Endoluminal vacuum therapy for anastomotic insufficiency after gastrectomy

The reported incidence of anastomotic leaks is between 5 % and 25 %. Depending on the position and dimensions of the leaks, they are associated with a mortality of up to 60 % [1]. So far endoluminal vacuum therapy has mainly been used for treatment of anastomotic insufficiencies of the rectum [2]. Its use in the esophagus was first reported in 2007 and in only three more cases since then [3] [4] [5].

Here we report a case of a 67-year-old man who developed an anastomotic insufficiency following gastrectomy. Postoperatively, the patient presented a severely septic clinical picture and therefore surgical revision was impossible. He was ventilated and given antibiotics. On endoscopic examination 7 days after gastrectomy, a 1-cm leak covering 30 % of the anastomotic circumference was noted, with an abdominal fistula. We started endoluminal vacuum therapy by endoscopic insertion of the Endo-SPONGE system (B. Braun Melsungen AG, Melsungen, Germany; [Fig. 1]) into the esophagus. The Endo-SPONGE is an open-pored polyurethane sponge. Before insertion, we adjusted its size according to the local topography of the esophagus ([Fig. 2]). The sponge was placed via an overtube into the region of the anastomotic insufficiency at the distal end of the esophagus ([Fig. 3]). The suction tube was extended with a nasogastric tube and secretions were continuously evacuated with a suction of 13.3 kPa. Following daily suction of 200 – 400 mL of secretions, the patient's condition improved remarkably within a few days. We carried out the procedure for a total of 18 days, changing the Endo-SPONGE system every second or third day. The abdominal fistula underwent marked reduction and the anastomotic area epithelialized ([Fig. 4]). The leak was no longer detectable on radiographs and the patient recovered completely.

Fig. 1 The Endo-SPONGE system: the sponge and drain.

Fig. 2 Adjusting the sponge size.

Fig. 3 Endoscopic views at the start of the treatment showing: a the anastomotic leak; and b the abdominal cavity, seen through the fistula.

Fig. 4 View at completion of endoluminal vacuum therapy: a epithelialization of the abdominal fistula; and b the closed anastomotic leak.

In summary, endoluminal vacuum therapy offers an alternative method for the treatment of complicated anastomotic insufficiency following esophageal or gastric surgery.

Competing interests: None

Endoscopy_UCTN_Code_TTT_1AO_2AI

References

• 1 Messmann H, Schmidbaur W, Jäckle J. et al . Endoscopic and surgical management of leakage and mediastinitis after esophageal surgery.  Best Pract Res Clin Gastroenterol. 2004;  18 809-827
• 2 Weidenhagen R, Grützner K U, Kopp R. et al . Role of vacuum therapy in the management of the septic abdomen.  Zentralbl Chir. 2006;  131 115-119
• 3 Wallstabe I, Weimann A. Eine neue endoskopische Technik im Management der Anastomoseninsuffizienz nach Ösophaguschirurgie.  Z Gastroenterol. 2007;  45 K14
• 4 Wedemeyer J, Schneider A, Manns M P. et al . Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks.  Gastrointest Endosc. 2008;  67 708-711
• 5 Loske G, Müller C. Vacuum therapy of an esophageal anastomotic leakage-a case report.  Zentralbl Chir. 2009;  134 267-270