dis 2020; 35:109-117. [PMID: 31792582 DOI: 10.1007/s00384-019-03456-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic or stump leakage is a common and serious complication of colorectal surgery. The objective of this study was to retrospectively investigate the clinical use and potential benefit of transanal rinsing treatment (TRT) using an innovative rinsing catheter (RC) after treatment with endoscopic vacuum therapy (EVT). METHODS Patients with leakage after low colorectal surgery who had been treated with EVT were retrospectively analyzed. A subset of patients was trained to perform TRT with a specially developed RC. We investigated the rate of complete healing of the leakage, septic complications, failure of the therapy, surgical revisions, ostomy closure rate, and complications related to endoscopic therapy. RESULTS Between February 2007 and January 2014, 98 patients with local complications after low colorectal surgery, treated with EVT, were identified. Eighty-nine patients were analyzed (the treatment of nine patients was stopped due to medical or technical problems): 31 patients were treated with EVT only (EVT group) and 58 patients with EVT followed by TRT (EVT/TRT group). Complete healing of the leakage was significantly better in the EVT/TRT group [84% vs. 58% (p < 0.009)], and significantly fewer septic complications needing surgical revision were detected [3% vs. 11% (p = 0.001)]. No significant differences regarding endoscopy-related complications and ostomy closure were found between EVT and EVT/TRT patients. CONCLUSIONS The use of patient-administered TRT with an innovative, customized RC after EVT is technically feasible and reliable and significantly improves therapeutic results. Further prospective trials with larger patient groups are needed to validate the results of our study.
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15
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Effectiveness of endosponge therapy for the management of presacral abscesses following rectal surgery. Tech Coloproctol 2019; 23:551-557. [PMID: 31338710 DOI: 10.1007/s10151-019-02007-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/13/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Anastomotic leak after rectal surgery is reported in 9% (range 3-28%) of patients. The aim of our study was to evaluate the effectiveness of endosponge therapy for anastomotic. Endpoints were the rate of restored continuity and the functional bowel outcome after anastomotic leakage. METHODS This was a multicenter retrospective observational cohort study. All patients with symptomatic anastomotic leakage after rectal surgery who had endosponge therapy between January 2012 and August 2017 were included. Functional bowel outcome was measured using the low anterior resection syndrome (LARS) score system. RESULTS Twenty patients were included. Eighteen patients had low anterior resection (90%) for rectal cancer. A diverting ileostomy was performed at primary surgical intervention in 14 patients (70%). Fourteen patients (70%) were treated with neoadjuvant (chemo-)radiotherapy. The median time between primary surgical intervention and first endosponge placement was 21 (5-537) days. The median number of endosponge changes was 9 (2-28). The success rate of the endosponge treatment was 88% and the restored gastrointestinal continuity rate was 73%. A chronic sinus occurred in three patients (15%). All patients developed LARS, of which 77% reported major LARS. CONCLUSIONS Endosponge therapy is an effective treatment for the closure of presacral cavities with high success rate and leading to restored gastrointestinal continuity in 73%. However, despite endosponge therapy many patients develop major LARS.
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16
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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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17
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Abstract
BACKGROUND Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage. OBJECTIVE There is an absence of further technical development of the standardized material from 2007 for the lower GI tract. MATERIAL AND METHODS New strategies and new materials for endoscopic vacuum therapy are presented. RESULTS Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects. CONCLUSION The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.
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18
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Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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19
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Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA. Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Affiliation(s)
- R E Clifford
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK.
| | - H Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - N Govindarajah
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - D Vimalachandran
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - P A Sutton
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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20
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Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2018; 3:153-160. [PMID: 30957061 PMCID: PMC6433422 DOI: 10.1002/bjs5.50124] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
Background Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. Methods A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. Results Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. Conclusion EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.
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Affiliation(s)
- M Shalaby
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of General Surgery Rome Tor Vergata University Rome Italy
| | - S Emile
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - H Elfeki
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of Surgery, Colorectal Surgery Unit Aarhus University Aarhus Denmark
| | - A Sakr
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - S D Wexner
- Department of Colorectal Surgery Cleveland Clinic Florida Weston Florida USA
| | - P Sileri
- Department of General Surgery Rome Tor Vergata University Rome Italy
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Sevim Y, Celik SU, Yavarifar H, Akyol C. Minimally invasive management of anastomotic leaks in colorectal surgery. World J Gastrointest Surg 2016; 8:621-626. [PMID: 27721925 PMCID: PMC5037335 DOI: 10.4240/wjgs.v8.i9.621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/06/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
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Aras A, Celik S, Kiziltan R, Yilmaz Ö, Kotan Ç. Successful Treatment of a Large Pelvic Abscess Using Intraluminal VAC: A Case Report. J Clin Diagn Res 2016; 10:PD19-20. [PMID: 27190889 DOI: 10.7860/jcdr/2016/18485.7659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 01/27/2016] [Indexed: 12/23/2022]
Abstract
The most feared complication of the surgical treatment of rectal cancer is anastomotic leakage, which is related to high rates of mortality and morbidity. Here, we present a patient who could not be treated with surgical drainage but treated by intraluminal Vacuum Associated Closure (VAC). A 34-year-old male patient was treated for rectal cancer by low anterior resection, colorectal anastomosis, and diverting ileostomy following neoadjuvant CRT. The patient reported with a postoperative anastomotic disruption and a large pelvic abscess. Due to the continuation of foul-smell drainage inspite of perianal incision and drainage, intraluminal VAC was applied and the pelvic abscess and the foul-smell were successfully treated. The presence of an adequate anal sphincter tonus is a disadvantage in anastomotic leakage, since it prevents the emptying of the intestinal content and also precludes the drainage of the pelvic abscess. The endoluminal application of VAC, similar to the results of application of VAC in open wounds, has been demonstrated to decrease fibrin and necrotic tissue in the pelvic cavity and increase granulation tissue. VAC, which has long been used in the treatment of open wounds, is a promising method in the treatment of large pelvic abscesses due to anastomotic leakage following rectum resection.
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Affiliation(s)
- Abbas Aras
- Assistant Professor, Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University , Van, Turkey
| | - Sebahattin Celik
- Assistant Professor, Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University , Van, Turkey
| | - Remzi Kiziltan
- Assistant Professor, Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University , Van, Turkey
| | - Özkan Yilmaz
- Assistant Professor, Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University , Van, Turkey
| | - Çetin Kotan
- Professor, Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University , Van, Turkey
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23
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Endoscopic vacuum-assisted closure system (E-VAC): case report and review of the literature. Wideochir Inne Tech Maloinwazyjne 2015; 10:299-310. [PMID: 26240633 PMCID: PMC4520842 DOI: 10.5114/wiitm.2015.52080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/15/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
Negative pressure wound therapy (NPWT) has become a standard in the treatment of chronic and difficult healing wounds. Negative pressure wound therapy is applied to the wound via a special vacuum-sealed sponge. Nowadays, the endoscopic vacuum-assisted wound closure system (E-VAC) has been proven to be an important alternative in patients with upper and lower intestinal leakage not responding to standard endoscopic and/or surgical treatment procedures. Endoscopic vacuum-assisted wound closure system provides perfect wound drainage and closure of various kinds of defect and promotes tissue granulation. Our experience has shown that E-VAC may significantly improve the morbidity and mortality rate. Moreover, E-VAC may be useful in a multidisciplinary approach - from upper gastrointestinal to rectal surgery complications. On the other hand, major limitations of the E-VAC system are the necessity of repeated endoscopic interventions and constant presence of well-trained staff. Further, large-cohort studies need to be performed to establish the applicability and effectiveness of E-VAC before routine widespread use can be recommended.
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Strangio G, Zullo A, Ferrara EC, Anderloni A, Carlino A, Jovani M, Ciscato C, Hassan C, Repici A. Endo-sponge therapy for management of anastomotic leakages after colorectal surgery: A case series and review of literature. Dig Liver Dis 2015; 47:465-9. [PMID: 25769505 DOI: 10.1016/j.dld.2015.02.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endo-sponge treatment is a novel approach to manage selected patients with anastomotic leakage following colorectal surgery. However, the available data are still scanty. AIMS To evaluate the efficacy and safety of the endo-sponge therapy in a large series, and to perform a review of the current evidence concerning such a treatment. METHODS Consecutive patients diagnosed with partial colonic anastomotic leakage managed with endo-sponge placement were enrolled. The endo-sponge system was changed every 48-72 h as outpatient, until to cavity closure. Literature review was performed for pooled-data analysis. RESULTS Twenty-five patients were enrolled, including 13 (52%) with diverting ileostomy. Following endo-sponge applications (median sessions: 9, range: 1-39; median treatment duration: 4 weeks, range: 1-32), a complete healing was achieved in 22 (88%) patients. Three (12%) patients developed a major complication (1 uretheric fistula, 1 ileal fistula, and 1 pararectal abscess), all successfully treated by surgery. Ileostomy closure was achieved in 11 (84.6%) patients. No mortality related to the procedure was observed. Overall, 174 patients treated with endo-sponge were reported in literature. By considering data of the larger 7 studies, a complete healing of presacral cavity was achieved in 131 (94.3%) out of 149 patients. CONCLUSIONS Our relatively large series of patients confirmed the efficacy, tolerability, and an acceptably low complication rate of endo-sponge therapy for colorectal anastomosis leakage treatment.
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Affiliation(s)
- Giuseppe Strangio
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Angelo Zullo
- Gastronterology and Digestive Endoscopy, 'Nuovo Regina Margherita' Hospital, Rome, Italy.
| | | | - Andrea Anderloni
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Alessandra Carlino
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Manol Jovani
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Camilla Ciscato
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Cesare Hassan
- Gastronterology and Digestive Endoscopy, 'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Alessandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
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Buxey K, Ranchod P. Transrectal negative pressure sponge treatment of full-thickness rectal perforation. ANZ J Surg 2014; 85:691-2. [PMID: 24456337 DOI: 10.1111/ans.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth Buxey
- General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Pravin Ranchod
- Department of Colorectal Surgery, Cabrini Medical Centre, Melbourne, Victoria, Australia
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26
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Gultekin FA, Bakkal BH, Tayfun S, Babuccu O, Comert M. Chronic pelvic abscedation after completion proctectomy in a rectal stump insufficiency; treatment with gracilis muscle flap following vacuum assisted closure therapy. Ann Coloproctol 2013; 29:172-6. [PMID: 24032119 PMCID: PMC3767868 DOI: 10.3393/ac.2013.29.4.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/05/2013] [Indexed: 12/12/2022] Open
Abstract
Presacral abscess formation due to rectal stump insufficiency following Hartmann procedure is very rare complication. If the abscess cavity is large, it might delay the reversal of the stoma and will probably result in a devastating future functioning of the neorectum. Moreover, very invasive treatments will be required in order to prevent severe septic complications. We present the case of a 58-year-old man with a past history of Hartmann procedure for a low rectal carcinoma who presented with rectal stump insufficiency and a large presacral abscess. Following extensive debridement and rectal stump resection, a vacuum-assisted closure (VAC) system was applied to the large abscess cavity to facilitate gracilis muscle flap reconstruction and to optimize wound healing. The satisfactory results showed in the present report led us to favor a combination of VAC therapy and a gracilis muscle flap in intrapelvic and perineal reconstruction in the case of large defects associated with high risks of septic complications.
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Affiliation(s)
- Fatma Ayca Gultekin
- Department of General Surgery, BulentEcevit University School of Medicine, Zonguldak, Turkey
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27
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Sloothaak DAM, Buskens CJ, Bemelman WA, Tanis PJ. Treatment of chronic presacral sinus after low anterior resection. Colorectal Dis 2013; 15:727-32. [PMID: 23216939 DOI: 10.1111/codi.12094] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 10/04/2012] [Indexed: 02/08/2023]
Abstract
AIM The aim of this retrospective study was to determine patient and treatment characteristics with corresponding clinical outcome of symptomatic chronic presacral sinus after low anterior resection. METHOD Twenty-two patients were treated for a presacral sinus persisting for at least 12 months after low anterior resection for rectal carcinoma between January 2005 and March 2012. Patient charts were reviewed and analysed using descriptive statistics. RESULTS Fistula formation was the most frequently observed secondary complication in 55% of patients. A median of 6 (1-44) surgical, endoscopic or radiological interventions related to the presacral sinus were performed. Overall, the chronic presacral sinus healed after multimodality treatment in nine (41%) patients at a median interval from primary surgery of 45 (24-93) months. If basic treatment principles were followed (anastomotic reconstruction or completion proctectomy with filling of the cavity), healing rate of the sinus was higher than where these principles were not adhered to (62% vs 11%). CONCLUSION Successful treatment of a chronic presacral sinus after low anterior resection appears to be achieved by salvage surgery with anastomotic reconstruction in highly selected patients or intersphincteric completion proctectomy and omentoplasty.
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Affiliation(s)
- D A M Sloothaak
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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28
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An initial experience using transanal vacuum therapy in pelvic anastomotic leakage. Tech Coloproctol 2012; 17:275-81. [PMID: 23111399 DOI: 10.1007/s10151-012-0911-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/30/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Treatment of the presacral cavity that forms after contained anastomotic leakage of a low pelvic anastomosis is challenging and often results in a permanent stoma. Endosponge™ therapy is a minimally invasive method of treating the presacral cavity which potentially avoids a permanent stoma. We report our initial experience of using Endosponge™ therapy. METHODS All patients who underwent Endosponge™ treatment for low pelvic anastomotic leakage in our hospital over a 45-month period were identified and data collected from clinical, operative and endoscopic notes. RESULTS Eight patients (seven males, one female) underwent Endosponge™ therapy for extraperitoneal pelvic anastomotic leak during the study period; all had had defunctioning ileostomies placed at their original surgery. Six out of eight patients had complete closure or a reduction in the size of the abscess cavity. Five patients have had their ileostomies reversed with good or reasonable bowel function after a median follow-up of 41 months and four of these patients had Endosponge™ therapy instituted within 6 weeks of initial surgery. One patient had Endosponge™ therapy abandoned and conversion to a permanent end colostomy after accidental intraperitoneal placement of the sponge. CONCLUSIONS Early use of Endosponge™ therapy appears to offer a minimally invasive and effective way of closing the presacral cavity after a pelvic anastomotic leak, reducing the risk of permanent stoma and resulting in acceptable bowel function. Endosponge™-specific complications can occur.
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Steinkamp M, Gress TM. Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum. Visc Med 2012. [DOI: 10.1159/000345837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.
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