Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses

Background and study aims: A major leak from a rectal anastomosis is an important surgical complication. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD) is a new method for treating nonseptic major anastomotic leaks after extraperitoneal rectal anastomoses.

Patients and methods: Between January 2002 and March 2007 a total of 17 patients (mean age 61.2 years) who developed anastomotic leakage after resection of the rectum or rectosigmoid colon were prospectively evaluated. Their treatment began with endoscopic debridement of the leak/cavity; nylon sponges were then endoscopically fitted into the cavity. Continuous suction was applied via suction tubes inserted into the sponges. Repeat endoscopies and sponge exchanges, including further debridement were essential.

Results: In 16/17 patients ETVARD was successful, relieving patients quickly from infectious symptoms and other complaints; one patient eventually required a Hartmann’s procedure. Cavity sizes varied from 2 cm × 2 cm to 10 cm × 13 cm. The mean duration of drainage was 21.4 days, with a mean of 5.4 sponge exchanges and 10.7 endoscopies, and a mean total time to closure of the cavity of 53.1 days. The total time to closure of the cavity was directly dependent on the size of the cavity (P< 0.015). Fifteeen patients received additional intramural fibrin glue injections. In eight patients ETVARD was continued on an outpatient basis. There was no advantage demonstrated for patients with diverting loop ileostomies. Patients with anastomoses that were 6 cm or less from the anocutaneous line had considerably longer healing times. The healing time depended significantly on age (P< 0.036). Follow-up endoscopies have shown only minor anastomotic changes in two patients.

Conclusions: ETVARD is a well-tolerated and effective therapeutic option for the treatment of major leaks after extraperitoneal rectal anastomoses. In most cases ETVARD obviates the need for additional surgery, in particular diverting loop ileostomy.

References

• 1 Yeh C Y, Changchien C R, Wang J Y. et al . Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients.  Ann Surg. 2005;  241 9-13
• 2 Schmidt O, Merkel S, Hohenberger W. Anastomotic leakage after low rectal stapler anastomosis: significance of intraoperative anastomotic testing.  Eur J Surg Oncol. 2003;  29 239-243
• 3 Rullier E, Laurent C, Garrelon J L. et al . Risk factors for anastomotic leakage after resection of rectal cancer.  Br J Surg. 1998;  85 355-358
• 4 Matthiessen P, Hallbook O, Andersson M. et al . Risk factors for anastomotic leakage after anterior resection of the rectum.  Colorectal Dis. 2004;  6 462-469
• 5 Eckmann C, Kujath P, Schiedeck T H. et al . Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach.  Int J Colorectal Dis. 2004;  19 128-133
• 6 Lim M, Akhtar S, Sasapu K. et al . Clinical and subclinical leaks after low colorectal anastomosis: a clinical and radiologic study.  Dis Colon Rectum. 2006;  49 1611-1619
• 7 Giovannini M, Bories E, Moutardier V. et al . Drainage of deep pelvic abscesses using therapeutic echo endoscopy.  Endoscopy. 2003;  35 511-514
• 8 Weidenhagen R, Grützner U, Spelsberg F. et al .First results of a new method to treat anastomotic leakages following deep anterior resection of the rectum: the Endo-V.A.C. System. Congress of the German Society of Endoscopy and Imaging Procedure; 2002 March 14 - 16. Munich, Gemany. Stuttgart; Georg Thieme Verlag; Endoscopy Today 2002; abstracts, XXXII Available at: URL: http://www.thieme.de/abstracts/endoheute/abstracts2002
• 9 Sauer R, Becker H, Hohenberger W. et al . Preoperative versus postoperative chemoradiotherapy for rectal cancer.  N Engl J Med. 2004;  351 1731-1740
• 10 Eriksen M T, Wibe A, Norstein J. et al . Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients.  Colorectal Dis. 2005;  7 51-57
• 11 Branagan G, Finnis D. Prognosis after anastomotic leakage in colorectal surgery.  Dis Colon Rectum. 2005;  48 1021-1026
• 12 Doniec J M, Schniewind B, Kahlke V. et al . Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy.  Endoscopy. 2003;  35 652-658
• 13 Gelbmann C M, Ratiu N L, Rath H C. et al . Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.  Endoscopy. 2004;  36 695-699
• 14 Isbert C, Strauss M, Germer C T. Transanal management of complications after low anterior resection of the rectum: how can leakages and stenoses be dealt with? Proceedings of the 122nd Congress of the German Society of Surgery; 2005 April 5 - 8. Munich, Germany. Düsseldorf, Köln; German Medical Science 2005, Doc 05dgch2998 Available at: URL: http://www.egms.de/en/meetings/dgch2005/05dgch725.shtml
• 15 Testi W, Vernillo R, Spagnulo M. et al . Endoscopic treatment of intestinal anastomotic leakage in low anterior resection of the rectum by using fibrin adhesive: our experience.  Minerva Chir. 2002;  57 683-688
• 16 Rexer M, Ditterich D, Rupprecht H. V.a. C.-therapy in abdominal surgery: experiences, limits and indications.  Zentralbl Chir. 2004;  129 (Suppl 1) S27-S32
• 17 Hedrick T L, Sawyer R G, Foley E F. et al . Anastomotic leak and the loop ileostomy: friend or foe?.  Dis Colon Rectum. 2006;  49 1167-1176
• 18 Basilico V, Griffa B, Castiglione N. et al . Anastomotic fistulas after colorectal resection for carcinoma: incidence and treatment in our recent experience.  Minerva Chir. 2006;  61 373-380
• 19 Platell C, Barwood N, Dorfmann G. et al . The incidence of anastomotic leaks in patients undergoing colorectal surgery.  Colorectal Dis. 2007;  9 71-79
• 20 Bussen D, Sailer M, Fuchs K H. et al . A teaching model for endorectal ultrasound-guided biopsy and drainage of pararectal tumors.  Endoscopy. 2004;  36 217-219
• 21 Raijman I, Siemens M, Marcon N. Use of an expandable Ultraflex stent in the treatment of malignant rectal stricture.  Endoscopy. 1995;  27 273-276
• 22 Karliczek A, Jesus E C, Matos D. et al . Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis.  Colorectal Dis. 2006;  8 259-265
• 23 Wong N Y, Eu K W. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study.  Dis Colon Rectum. 2005;  48 2076-2079
• 24 Bell S W, Walker K G, Rickard M J. et al . Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence.  Br J Surg. 2003;  90 1261-1266
• 25 Chang S C, Lin J K, Yang S H. et al . Long-term outcome of anastomosis leakage after curative resection for mid and low rectal cancer.  Hepatogastroenterology. 2003;  50 1898-1902

1 These authors contributed equally to this work and share first authorship.