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

Eduardo Rodrigues-Pinto; Alessandro Repici; Gianfranco Donatelli; Guilherme Macedo; Jacques Devière; Jeanin E. van Hooft; Josemberg M. Campos; Manoel Galvao Neto; Marco Silva; Pierre Eisendrath; Vivek Kumbhari; Mouen A. Khashab

doi:10.1055/a-1005-6632

Endoscopy International Open, Table of Contents

CC BY-NC-ND 4.0 · Endosc Int Open 2019; 07(12): E1671-E1682
DOI: 10.1055/a-1005-6632

Original article

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

Eduardo Rodrigues-Pinto

¹Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal

,

Alessandro Repici

²Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan; Humanitas University, Rozzano, Milan, Italy

,

Gianfranco Donatelli

³Department of Gastroenterology and Hepatology, Hôpital Privé des Peupliers Paris, France

,

Guilherme Macedo

¹Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal

,

Jacques Devière

⁴Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium

,

Jeanin E. van Hooft

⁵Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands

,

Josemberg M. Campos

⁶Department of Surgery, University of Pernambuco, Recife, Pernambuco, Brazil

,

Manoel Galvao Neto

⁷Herbert Wertheim College of Medicine at Florida International University, Department of Surgery, Miami, Florida, United States

,

Marco Silva

¹Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal

,

Pierre Eisendrath

⁸Department of Gastroenterology & Hepatology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium

,

Vivek Kumbhari

⁹Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, United States

,

Mouen A. Khashab^*

⁹Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, United States

› Author Affiliations

Abstract

Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks.

Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks.

Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively.

Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

Full Text

References

References
1 Bemelman WA, Baron TH. Endoscopic management of transmural defects (leaks/perforations/fistulae). Gastroenterology 2018; 154: 1938-1946.e1
2 Rutegård M, Lagergren P, Rouvelas I. et al. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2012; 19: 99-103
3 Lang H, Piso P, Stukenborg C. et al. Management and results of proximal anastomotic leak in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000; 26: 168-71
4 Messager M, Warlaumont M, Renaud F. et al. Recent improvements in the management of esophageal anastomotic leak after surgery for cancer. Eur J Surg Oncol 2017; 43: 258-269
5 Blencowe NS, Strong S, McNair AG. et al. Reporting of short-term clinical outcomes after esophagectomy: a systematic review. Ann Surg 2012; 255: 658-66
6 Morales MP, Miedema BW, Scott JS. et al. Management of postsurgical leaks in the bariatric patient. Gastrointest Endosc Clin N Am 2011; 21: 295-304
7 Gonzalez R, Sarr MG, Smith CD. et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg 2007; 204: 47-55
8 Cho J, Sahakian AB. Endoscopic Closure of Gastrointestinal Fistulae and Leaks. Gastrointest Endosc Clin N Am 2018; 28: 233-249
9 Di Leo M, Maselli R, Ferrara EC. et al. Endoscopic management of benign esophageal ruptures and leaks. Curr Treat Options Gastroenterol 2017; 15: 268-284
10 Eisendrath P, Devière J. Digestive leaks: An approach tailored to both indication and anatomy. Endosc Int Open 2016; 4: E652-E653
11 Vargas EJ, Abu Dayyeh BK. Keep calm under pressure: a paradigm shift in managing postsurgical leaks. Gastrointest Endosc 2018; 87: 438-441
12 Rodrigues-Pinto E, Morais R, Macedo G. et al. Choosing the appropriate endoscopic armamentarium for treatment of anastomotic leaks. Am J Gastroenterol 2019; 114: 367-371
13 Bick BL, Imperiale TF, Johnson CS. et al. Endoscopic suturing of esophageal fully covered self-expanding metal stents reduces rates of stent migration. Gastrointest Endosc 2017; 86: 1015-1021
14 Kumbhari V, Cai JX, Schweitzer MA. Endoscopic management of bariatric surgical complications. Curr Opin Gastroenterol 2015; 31: 359-367
15 Kumbhari V, Abu Dayyeh BK. Keeping the fistula open: paradigm shift in the management of leaks after bariatric surgery?. Endoscopy 2016; 48: 789-791
16 Donatelli G, Dumont JL, Cereatti F. et al. Endoscopic internal drainage as first-line treatment for fistula following gastrointestinal surgery: a case series. Endosc Int Open 2016; 4: E647-E651

Supplementary Material

Supplementary material