Pre-emptive endoscopic vacuum therapy for treatment of anastomotic ischemia after esophageal resections

Abstract

Background and study aims Endoscopic vacuum therapy (EVT) is a promising new approach for the treatment of anastomotic leakage in the gastrointestinal tract. Here, we present the first case series demonstrating successful use of EVT for the treatment of post-esophagectomy anastomotic ischemia prior to development of leakage.

Patients and methods Between 2012 and 2015, intraluminal EVT was performed in eight patients with anastomotic ischemia following esophagectomy. The primary outcome measure was successful mucosal recovery. Secondary outcome measures were duration of treatment, number of sponge changes, septic course, and associated complications.

Results Complete mucosal recovery was achieved in six patients (75 %) with different degrees of anastomotic ischemia. In two patients (25 %), small anastomotic leaks developed, which resolved by continuing the EVT treatment. Median duration of EVT treatment until mucosal recovery was 16 days (range 6 – 35), with a median of 5 sponge changes per patient (range 2 – 11). No EVT-associated complications were noted. Three patients developed anastomotic stenoses, which were treated by endoscopic dilation therapy.

Conclusion This is the first case series to demonstrate that the early use of EVT potentially modulates clinical outcomes and infection parameters in patients with anastomotic ischemia following esophagectomy. Further studies are needed to define the indications and patients who are most likely to benefit from early EVT.

• References

• 1 Lang H. Piso P. Stukenborg C. et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000; 26: 168-171
• 2 Pennathur A. Luketich JD. Resection for esophageal cancer: strategies for optimal management. Ann Thorac Surg 2008; 85: S751-756
• 3 Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic complications following esophagectomy. Semin Thorac Cardiovasc Surg 2004; 16: 124-132
• 4 Kassis ES. Kosinski AS. Ross Jr P. et al. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 2013; 96: 1919-1926
• 5 Maish MS. DeMeester SR. Choustoulakis E. et al. The safety and usefulness of endoscopy for evaluation of the graft and anastomosis early after esophagectomy and reconstruction. Surg Endosc 2005; 19: 1093-1102
• 6 Briel JW. Tamhankar AP. Hagen JA. et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004; 198: 536-541
• 7 Schniewind B. Schafmayer C. Voehrs G. et al. Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study. Surg Endosc 2013; 27: 3883-3890
• 8 Mennigen R. Senninger N. Laukoetter MG. Novel treatment options for perforations of the upper gastrointestinal tract: endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20: 7767-7776
• 9 Schorsch T. Muller C. Loske G. Endoscopic vacuum therapy of anastomotic leakage and iatrogenic perforation in the esophagus. Surg Endosc 2013; 27: 2040-2045
• 10 Loske G. Schorsch T. Müller C. Endoscopic vacuum sponge therapy for esophageal defects. Surg Endosc 2010; 24: 2531-2535
• 11 Weidenhagen R. Hartl WH. Gruetzner KU. et al. Anastomotic leakage after esophageal resection: new treatment options by endoluminal vacuum therapy. Ann Thorac Surg 2010; 90: 1674-1681
• 12 Brangewitz M. Voigtlander T. Helfritz FA. et al. Endoscopic closure of esophageal intrathoracic leaks: stent versus endoscopic vacuum-assisted closure, a retrospective analysis. Endoscopy 2013; 45: 433-438
• 13 Bludau M. Holscher AH. Herbold T. et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted closure system (E-VAC). Surg Endosc 2014; 28: 896-901
• 14 Smallwood NR. Fleshman JW. Leeds SG. et al. The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations. Surg Endosc 2016; 30: 2473-2480
• 15 Kuehn F. Schiffmann L. Janisch F. et al. Surgical endoscopic vacuum therapy for defects of the upper gastrointestinal tract. J Gastrointest Surg 2016; 20: 237-243
• 16 Laukoetter MG. Mennigen R. Neumann PA. et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc 2016;
• 17 Mennigen R. Harting C. Lindner K. et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. J Gastrointest Surg 2015; 19: 1229-1235
• 18 Mennigen R. Senninger N. Laukoetter MG. Endoscopic vacuum therapy of esophageal anastomotic leakage. Gastrointest Endosc 2015; 82: 397
• 19 Loske G. Schorsch T. Schmidt-Seithe H. et al. Intraluminal endoscopic vacuum therapy in a case of ischemia of the blind end of the jejunal loop after Roux-en-Y gastrectomy. Endoscopy 2014; 46 (Suppl. 01) E575-576
• 20 Neumann PA. Laukoetter M. Mennigen R. et al. Solving a disaster following coronary bypass operation. Gut 2016; 65: 1601
• 21 Loske G. Aumiller J. Rucktaschel F. et al. Spontaneous perforation of an intramural esophageal pseudodiverticulosis treated with intraluminal endoscopic vacuum therapy using a double-lumen vacuum drainage with intestinal feeding tube. Endoscopy 2016; 48 (Suppl. 01) E154-155