Endoscopic vacuum therapy for postoperative GI fistula.
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ABSTRACT:
SUBMITTER: Funari MP
PROVIDER: S-EPMC7278024 | biostudies-literature | 2020 Jun
REPOSITORIES: biostudies-literature
Publications
Endoscopic vacuum therapy for postoperative GI fistula.
Funari Mateus Pereira MP Coutinho Neto Antonio Madruga AM Farias Galileu Ferreira Ayala GFA de Moura Eduardo Guimarães Hourneaux EGH Dos Santos Marcos Eduardo Lera MEL
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 20200512 6
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Project description:Background and study aims Endoscopic vacuum therapy (EVT) has become the most effective therapeutic option for upper gastrointestinal leakage. Despite its efficiency, this treatment can necessitate a long hospitalization. The aim of this study was to evaluate whether additional use of an over-the-scope-clips (OTSC) closure after successful EVT can shorten leakage therapy. Patients and methods All patients treated with EVT for leakages in the upper gastrointestinal tract at our center from 2012 to 2022 were divided into two propensity matched cohorts (EVT+OTSC vs. EVT only). The EVT+OTSC patients received OSTC application at the end of successful EVT directly after removal of the last sponge. The primary endpoint was the time interval from leakage diagnosis until discharge. Secondary endpoints included EVT efficacy, complications, and nutritional status at discharge. Results A total of 84 matched patients were analyzed. EVT efficacy was 100% in both groups. The time interval from leakage until discharge was significantly shorter in the EVT+OTSC vs. EVT group (33 [19-48] vs. 46 days [29-77] P = 0.004). No patient in the EVT+OTSC group required additional procedures for leakage management, whereas five (12%) in the EVT group needed additional stent placement ( P = 0.021). More patients could be discharged on sufficient oral nutrition in the EVT+OTSC group (98% vs. 60%; P < 0.001). Conclusions The addition of OTSCs after successful EVT is safe and has the potential to shorten leakage therapy, enabling earlier discharge along with better functional outcomes.
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Project description:An acquired esophago-respiratory fistula represents an abnormal connection between the esophagus and the respiratory system. It is usually caused by malignancy and infection, or it occurs as a complication after surgery or radiation therapy. It can be divided according to its anatomical level into esophago-tracheal fistula, esophago-bronchial fistula, and in the rarest case, esophago-pulmonary fistula (EPF). We present a case of EPF aggravating an anastomotic leak (AL) after the Ivor-Lewis operation for esophageal cancer. The leak was treated with endoscopic vacuum therapy (EVT) using the Eso-Sponge® system (B. Braun Melsungen AG, Melsungen, Germany). In the further course of treatment, an EPF was suspected by a new onset of severe cough after oral fluid intake. The suspicion was confirmed by injecting methylene blue dye into the paraesophageal-extraluminal cavity during endoscopy and attesting to its presence in the respiratory tract by simultaneous bronchoscopy. Furthermore, an oral contrast computed tomography scan showed the presence of contrast in the right lower lobe of the lung. This complication was treated conservatively with EVT and antibiotics. Nutrition was administered through the existing jejunostomy. Both fistulas and the paraesophageal cavity were fully healed, oral intake was maintained, and the patient was discharged. This rare life-threatening complication can be treated conservatively. Its management is challenging, controversial, and lacks a general consensus.
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Project description:Video 1Successful endoscopic management of a large esophageal defect due to Boerhaave syndrome with endoscopic vacuum therapy using EsoSponge and VACStent.
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Project description:Injuries to the esophageal wall, such as perforations and anastomotic leaks, are serious complications of surgical and endoscopic interventions. Since 2006, a new treatment has been introduced, in the form of endoscopically placed vacuum sponge therapy.Between April 2012 and October 2014, 10 patients (5 men and 5 women) aged 57 to 94 years were treated at our institution using endoscopic vacuum therapy (EVT) in the upper gastrointestinal tract.The defect in the esophageal wall was successfully closed in seven of the 10 patients (70 %). No severe complications occurred.EVT is a valuable tool for management of defects in the esophageal wall and should be considered as a treatment option for patients with this condition.
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Project description:This article provides a comprehensive review of the use of endoscopic vacuum therapy (EVT) in the management of transmural gastrointestinal (GI) defects (TGIDs) and its future perspectives, such as pre-emptive EVT and novel indications, including GI bleeding and large gastroduodenal ulcers management. This review is based on the available literature data and personal experience to demystify the mentioned limitations of EVT as technical difficulties related to the procedure, possible patients' complaints, and institutions' concerns, by sharing several tips and tricks to overcome EVT-related challenges that may discourage endoscopists from using this live-saving technique, and consequently, restricting patients to receive this therapy, which may lead to undesired outcomes. Several factors, such as placement techniques, EVT type selection, management during its use, EVT system exchanges, device removal, type of anesthesia, and how to avoid EVT-related adverse events are described in detail. Additionally, this review discusses good ways to promote effective communication with patients and relatives, surgeons, and multidisciplinary team. EVT possesses a unique mechanism of action including macro/micro deformation, changes in perfusion (stimulating angioneogenesis), exudate control, and bacterial clearance, promoting healing. EVT has an adequate safety profile and higher clinical success rate compared to any other endoscopic therapy for TGID. Additionally, pre-emptive EVT and its novel indications are promising due to its satisfactory effectiveness in initial studies. Therefore, detailing some practical solutions obtained by years of experience may collaborate to widespread EVT adoption, providing less-invasive treatment for several critical conditions to more patients worldwide.
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Project description:Background Recently, endoscopic vacuum therapy (EVT) was introduced as treatment for anastomotic leakage after upper gastrointestinal (GI) surgery. The aim of this study was to describe the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center.Methods Patients treated with EVT for anastomotic leakage after upper GI surgery were included retrospectively (January 2018-June 2021) and prospectively (June 2021-October 2021). The primary end point was the EVT success rate. Secondary end points included mortality and adverse events.Results 38 patients were included (31 men; mean age 66 years): 27 had undergone an esophagectomy with gastric conduit reconstruction and 11 a total gastrectomy with esophagojejunal anastomosis. EVT was successful in 28 patients (74 %, 95 %CI 57 %-87 %). In 10 patients, EVT failed: deceased owing to radiation pneumonitis (n = 1), EVT-associated complications (n = 2), and defect closure not achieved (n = 7). Mean duration of successful EVT was 33 days, with a median of six EVT-related endoscopies. Median hospital stay was 45 days.Conclusion This initial experience with EVT for anastomotic leakage after upper GI surgery demonstrated a success rate of 74 %. EVT is a promising therapy that could prevent further major surgery. More experience with the technique and its indications will likely improve success rates in the future.
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Project description:Video 1Endoscopic vacuum therapy for nonhealing cavity with fistulous tract after peroral endoscopic myotomy for Zenker diverticulum.
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Project description:IntroductionEndoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent.Patients and methodsThis prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events.ResultsIn total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed.ConclusionThe vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.
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Project description:Background and aimsTherapeutic endoscopy plays a major role in the management of postbariatric anastomotic leaks, offering an effective treatment alternative to repeated surgery. In recent years, management has been moving from bridging and closing the leak's orifice toward an approach that uses vacuum therapy or internal drainage. Our aim was to demonstrate different treatment options for the management of postbariatric leaks.MethodsWe describe 3 different endoscopic techniques for postbariatric leaks in 2 patients who had undergone Roux-en-Y gastric bypass (RYGB) and 1 patient who had undergone sleeve gastrectomy.ResultsThe first patient had a 20-mm early post-RYGB leak with an intra-abdominal associated collection treated with 5 sessions of endoscopic vacuum therapy (EVT). The second patient had a 12-mm acute postgastric sleeve leak with an associated collection, in whom therapy with EVT had failed, and who was then treated with endoscopic internal drainage (EID). The last patient had a chronic intra-abdominal collection after RYGB, despite reoperation, in whom therapy with EID and esophageal stent had failed, and who was treated with a diabolo-shaped lumen-apposing metal stent placed between the gastric pouch and the gastric remnant. Weight-loss intention was not compromised in any patient. All patients remain well.ConclusionsStaple-line or anastomotic leaks are an important cause of morbidity and mortality after surgery. There are myriad endoscopic techniques, with varying reported efficacy. Often, more than one endoscopic approach can be used concomitantly, whereas in other cases, therapies are applied sequentially depending on the initial clinical response. Multiple therapeutic options should be considered before endoscopic failure.
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