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Ardila CM, González-Arroyave D, Ramírez-Arbeláez J. Comprehensive Umbrella Review of the Management of Esophageal Anastomotic Leaks. J Clin Med 2025; 14:2881. [PMID: 40363913 PMCID: PMC12072935 DOI: 10.3390/jcm14092881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2025] [Revised: 04/09/2025] [Accepted: 04/21/2025] [Indexed: 05/15/2025] Open
Abstract
Background/Objectives: Esophageal anastomotic leaks (EALs) are among the most feared complications following upper gastrointestinal surgery, particularly esophagectomy, given their profound impact on patient outcomes and healthcare resource utilization. This study aims to synthesize the evidence and determine the most effective interventions for achieving leak closure in patients with esophageal anastomotic leaks. Methods: This umbrella review followed PRISMA guidelines. A comprehensive search was conducted in PubMed, the Web of Science, Scopus, Google Scholar, Cochrane, and PROSPERO. Systematic reviews/meta-analyses on esophageal anastomotic leak management were included. The outcomes analyzed included leak closure success, mortality, complications, hospital stay, and costs. Data were synthesized narratively, with disagreements resolved by a third reviewer. Results: A systematic search identified 730 records, from which six systematic reviews and meta-analyses (evaluating 65 studies and 2186 patients) met the inclusion criteria. Most studies compared endoscopic vacuum therapy (EVT) and self-expanding metal stents (SEMSs) for EALs, with Germany contributing the majority. EVT consistently demonstrated superior leak closure rates and lower mortality compared to SEMSs, with pooled odds ratios favoring EVT. EVT also showed reduced complication rates, particularly fewer major adverse events, although with a slightly higher risk of post-therapy strictures. Hospital stay durations varied, with some studies reporting shorter treatment periods for EVT but no significant differences in the overall hospitalization length. Limited data suggested that EVT incurs higher treatment costs, largely due to intensive care unit stays. Conclusions: EVT is the most effective intervention for EALs, offering superior leak closure, lower mortality, and fewer complications. However, its economic impact requires further evaluation.
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Affiliation(s)
- Carlos M. Ardila
- Department of Periodontics, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University, Chennai 600077, India
- Biomedical Stomatology Research Group, Basic Sciences Department, Faculty of Dentistry Universidad de Antioquia U de A, Medellín 050010, Colombia
| | - Daniel González-Arroyave
- Department of Surgery, Faculty of Medicine, Pontificia Universidad Bolivariana, Medellín 050031, Colombia;
| | - Jaime Ramírez-Arbeláez
- Department of Transplantation, Hospital San Vicente Fundación, Rionegro 054047, Colombia;
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2
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Mucha AW, Strandby RB, Nerup NA, Achiam MP. Treatment of intrathoracic anastomotic leakage following esophagectomy for gastroesophageal cancer: a systematic review. Dis Esophagus 2025; 38:doaf016. [PMID: 40048658 DOI: 10.1093/dote/doaf016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 10/20/2024] [Accepted: 02/24/2025] [Indexed: 05/13/2025]
Abstract
Anastomotic leakage (AL) is a significant complication following esophagectomy. AL affects 8%-17% of patients and is associated with increased morbidity, mortality, and hospital stay. To this date, no consensus exists on the most optimal treatment. This systematic review aimed to determine the most effective treatment approach. A systematic search of Medline, Web of Science, Cochrane, Scopus, and Embase databases was conducted. Only studies reporting on the treatment of intrathoracic anastomotic leakage after esophagectomy with gastric conduit reconstruction for cancer were included. Studies investigating other esophageal disorders or failing to report the location of the anastomosis were excluded. The methodological quality and risk of bias were assessed using the Newcastle-Ottawa Scale for cohort studies. Out of 12,966 identified studies, 38 were included for analysis after removing duplicates and screening titles, abstracts, and full texts. Of these, five were found to be of poor methodological quality and 33 were of moderate quality. The most researched treatment methods were Endoluminal vacuum therapy (EVT), naso-fistula tube drainage (NFTD), and stent treatment. The success and mortality rates for EVT were 82% and 10.7%, for NFTD, 94% and 5.2%, and, for stent treatment, 75.1% and 13.5%, respectively. AL can be effectively treated with EVT, stent treatment, and NFTD. The NFTD approach appeared to have a higher success rate and lower mortality than other treatment modalities. However, it requires a longer treatment duration. Due to limitations within the included studies, a definitive recommendation regarding the optimal treatment for AL cannot be made.
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Affiliation(s)
- Andreas Weise Mucha
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Rune Broni Strandby
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Nikolaj Albeck Nerup
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Lushniak L, Dharmadhikari N, Zivari K, Reyes Genere JP, Kushnir V, Bazarbashi AN. Endoscopic Vacuum Therapy for the Treatment of Atrial Fibrillation Ablation-Induced Esophageal Perforation. ACG Case Rep J 2025; 12:e01650. [PMID: 40078483 PMCID: PMC11902978 DOI: 10.14309/crj.0000000000001650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2025] [Accepted: 02/18/2025] [Indexed: 03/14/2025] Open
Abstract
Esophageal thermal injury from atrial fibrillation ablation is not uncommon; however, full-thickness perforation is rare. Such injuries are often treated with surgical revision, stent placement, or medical management. Endoscopic vacuum therapy is a novel and emerging technique to repair transmural gastrointestinal defects; however, its use in the management of esophageal thermal ulceration and perforation after a cardiac ablation procedure is limited. We present a 52-year-old man who developed a refractory esophageal perforation and leak secondary to atrial fibrillation radiofrequency ablation that was successfully treated with endoscopic vacuum therapy, demonstrating a minimally invasive endoscopic treatment modality when alternative therapies fail.
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Affiliation(s)
- Larissa Lushniak
- Department of Internal Medicine, Duke University Medical Center, Durham, NC
| | - Neal Dharmadhikari
- Department of Medicine, Division of Gastroenterology & Hepatology, Barnes-Jewish Hospital/Washington University in St. Louis, St. Louis, MO
| | - Kaveh Zivari
- Department of Medicine, Division of Gastroenterology & Hepatology, Barnes-Jewish Hospital/Washington University in St. Louis, St. Louis, MO
| | - Juan Pablo Reyes Genere
- Department of Medicine, Division of Gastroenterology & Hepatology, Barnes-Jewish Hospital/Washington University in St. Louis, St. Louis, MO
| | - Vladimir Kushnir
- Department of Medicine, Division of Gastroenterology & Hepatology, Barnes-Jewish Hospital/Washington University in St. Louis, St. Louis, MO
| | - Ahmad Najdat Bazarbashi
- Department of Medicine, Division of Gastroenterology & Hepatology, Barnes-Jewish Hospital/Washington University in St. Louis, St. Louis, MO
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Nachira D, Calabrese G, Senatore A, Pontecorvi V, Kuzmych K, Belletatti C, Boskoski I, Meacci E, Biondi A, Raveglia F, Bove V, Congedo MT, Vita ML, Santoro G, Petracca Ciavarella L, Lococo F, Punzo G, Trivisonno A, Petrella F, Barbaro F, Spada C, D'Ugo D, Cioffi U, Margaritora S. How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience. World J Gastrointest Surg 2024; 16:3471-3483. [PMID: 39649190 PMCID: PMC11622094 DOI: 10.4240/wjgs.v16.i11.3471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 09/09/2024] [Accepted: 09/25/2024] [Indexed: 10/30/2024] Open
Abstract
BACKGROUND Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition. The optimal management strategy is still unclear. AIM To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks. METHODS A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023. Clinical outcomes were analyzed, and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus, when feasible. RESULTS Among the whole series of 60 patients, an urgent surgery was required in 8 cases due to a septic state. Fifty-six patients were managed by endoscopic or hybrid treatments, obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus. The mean time to resolution was 54.95 ± 52.64 days, with a median of 35.5 days. No severe complications were recorded. Ten patients out of 56 (17.9%) developed pneumonia that was treated by specific antibiotic therapy, and in 6 cases (10.7%) an atrial fibrillation was recorded. Seven patients (12.5%) developed a stricture within 12 months, requiring one or two endoscopic pneumatic dilations to solve the problem. Mortality was 1.7%. CONCLUSION A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.
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Affiliation(s)
- Dania Nachira
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Giuseppe Calabrese
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Alessia Senatore
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Khrystyna Kuzmych
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Claudia Belletatti
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Università Cattolica del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and Training, Rome 00168, Italy
| | - Elisa Meacci
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Alberto Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Rome 00168, Italy
| | - Federico Raveglia
- Department of Thoracic Surgery, IRCCS-San Gerardo dei Tintori, Monza 20900, Lombardy, Italy
| | - Vincenzo Bove
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Maria Teresa Congedo
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Maria Letizia Vita
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Gloria Santoro
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Rome 00168, Italy
| | - Leonardo Petracca Ciavarella
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Filippo Lococo
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Giovanni Punzo
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Lazio, Italy
| | - Angelo Trivisonno
- Department of Plastic Surgery, Assunzione di Maria Santissima Clinic, Rome 00135, Italy
| | - Francesco Petrella
- Department of Thoracic Surgery, IRCCS-San Gerardo dei Tintori, Monza 20900, Lombardy, Italy
| | - Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Domenico D'Ugo
- Department of Surgery, “Agostino Gemelli” University Hospital, Catholic University of Rome, Rome 00168, Italy
| | - Ugo Cioffi
- Department of Surgery, University of Milan, Milan 20122, Italy
| | - Stefano Margaritora
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
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Papadakos SP, Argyrou A, Katsaros I, Lekakis V, Mpouga G, Vergadis C, Fytili P, Koutsoumpas A, Schizas D. The Impact of EndoVAC in Addressing Post-Esophagectomy Anastomotic Leak in Esophageal Cancer Management. J Clin Med 2024; 13:7113. [PMID: 39685572 PMCID: PMC11642085 DOI: 10.3390/jcm13237113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Revised: 11/10/2024] [Accepted: 11/21/2024] [Indexed: 12/18/2024] Open
Abstract
Anastomotic leakage (AL) remains a major complication after esophagectomy, especially in patients with esophagogastric cancers who have undergone neoadjuvant therapies, which can impair tissue healing. Endoscopic vacuum-assisted closure (EndoVAC) is an innovative approach aimed at managing AL by facilitating wound drainage, reducing infection, and promoting granulation tissue formation, thus supporting effective healing. This review explores the role and effectiveness of EndoVAC in treating AL post-esophagectomy in esophageal cancer patients. We present an overview of its physiological principles, including wound contraction, enhanced tissue perfusion, and optimized microenvironment, which collectively accelerate wound closure. In addition, we examine clinical outcomes from recent studies, which indicate that EndoVAC is associated with improved leak resolution rates and potentially shorter hospital stays compared to traditional methods. Overall, this review highlights EndoVAC as a promising tool for AL management and underscores the need for continued investigation to refine its protocols and broaden its accessibility. By optimizing EndoVACs use, multidisciplinary teams can improve patient outcomes and advance esophageal cancer care.
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Affiliation(s)
- Stavros P. Papadakos
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Alexandra Argyrou
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece
| | - Vasileios Lekakis
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Georgia Mpouga
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | | | - Paraskevi Fytili
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Andreas Koutsoumpas
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece
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Fahrenkrog C, Miftode S, Al-Mawsheki A, Alfarawan F, Wilters S, Bockhorn M, El-Sourani N. Effect of Neoadjuvant Therapy on Endoluminal Vacuum-Assisted Closure Therapy (EVAC) for Anastomotic Leakage After Oesophagectomy. Cancers (Basel) 2024; 16:3597. [PMID: 39518039 PMCID: PMC11545023 DOI: 10.3390/cancers16213597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Revised: 10/20/2024] [Accepted: 10/23/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a dreaded complication after oesophagectomy. Endoluminal vacuum-assisted closure therapy (EVAC) has been increasingly used as a first-line treatment for AL. We aimed to identify any potential adverse effects of a neoadjuvant therapy (chemotherapy (CT) or radiochemotherapy (RCT)) on EVAC. METHODS We performed a retrospective cohort study at our tertiary centre between 2013 and 2024. All patients who underwent EVAC for AL after oesophagectomy were included in this study. Parameters such as success rate, length of therapy, number of sponges needed, changes in treatment, and survival were analysed. RESULTS A total of 29 patients were included, 19 of whom received CT/RCT and 10 of whom received no neoadjuvant treatment (NT). There was no significant difference in patient survival (30-day survival rate CT/RCT n = 1 (5.3%) vs. NT n = 1 (10%), p = 0.632), success rate (CT/RCT n = 15 (78.9%) vs. NT n = 9 (90%), p = 0.454), and length of therapy (CT/RCT vs. NT 24.11 vs. 23.8, p = 0.681), the number of sponges required (CT/RCT vs. NT 6.26 vs. 6.6, p = 0.835), and the need for changing treatment (CT/RCT n = 5 (26.3%) vs. NT n = 1 (10%), p = 0.303). CONCLUSIONS NT did not affect the success rate or length of therapy. Thus, we found no significant influence of CT/RCT on EVAC for AL after oesophagectomy.
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Affiliation(s)
- Catharina Fahrenkrog
- Universitätsmedizin Oldenburg, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
| | - Sorin Miftode
- Universitätsklinik für Allgemein-und Viszeralchirurgie, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Ahmed Al-Mawsheki
- Universitätsklinik für Allgemein-und Viszeralchirurgie, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Fadl Alfarawan
- Universitätsklinik für Allgemein-und Viszeralchirurgie, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Stella Wilters
- Universitätsmedizin Oldenburg, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
| | - Maximilian Bockhorn
- Universitätsmedizin Oldenburg, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
- Universitätsklinik für Allgemein-und Viszeralchirurgie, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Nader El-Sourani
- Universitätsmedizin Oldenburg, Carl von Ossietzky Universität Oldenburg, 26129 Oldenburg, Germany
- Klinik für Allgemein-, Viszeral-und Transplantationschirurgie, Universitätsklinikum Münster, 48149 Münster, Germany
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7
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Kollmann L, Weich A, Gruber M, Flemming S, Meining A, Germer CT, Lock JF, Seyfried F, Brand M, Reimer S. Additional over-the-scope-clip closure can shorten endoscopic vacuum therapy for postoperative upper gastrointestinal leakage. Endosc Int Open 2024; 12:E1023-E1028. [PMID: 39263560 PMCID: PMC11383616 DOI: 10.1055/a-2387-2054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/07/2024] [Indexed: 09/13/2024] Open
Abstract
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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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Alexander Weich
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Johann Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Markus Brand
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Stanislaus Reimer
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
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8
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Han S, Girotra M, Abdi M, Akshintala VS, Chen D, Chen YI, Das KK, Desilets DJ, Vinsard DG, Leung G, Mishra G, Muthusamy VR, Onyimba FU, Pawa S, Rustagi T, Sakaria S, Shahnavaz N, Law RJ. Endoscopic vacuum therapy. IGIE 2024; 3:333-341. [DOI: 10.1016/j.igie.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
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9
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Hauge T, Dretvik T, Johnson E, Mala T. Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center. Dis Esophagus 2024; 37:doae040. [PMID: 38745429 PMCID: PMC11360862 DOI: 10.1093/dote/doae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 04/13/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.
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Affiliation(s)
- Tobias Hauge
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Thomas Dretvik
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Egil Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
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Yohannes A, Knievel J, Lange J, Dormann AJ, Hügle U, Eisenberger CF, Heiss MM. VacStent as an Innovative Approach in the Treatment of Anastomotic Insufficiencies and Leakages in the Gastrointestinal Tract-Review and Outlook. Life (Basel) 2024; 14:821. [PMID: 39063574 PMCID: PMC11277949 DOI: 10.3390/life14070821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to prolonged hospitalization, serious tissue inflammation, and even sepsis, along with the need for recurrent surgery. Current non-surgical treatments such as self-expanding metal stents (SEMSs) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GITM (Möller Medical GmbH, Fulda, Germany), a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GITM application demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal promising and most importantly equally good outcomes while maintaining the possibility for sustained enteral nutrition and reducing the risk of stent migration. The VacStent GITM presents a promising alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and comprehensively establish its role in leak management. Further investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GITM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma.
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Affiliation(s)
- Alexander Yohannes
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Judith Knievel
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Jonas Lange
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Arno J. Dormann
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
| | - Ulrich Hügle
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
| | - Claus F. Eisenberger
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Markus M. Heiss
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
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11
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Kamarajah SK, Markar SR. Navigating complexities and considerations for suspected anastomotic leakage in the upper gastrointestinal tract: A state of the art review. Best Pract Res Clin Gastroenterol 2024; 70:101916. [PMID: 39053974 DOI: 10.1016/j.bpg.2024.101916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/02/2024] [Indexed: 07/27/2024]
Abstract
This state-of-the-art review explores the intricacies of anastomotic leaks following oesophagectomy and gastrectomy, crucial surgeries for globally increasing esophageal and gastric cancers. Despite advancements, anastomotic leaks occur in up to 30 % and 10 % of oesophagectomy and gastrectomy cases, respectively, leading to prolonged hospital stays, substantial impact upon short- and long-term health-related quality of life and greater mortality. Recognising factors contributing to leaks, including patient characteristics and surgical techniques, are vital for preoperative risk stratification. Diagnosis is challenging, involving clinical signs, biochemical markers, and various imaging modalities. Management strategies range from non-invasive approaches, including antibiotic therapy and nutritional support, to endoscopic interventions such as stent placement and emerging vacuum-assisted closure devices, and surgical interventions, necessitating timely recognition and tailored interventions. A step-up approach, beginning non-invasively and progressing based on treatment success, is more commonly advocated. This comprehensive review highlights the absence of standardised treatment algorithms, emphasizing the importance of individualised patient-specific management.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Global Health and Surgery, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Sheraz R Markar
- Surgical Intervention Trials Unit, Nuffield Department of Surgery, University of Oxford, United Kingdom.
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12
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de Oliveira AT, Barreira MA, da Cunha Parente Júnior JW, Junior JRLH, Ribeiro JBES, de Azevedo OGR, de Vasconcelos PRC. Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study. Surg Endosc 2024; 38:2142-2147. [PMID: 38448621 PMCID: PMC10978687 DOI: 10.1007/s00464-024-10755-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Traumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP. METHODS Retrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome. RESULTS Patients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant. CONCLUSION E-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.
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Affiliation(s)
- Alessandrino Terceiro de Oliveira
- Department of Digestive Endoscopy, Dr. José Frota Institute, Fortaleza, CE, Brazil.
- Department of Surgery, Federal University of Ceara, Fortaleza, CE, Brazil.
- Department of Digestive Endoscopy, General Hospital of Fortaleza, Fortaleza, CE, Brazil.
- Department of Surgery, Federal University of Ceara, 1608 N. Prof Costa Mendes St, 3rd Floor, Fortaleza, CE, 60416-200, Brazil.
| | - Márcio Alencar Barreira
- Department of Surgery, Federal University of Ceara, Fortaleza, CE, Brazil
- Department of Surgery, Dr. José Frota Institute, Fortaleza, CE, Brazil
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13
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Felinska EA, Studier-Fischer A, Özdemir B, Willuth E, Wise PA, Müller-Stich B, Nickel F. Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy. Surg Endosc 2024; 38:1422-1431. [PMID: 38180542 PMCID: PMC10881612 DOI: 10.1007/s00464-023-10647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. MATERIAL AND METHODS A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). RESULTS Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg. CONCLUSIONS EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.
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Affiliation(s)
- Eleni Amelia Felinska
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Berkin Özdemir
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Estelle Willuth
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philipp Anthony Wise
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clara Hospital Basel, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany.
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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14
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Yoshidome S, Sasaki K, Fumoto H, Tsuruda Y, Shimonosono M, Uchikado Y, Matsushita D, Arigami T, Baba K, Kurahara H, Ohtsuka T. Refractory esophageal-mediastinal fistula successfully treated with endoluminal vacuum therapy and enteral nutrition using a double-lumen elemental diet tube: a case report. GENERAL THORACIC AND CARDIOVASCULAR SURGERY CASES 2023; 2:103. [PMID: 39516953 PMCID: PMC11533645 DOI: 10.1186/s44215-023-00114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2024]
Abstract
BACKGROUND Aortic-esophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) has a high fatality rate and is difficult to treat. Endoluminal vacuum therapy (EVT) has recently appeared and proven to be a useful method for anastomotic leakage. CASE PRESENTATION A 76-year-old man underwent aortic arch replacement for a stent graft infection after TEVAR. Persistent mediastinitis and pyothorax were observed after aortic arch replacement, and further examination revealed an esophageal-mediastinal fistula (EMF). Over-the-scope clip (OTSC®) closure was performed to treat EMF but achieved no cure. Then, the patient was referred to our hospital. First, we removed the OTSC® that interfered with the treatment using the remOVE System® and started EVT using a double-lumen elemental diet tube (W-EDT®). The vacuum sponge was affixed to the vacuum side of W-EDT®, and enteral nutrition administered through W-EDT was combined with EVT. EMF was cured 11 days after EVT, and the patient was able to feed himself. CONCLUSION The combination of EVT and enteral nutrition feeding using W-EDT® is a successful novel procedure to treat refractory EMF.
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Affiliation(s)
- Shizuka Yoshidome
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan.
| | - Hideyuki Fumoto
- Department of Cardiovascular Surgery, Ohsumi Kanoya Hospital, 6081-1 Shinkawa-Machi, Kanoya-Shi, Kagoshima, 893-0015, Japan
| | - Yusuke Tsuruda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Masataka Shimonosono
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Daisuke Matsushita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Kenji Baba
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
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15
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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16
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Momblan D, Gimeno Garcia AZ, Busquets D, Juzgado D, García Lledó J, Ferrero E, Tejedor-Tejada J, Junquera F, Díaz-Tasende J, Moris M, Rodriguez de Santiago E, Gornals J, Garrido C, Gonzalez-Vazquez S, Guarner-Argente C, Repiso A, Esteban JM, Loras C, Seoane A, Fernández-Simon A, Guevara HC, Ibarzabal A, Morales X, Curell A, Cardenas A, Ríos J, de Lacy AM, Sendino O. Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry. Am J Gastroenterol 2023; 118:1797-1806. [PMID: 37606066 DOI: 10.14309/ajg.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.
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Affiliation(s)
- Dulce Momblan
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antonio Z Gimeno Garcia
- Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - David Busquets
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Diego Juzgado
- Department of Gastroenterology, Hospital Quirón Madrid, Madrid, Spain
| | - Javier García Lledó
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Esther Ferrero
- Department of General and Digestive Surgery, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | | | - Félix Junquera
- Department of Gastroenterology, Hospital de Sabadell, Institut d´Investigació i Innovació Parc Taulí I3PT, CIBERehd, Sabadell, Spain
| | - José Díaz-Tasende
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Moris
- Department of Gastroenterology and Hepatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, IRYCIS, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Joan Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carmen Garrido
- Endoscopy Unit, Department of Gastroenterology, Son Espases University Hospital, Illes Balears, Spain
| | | | | | - Alejandro Repiso
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Jose Miguel Esteban
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Agustín Seoane
- Department of Gastroenterology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Henry Cordova Guevara
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ainitze Ibarzabal
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Xavier Morales
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Curell
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrés Cardenas
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Ríos
- Department of Clinical Farmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Maria de Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
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Aiolfi A, Griffiths EA, Sozzi A, Manara M, Bonitta G, Bonavina L, Bona D. Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination. Ann Surg Oncol 2023; 30:5564-5572. [PMID: 37210447 DOI: 10.1245/s10434-023-13670-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. RESULTS Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31). CONCLUSIONS This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
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18
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:19-34. [PMID: 37818397 PMCID: PMC10561327 DOI: 10.1159/000527202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/22/2022] [Indexed: 10/12/2023]
Abstract
Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Monique Barakat
- Division of Gastroenterology, Stanford University, Stanford, California, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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19
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Mandarino FV, Barchi A, Leone L, Fanti L, Azzolini F, Viale E, Esposito D, Salmeri N, Puccetti F, Barbieri L, Cossu A, Treppiedi E, Elmore U, Rosati R, Danese S. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc 2023; 37:7039-7050. [PMID: 37353654 DOI: 10.1007/s00464-023-10213-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Management of anastomotic leaks after Ivor-Lewis esophagectomy remains a challenge. Although intracavitary endoscopic vacuum therapy (EVT) has shown great efficacy for large dehiscences, the optimal management of smaller leaks has not been standardized. This study aims to compare EVT versus self-expandable metal stent (SEMS) in the treatment of leaks < 30 mm in size, due to the lack of current data on this topic. METHODS Patients undergoing EVT (cases) or SEMS (controls) between May 2017 and July 2022 for anastomotic leaks < 3 cm following oncologic Ivor-Lewis esophagectomy were enrolled. Controls were matched in a 1:1 ratio based on age (± 3 years), BMI (± 3 kg/m2) and leak size (± 4 mm). RESULTS Cases (n = 22) and controls (n = 22) showed no difference in baseline characteristics and leak size, as per matching at enrollment. No differences were detected between the two groups in terms of time from surgery to endoscopic treatment (p = 0.11) or total number of procedures per patient (p = 0.05). Remarkably, the two groups showed comparable results in terms of leaks resolution (90.9% vs. 72.7%, p = 0.11). The number of procedures per patient was not significant between the two cohorts (p = 0.05). The most frequent complication in the SEMS group was migration (15.3% of procedures). CONCLUSION EVT and SEMS seem to have similar efficacy outcomes in the treatment of anastomotic defects < 30 mm after Ivor-Lewis esophagectomy. However, larger studies are needed to corroborate these findings.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy.
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorenzo Leone
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorella Fanti
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Edi Viale
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Dario Esposito
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Noemi Salmeri
- Department of Gynecology/Obstetrics Unit, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Puccetti
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lavinia Barbieri
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Andrea Cossu
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Elio Treppiedi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
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20
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Kollmann L, Reimer S, Lock JF, Flemming I, Widder A, May J, Krietenstein L, Gruber M, Meining A, Hankir M, Germer CT, Seyfried F. Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience. Surg Obes Relat Dis 2023; 19:1041-1048. [PMID: 36948972 DOI: 10.1016/j.soard.2023.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/04/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery. OBJECTIVE The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed. SETTING This study was performed at a tertiary clinic and certified center of reference for bariatric surgery. METHODS In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay. RESULTS A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015). CONCLUSIONS EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stanislaus Reimer
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ilona Flemming
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Anna Widder
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jana May
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Laura Krietenstein
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
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21
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Le KHN, Kim KY, Skinner MJ. Management of a gastric pouch staple-line leak and its adverse events with multimodal endoscopic techniques including endoscopic vacuum therapy. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:342-347. [PMID: 37719947 PMCID: PMC10500158 DOI: 10.1016/j.vgie.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Video 1Management of a gastric pouch staple-line leak and its adverse events with multimodal endoscopic techniques including endoscopic vacuum therapy.
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Affiliation(s)
| | - Ki-Yoon Kim
- Division of Gastroenterology/Hepatology and Therapeutic Endoscopy, Scripps Clinic, La Jolla, California
| | - Matthew J Skinner
- Division of Gastroenterology/Hepatology and Therapeutic Endoscopy, Scripps Clinic, La Jolla, California
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22
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Fuentes KMI, Seastedt KP, Kidane B, Servais EL. Advanced Endoscopy for Thoracic Surgeons. Thorac Surg Clin 2023; 33:251-263. [PMID: 37414481 DOI: 10.1016/j.thorsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.
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Affiliation(s)
- Kathleen M I Fuentes
- Department of General Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Kenneth P Seastedt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Room GE-611, 820 Sherbook Street, Winnipeg, Manitoba R3A 1R9, Canada
| | - Elliot L Servais
- Division of Thoracic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
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23
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Ding X, Zhang C, Li X, Liu T, Ma Y, Yin M, Li C, Zhou G, Wu G. The three-tube method via precise interventional placement for esophagojejunal anastomotic fistula after gastrectomy: a single-center experience. World J Surg Oncol 2023; 21:236. [PMID: 37528403 PMCID: PMC10391983 DOI: 10.1186/s12957-023-03105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Esophagojejunal anastomotic leakage is a serious complication after total gastrectomy. This study evaluated the safety and efficacy of transnasal placement of drainage catheter, jejunal decompression tube, and jejunal nutrition tube under fluoroscopy for treatment of esophagojejunal anastomotic fistula after gastrectomy in gastric cancer patients. METHODS This is retrospective review of patients with esophagojejunal anastomotic fistula treated with transnasal placement of abscess drainage catheter, decompression tube, and jejunal nutrition tube under fluoroscopy. Fistula healing time, patient survival, and Eastern Cooperative Oncology Group (ECOG) performance status before and after treatment were evaluated. RESULTS Sixty-four patients were included in the study. Insertion of the transnasal abscess drainage catheter, decompression tube, and jejunal nutrition tube was successful on the first attempt in all patients, while 35 patients received transnasal abscess drainage, 13 received percutaneous abscess drainage, and 16 received transnasal drainage plus percutaneous abscess drainage. Immediately after placement of the tube, the mean volume of drainage was 180 mL (range, 10-850 mL); the amount steadily decreased from then on. The clinical success rate was 84.3% (54/64). Median time to fistula healing was 58 days (range, 7-357 days). CONCLUSIONS Transnasal insertion of transnasal abscess drainage catheter, jejunal decompression tube, and jejunal nutrition tube under fluoroscopy appears to be a simple, minimally invasive, effective, and safe method for treating esophagojejunal anastomotic fistula after gastrectomy.
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Affiliation(s)
- Xiaolong Ding
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Chenchen Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Xiaobing Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Tao Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yaozhen Ma
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Meipan Yin
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Chunxia Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Gang Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Gang Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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24
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Kouladouros K. Applications of endoscopic vacuum therapy in the upper gastrointestinal tract. World J Gastrointest Endosc 2023; 15:420-433. [PMID: 37397978 PMCID: PMC10308278 DOI: 10.4253/wjge.v15.i6.420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the "piggyback" technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Surgical Clinic, Mannheim University Hospital, University of Heidelberg, Mannheim 68167, Baden-Wuerttemberg, Germany
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25
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Ubels S, Verstegen MHP, Klarenbeek BR, Bouwense S, van Berge Henegouwen MI, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Nieuwenhuijzen G, Polat F, Schouten J, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Treatment of anastomotic leak after oesophagectomy for oesophageal cancer: large, collaborative, observational TENTACLE cohort study. Br J Surg 2023; 110:852-863. [PMID: 37196149 PMCID: PMC10364505 DOI: 10.1093/bjs/znad123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/16/2023] [Accepted: 04/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Anastomotic leak is a severe complication after oesophagectomy. Anastomotic leak has diverse clinical manifestations and the optimal treatment strategy is unknown. The aim of this study was to assess the efficacy of treatment strategies for different manifestations of anastomotic leak after oesophagectomy. METHODS A retrospective cohort study was performed in 71 centres worldwide and included patients with anastomotic leak after oesophagectomy (2011-2019). Different primary treatment strategies were compared for three different anastomotic leak manifestations: interventional versus supportive-only treatment for local manifestations (that is no intrathoracic collections; well perfused conduit); drainage and defect closure versus drainage only for intrathoracic manifestations; and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis. The primary outcome was 90-day mortality. Propensity score matching was performed to adjust for confounders. RESULTS Of 1508 patients with anastomotic leak, 28.2 per cent (425 patients) had local manifestations, 36.3 per cent (548 patients) had intrathoracic manifestations, 9.6 per cent (145 patients) had conduit ischaemia/necrosis, 17.5 per cent (264 patients) were allocated after multiple imputation, and 8.4 per cent (126 patients) were excluded. After propensity score matching, no statistically significant differences in 90-day mortality were found regarding interventional versus supportive-only treatment for local manifestations (risk difference 3.2 per cent, 95 per cent c.i. -1.8 to 8.2 per cent), drainage and defect closure versus drainage only for intrathoracic manifestations (risk difference 5.8 per cent, 95 per cent c.i. -1.2 to 12.8 per cent), and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis (risk difference 0.1 per cent, 95 per cent c.i. -21.4 to 1.6 per cent). In general, less morbidity was found after less extensive primary treatment strategies. CONCLUSION Less extensive primary treatment of anastomotic leak was associated with less morbidity. A less extensive primary treatment approach may potentially be considered for anastomotic leak. Future studies are needed to confirm current findings and guide optimal treatment of anastomotic leak after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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26
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Azevedo I, Ortigão R, Pimentel-Nunes P, Bastos P, Silva R, Dinis-Ribeiro M, Libânio D. Anastomotic Leakages after Surgery for Gastroesophageal Cancer: A Systematic Review and Meta-Analysis on Endoscopic versus Surgical Management. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:192-203. [PMID: 37387719 PMCID: PMC10305273 DOI: 10.1159/000527769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/11/2022] [Indexed: 04/11/2025]
Abstract
INTRODUCTION With the increase of esophageal and gastric cancer, surgery will be more often performed. Anastomotic leakage (AL) is one of the most feared postoperative complications of gastroesophageal surgery. It can be managed by conservative, endoscopic (such as endoscopic vacuum therapy and stenting), or surgical methods, but optimal treatment remains controversial. The aim of our meta-analysis was to compare (a) endoscopic and surgical interventions and (b) different endoscopic treatments for AL following gastroesophageal cancer surgery. METHODS Systematic review and meta-analysis, with search in three online databases for studies evaluating surgical and endoscopic treatments for AL following gastroesophageal cancer surgery. RESULTS A total of 32 studies comprising 1,080 patients were included. Compared with surgical intervention, endoscopic treatment presented similar clinical success, hospital length of stay, and intensive care unit length of stay, but lower in-hospital mortality (6.4% [95% CI: 3.8-9.6%] vs. 35.8% [95% CI: 23.9-48.5%]. Endoscopic vacuum therapy was associated with a lower rate of complications (OR 0.348 [95% CI: 0.127-0.954]), shorter ICU length of stay (mean difference -14.77 days [95% CI: -26.57 to -2.98]), and time until AL resolution (17.6 days [95% CI: 14.1-21.2] vs. 39.4 days [95% CI: 27.0-51.8]) when compared with stenting, but there were no significant differences in terms of clinical success, mortality, reinterventions, or hospital length of stay. CONCLUSIONS Endoscopic treatment, in particular endoscopic vacuum therapy, seems safer and more effective when compared with surgery. However, more robust comparative studies are needed, especially for clarifying which is the best treatment in specific situations (according to patient and leak characteristics).
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Affiliation(s)
- Isabel Azevedo
- MEDCIDS - Departamento de Medicina da Comunidade, Informação e Decisão em Saúde/CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Raquel Ortigão
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Pedro Bastos
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Rui Silva
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- MEDCIDS - Departamento de Medicina da Comunidade, Informação e Decisão em Saúde/CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Diogo Libânio
- MEDCIDS - Departamento de Medicina da Comunidade, Informação e Decisão em Saúde/CINTESIS (Center for Health Technology and Services Research), Faculty of Medicine, University of Porto, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
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Lange J, Knievel J, Wichmann D, Kähler G, Wiedbrauck F, Hellmich T, Kandler M, Bernhardt J, Scholz D, Beyna T, Hausmann J, Wedi E, Ellrichmann M, Hügle U, Dormann AJ, Eisenberger CF, Heiss MM. Clinical implantation of 92 VACStents in the upper gastrointestinal tract of 50 patients-applicability and safety analysis of an innovative endoscopic concept. Front Surg 2023; 10:1182094. [PMID: 37215348 PMCID: PMC10198570 DOI: 10.3389/fsurg.2023.1182094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Endoscopic vacuum therapy (EVT) has emerged as a promising treatment option for upper gastrointestinal wall defects, offering benefits such as evacuation of secretions and removal of wound debris by suction, and reduction and healing of wound cavities to improve clinical outcomes. In contrast, covered stents have a high rate of migration and lack functional drainage, while endoluminal EVT devices obstruct the GI tract. The VACStent is a novel device that combines the benefits of EVT and stent placement. Its design features a fully covered Nitinol-stent within a polyurethane sponge cylinder, enabling EVT while maintaining stent patency. Methods This study analyzes the pooled data from three different prospective study cohorts to assess the safe practicality of VACStent placement, complete leak coverage, and effective suction-treatment of esophageal leaks. By pooling the data, the study aims to provide a broader base for analysis. Results In total, trans-nasal derivation of the catheter, suction and drainage of secretion via vacuum pump were performed without any adversity. In the pooled study cohort of 92 VACStent applications, the mean stent indwelling time was 5.2 days (range 2-8 days) without any dislocation of the device. Removal of the VACStent was done without complication, in one case the sponge was lost but subsequently fully preserved. Minor local erosions and bleeding and one subsequent hemostasis were recorded unfrequently during withdrawal of the device (5.4%, 5/92) but no perforation or pressure ulcer. Despite a high heterogeneity regarding primary disease and pretreatments a cure rate of 76% (38/50 patients) could be achieved. Discussion In summary, insertion and release procedure was regarded as easy and simple with a low potential of dislocation. The VACStent was well tolerated by the patient while keeping the drainage function of the sponge achieving directly a wound closure by continuous suction and improving the healing process. The implantation of the VACStent provides a promising new procedure for improved clinical treatment in various indications of the upper gastrointestinal wall, which should be validated in larger clinical studies.Clinical Trial Registration: Identifier [DRKS00016048 and NCT04884334].
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Affiliation(s)
- J. Lange
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - J. Knievel
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - D. Wichmann
- Department for Visceral, General and Transplant Surgery, Tübingen University Hospital, Tübingen, Germany
| | - G. Kähler
- Multispecialty Endoscopy Center, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany
| | - F. Wiedbrauck
- Department of Gastroenterology, AKH Celle, Celle, Germany
| | - T. Hellmich
- Department of Gastroenterology, Städtisches Klinikum Dresden, Dresden, Germany
| | - M. Kandler
- Department of Gastroenterology, Städtisches Klinikum Dresden, Dresden, Germany
| | - J. Bernhardt
- Department of Surgery, Klinikum Suedstadt Rostock, Rostock, Germany
| | - D. Scholz
- Department of Gastroenterology and Metabolism, Ameos Klinikum Am Bürgerpark, Bremerhaven, Germany
| | - T. Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - J. Hausmann
- Department of Gastroenterology/Internal Medicine, St. Vinzenz-Hospital Hanau, Hanau, Germany
| | - E. Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - M. Ellrichmann
- Department of Interdisciplinary Endoscopy, Medical Department 1, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - U. Hügle
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - A. J. Dormann
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - C. F. Eisenberger
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - M. M. Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
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Rosianu CG, Hoara P, Achim F, Birla R, Bolocan A, Mohssen A, Copca N, Constantinoiu S. The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review. Life (Basel) 2023; 13:life13040966. [PMID: 37109495 PMCID: PMC10144597 DOI: 10.3390/life13040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.
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Affiliation(s)
- Cristian Gelu Rosianu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Petre Hoara
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Florin Achim
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Rodica Birla
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Alexandra Bolocan
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ahmed Mohssen
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Narcis Copca
- Second Department of Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
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29
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Current Issues and Future Technologies in Esophageal Cancer Surgery. J Clin Med 2022; 12:jcm12010209. [PMID: 36615010 PMCID: PMC9821094 DOI: 10.3390/jcm12010209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022] Open
Abstract
Gastrointestinal surgery has evolved rapidly in recent years, with laparoscopic techniques being implemented as the standard procedure and robotic surgery becoming increasingly important [...].
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30
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Hua F, Sun D, Zhao X, Song X, Yang W. Update on therapeutic strategy for esophageal anastomotic leak: A systematic literature review. Thorac Cancer 2022; 14:339-347. [PMID: 36524684 PMCID: PMC9891862 DOI: 10.1111/1759-7714.14734] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
Anastomotic leak is still a severe complication in esophageal surgery due to high mortality. This article reviews the updates on the treatment of anastomotic leak after esophagectomy in order to provide reference for clinical treatment and research. The relevant studies published in the Chinese Zhiwang, Wanfang, and MEDLINE databases to December 21, 2021 were retrieved, and esophageal carcinoma, esophagectomy, anastomotic leakage, and fistula selected as the keywords. A total of 78 studies were finally included. The treatments include traditional surgical drainage, new reverse drainage trans-fistula, stent plugging, endoscopic clamping, biological protein glue injection plugging, endoluminal vacuum therapy (EVT), and reoperation, etc. Early diagnosis, accurate classification and optimal treatment can promote the rapid healing of anastomotic leaks. EVT may be the most valuable approach, simultaneously with good commercial prospects. Reoperation should be considered in patients with complex fistula in which conservative treatment is insufficient or has failed.
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Affiliation(s)
- Feng Hua
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Dongfeng Sun
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xiaoming Zhao
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xuemin Song
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Wenfeng Yang
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
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31
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Simas de Lima M, Uemura RS, Gusmon-Oliveira CC, Pombo AADM, Martins BC, Lenz L, Kawaguti FS, De Paulo GA, Baba ER, Safatle-Ribeiro AV, Ribeiro U, Monkemüller K, Maluf-Filho F. Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations. Endoscopy 2022; 54:980-986. [PMID: 35378562 DOI: 10.1055/a-1774-4630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND : Although endoscopic vacuum therapy (EVT) has been successfully used to treat postoperative upper gastrointestinal (UGI) wall defects, its use demands special materials and several endoscopic treatment sessions. Herein, we propose a technical modification of EVT using a double tube (tube-in-tube drain) without polyurethane sponges for the drainage element. The tube-in-tube drainage device enables irrigation and application of suction. A flowchart for standardizing the management of postoperative UGI wall defects with this device is presented. METHODS : An EVT modification was made to achieve frequent fistula cleansing, with 3 % hydrogen peroxide rinsing, and the application of negative pressure. A tube-in-tube drain without polyurethane sponges can be inserted like a nasogastric tube or passed through a previously positioned surgical drain. This was a retrospective two-center observational study, with data collected from 30 consecutive patients. Technical success, clinical success, adverse events, time under therapy, interval time from procedure to fistula diagnosis and treatment start, size of transmural defect, volume of cavity, number of endoscopic treatment sessions, and mortality were reviewed. RESULTS : 30 patients with UGI wall defects were treated. The technical and clinical success rates were 100 % and 86.7 %, respectively. Three patients (10 %) had adverse events and three patients (10 %) died. The median time under therapy was of 19 days (range 1-70) and the median number of endoscopic sessions was 3 (range 1-9). CONCLUSIONS : This standardized approach and EVT modification using a tube-in-tube drain, with frequent fistula cleansing, were successful and safe in a wide variety of UGI wall defects.
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Affiliation(s)
- Marcelo Simas de Lima
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ricardo Sato Uemura
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carla Cristina Gusmon-Oliveira
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Amanda Aquino de Miranda Pombo
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruno Costa Martins
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luciano Lenz
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fabio Shiguehissa Kawaguti
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gustavo Andrade De Paulo
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Elisa Ryoka Baba
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Adriana V Safatle-Ribeiro
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Klaus Monkemüller
- Division of Gastroenterology, University Teaching Hospital Ameos Klinikum, Halberstadt, Germany
| | - Fauze Maluf-Filho
- Department of Gastroenterology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Seika P, Biebl M, Raakow J, Berndt N, Feldbrügge L, Maurer MM, Dobrindt E, Thuss-Patience P, Pratschke J, Denecke C. The Association between Neoadjuvant Radio-Chemotherapy and Prolonged Healing of Anastomotic Leakage after Esophageal Resection Treated with EndoVAC Therapy. J Clin Med 2022; 11:jcm11164773. [PMID: 36013012 PMCID: PMC9410280 DOI: 10.3390/jcm11164773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 12/24/2022] Open
Abstract
(1) Background: Endoscopic vacuum therapy (EVT) has become the mainstay in the treatment of early anastomotic leakage (AL) after esophageal resection. The effect of nRCT on the efficacy of EVT is currently unknown. (2) Methods: Data of 427 consecutive patients undergoing minimally invasive esophagectomy between 2013 and 2022 were analyzed. A total of 26 patients received EVT for AL after esophagectomy between 2010 and 2021. We compared a cohort of 13 patients after treatment with EVT for anastomotic leakage after neoadjuvant radiochemotherapy (nRCT) with a control group of 13 patients after neoadjuvant chemotherapy (nCT) using inverse propensity score weighting to adjust for baseline characteristics between the groups. EVT therapy was assessed regarding patient survival, treatment failure as defined by a change in treatment to stent/operation, duration of treatment, and secondary complications. Statistical analysis was performed using linear regression analysis. (3) Results: Time to EVT after initial tumor resection did not vary between the groups. The duration of EVT was longer in patients after nRCT (14.69 days vs. 20.85 days, p = 0.002) with significantly more interventions (4.38 vs. 6.85, p = 0.001). The success rate of EVT did not differ between the two groups (nCT n = 8 (61.54%) vs. nCT n = 5 (38.46%), p = 0.628). The rate of operative revision did not vary between the groups. Importantly, no mortality was reported within 30 days and 90 days in both groups. (4) Conclusions: EVT is a valuable tool for the management of AL after esophageal resection in patients after nRCT. While the success rates were comparable, EVT was associated with a significantly longer treatment duration. Anastomotic leakages after nRCT often require prolonged and multimodal treatment strategies while innovative strategies such as prophylactic endoVAC placement or use of a VAC-Stent may be considered.
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Affiliation(s)
- Philippa Seika
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Surgery, Division of Surgical Sciences, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Matthias Biebl
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Jonas Raakow
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Nadja Berndt
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Linda Feldbrügge
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Max Magnus Maurer
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Eva Dobrindt
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Peter Thuss-Patience
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Johann Pratschke
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Christian Denecke
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Correspondence:
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Differences in fluid removal of different open-pore elements for endoscopic negative pressure therapy in the upper gastrointestinal tract. Sci Rep 2022; 12:13889. [PMID: 35974057 PMCID: PMC9381550 DOI: 10.1038/s41598-022-17700-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 07/29/2022] [Indexed: 11/09/2022] Open
Abstract
Endoscopic negative pressure therapy is an effective treatment strategy for various defects of the gastrointestinal tract. The functional principle is based on an open-pore element, which is placed around a perforated drainage tube and connected to a vacuum source. The resulting open-pore suction device can undergo endoluminal or intracavitary placement. Different open-pore suction devices are used for endoscopic negative pressure therapy of upper gastrointestinal tract defects. Comparative analyses for features and properties of these devices are still lacking. Eight different (six hand-made devices and two commercial devices) open-pore suction devices for endoscopic negative pressure therapy of the upper gastrointestinal tract were used, amount fluid removed was evaluated. The evaluation parameters included the time to reach the target pressure, the time required to remove 100 ml of water, and the material resistance of the device. All open-pore suction devices are able to aspirate the target volume of fluids. The time to reach the target volume varied considerably. Target negative pressure was not achieved with all open-pore suction devices during the aspiration of fluids; however, there was no negative effect on suction efficiency. Of the measurement data, material resistance could be calculated for six open-pore elements. We present a simple experimental, nonphysiologically setup for open-pore suction devices used for endoscopic negative pressure therapy. The expected quantity of fluids secreted into the treated organs should affect open-pore suction device for endoscopic negative pressure therapy.
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34
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Scognamiglio P, Reeh M, Melling N, Kantowski M, Eichelmann AK, Chon SH, El-Sourani N, Schön G, Höller A, Izbicki JR, Tachezy M. Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting. BMC Surg 2022; 22:309. [PMID: 35953796 PMCID: PMC9367146 DOI: 10.1186/s12893-022-01764-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022] Open
Abstract
Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.
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Affiliation(s)
- Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marcus Kantowski
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Eichelmann
- General, Visceral and Transplantation Surgery, University Hospital Münster, Münster, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Nader El-Sourani
- Department for General and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Höller
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Lu CY, Liu YL, Liu KJ, Xu S, Yao HL, Li L, Guo ZS. Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments: A case report. World J Clin Cases 2022; 10:7609-7616. [PMID: 36157983 PMCID: PMC9353917 DOI: 10.12998/wjcc.v10.i21.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrografin swallow, methylthioninium chloride test, and computed tomography (CT) are the main methods for postoperative anastomotic fistula detection. Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy, which are conducive to postoperative recovery.
CASE SUMMARY A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer. The patient developed a fever after surgery. The methylthioninium chloride test and early CT suggested no anastomotic fistula, but gastrografin swallow and late CT showed the opposite result. The fistula was successfully closed using an endoscopic clip. The methylthioninium chloride test, gastrografin, and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different. The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.
CONCLUSION The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy. The size of the leakage of the anastomosis is an important basis for selecting the repair method.
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Affiliation(s)
- Chen-Yang Lu
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Ya-Li Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Kui-Jie Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Shu Xu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Lun Li
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
| | - Zhu-Shu Guo
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Central South University, Changsha 410011, Hunan Province, China
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Yurttas C, Thiel C, Wichmann D, Horvath P, Strohäker J, Bongers MN, Schenk M, Stüker D, Königsrainer A, Thiel K. Retrospective analysis of different therapeutic approaches for retroperitoneal duodenal perforations. Sci Rep 2022; 12:10243. [PMID: 35715523 PMCID: PMC9205956 DOI: 10.1038/s41598-022-14278-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 05/17/2022] [Indexed: 11/24/2022] Open
Abstract
Surgical therapy of duodenal perforation into the retroperitoneum entails high morbidity. Conservative treatment and endoscopic negative pressure therapy have been suggested as promising therapeutic alternatives. We aimed to retrospectively assess outcomes of patients treated for duodenal perforation to the retroperitoneum at our department. A retrospective analysis of all patients that were treated for duodenal perforation to the retroperitoneum at our institution between 2010 and 2021 was conducted. Different therapeutic approaches with associated complications within 30 days, length of in-hospital stay, number of readmissions and necessity of parenteral nutrition were assessed. We included thirteen patients in our final analysis. Six patients underwent surgery, five patients were treated conservatively and two patients received interventional treatment by endoscopic negative pressure therapy. Length of stay was shorter in patients treated conservatively. One patient following conservative and surgical treatment each was readmitted to hospital within 30 days after initial therapy whereas no readmissions after interventional treatment occurred. There was no failure of therapy in patients treated without surgery whereas four (66.7%) of six patients required revision surgery following primary surgical therapy. Conservative and interventional treatment were associated with fewer complications than surgical therapy which involves high morbidity. Conservative and interventional treatment using endoscopic negative pressure therapy in selected patients might constitute appropriate therapeutic alternatives for duodenal perforations to the retroperitoneum.
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Affiliation(s)
- Can Yurttas
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Christian Thiel
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Dörte Wichmann
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Jens Strohäker
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Malte Niklas Bongers
- Department for Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Martin Schenk
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Dietmar Stüker
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Karolin Thiel
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.
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Gutschow CA, Schlag C, Vetter D. Endoscopic vacuum therapy in the upper gastrointestinal tract: when and how to use it. Langenbecks Arch Surg 2022; 407:957-964. [PMID: 35041047 PMCID: PMC9151563 DOI: 10.1007/s00423-022-02436-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) has emerged as a novel treatment option for upper gastrointestinal wall defects. The basic principle of action of EVT entails evacuation of secretions, removal of wound debris, and containment of the defect. Furthermore, there is increasing evidence that EVT reduces interstitial edema, increases oxygen saturation, and promotes tissue granulation and microcirculation. Various devices, such as macroporous polyurethane sponge systems or open-pore film drains, have been developed for specific indications. Depending on the individual situation, EVT devices can be placed in- or outside the intestinal lumen, as a stand-alone procedure, or in combination with surgical, radiological, and other endoscopic interventions. PURPOSE The aim of this narrative review is to describe the current spectrum of EVT in the upper gastrointestinal tract and to assess and summarize the related scientific literature. CONCLUSIONS There is growing evidence that the efficacy of EVT for upper GI leakages exceeds that of other interventional treatment modalities such as self-expanding metal stents, clips, or simple drainages. Owing to the promising results and the excellent risk profile, EVT has become the therapy of choice for perforations and anastomotic leakages of the upper gastrointestinal tract in many centers of expertise. In addition, recent clinical research suggests that preemptive use of EVT after high-risk upper gastrointestinal resections may play an important role in reducing postoperative morbidity.
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Affiliation(s)
- Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Serum albumin at resection predicts in-hospital death, while serum lactate and aPTT on the first postoperative day anticipate anastomotic leakage after Ivor-Lewis-esophagectomy. Langenbecks Arch Surg 2022; 407:2309-2317. [PMID: 35482049 PMCID: PMC9468131 DOI: 10.1007/s00423-022-02510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/08/2022] [Indexed: 12/02/2022]
Abstract
Background Anastomotic leakage (AL) is a major complication after esophagectomy, potentiating morbidity and mortality. There are several patient risk factors associated with AL, but high-fidelity postoperative predictors are still under debate. The aim was to identify novel reliable predictors for AL after esophagectomy. Methods A high-volume single-center database study, including 138 patients receiving Ivor-Lewis-esophagectomy between 2017 and 2019, was performed. Serum levels of albumin, aPTT, and lactate before and after surgery were extracted to assess their impact on AL and in-hospital mortality. Results High serum lactate on postoperative day 1 (POD1) could be shown to predict AL after esophagectomy [AL vs. no AL: 1.2 (0.38) vs. 1.0 (0.37); p < 0.001]. Accordingly, also differences of serum lactate level between end (POD0-2) and start of surgery (POD0-1) (p < 0.001) as well as between POD1 and POD0-1 (p < 0.001) were associated with AL. Accordingly, logistic regression identified serum lactate on POD 1 as an independent predictor of AL [HR: 4.37 (95% CI: 1.28–14.86); p = 0.018]. Further, low serum albumin on POD0 [2.6 (0.53) vs. 3.1 (0.56); p = 0.001] and high serum lactate on POD 0–1 [1.1 (0.29) vs. 0.9 (0.30); p = 0.043] were associated with in-hospital death. Strikingly, logistic-regression (HR: 0.111; p = 0.008) and cox-regression analysis (HR: 0.118; p = 0.003) showed low serum albumin as an independently predictor for in-hospital death after esophagectomy. Conclusions This study identified high serum lactate as an independent predictor of AL and low serum albumin as a high-fidelity predictor of in-hospital death after esophagectomy. These parameters can facilitate improved postoperative treatment leading to better short-term as well as long-term outcomes.
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Chon SH, Scherdel J, Rieck I, Lorenz F, Dratsch T, Kleinert R, Gebauer F, Fuchs HF, Goeser T, Bruns CJ. A new hybrid stent using endoscopic vacuum therapy in treating esophageal leaks: a prospective single-center experience of its safety and feasibility with mid-term follow-up. Dis Esophagus 2022; 35:6375055. [PMID: 34561712 DOI: 10.1093/dote/doab067] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/02/2021] [Indexed: 12/11/2022]
Abstract
Self-expandable metal stents (SEMS) and endoscopic vacuum therapy (EVT) are endoscopic options for treating leaks of the esophagus. VACStent® is a variant of SEMS that aims to combine the advantages of SEMS and EVT in one device. Due to this unique construction, VACStent® can build a barrier to the leak and facilitate wound healing with EVT, all while maintaining intestinal passage. We present the first prospective feasibility study of VACStent® for treating leaks of the upper gastrointestinal tract. Between September 2019 and November 2020, we performed a prospective, investigator-initiated, single-center study and included all patients who underwent endoscopic stenting with VACStent® for various kinds of esophageal leaks, such as spontaneous, iatrogenic or anastomotic leaks. We included 20 patients, who underwent a total of 24 endoscopic VACStent® implantations. Technical success of the application of the VACStent® was achieved in all interventions (n = 24, 100%). Overall, clinical success in closing the leaks with VACStent® treatment was achieved in 60% of patients (12/20). No severe VACStent® treatment-related adverse events occurred. Oral feeding with supplement high-energy drinks failed in all patients due to clogging of the suction tube. VACStent® is a safe and feasible endoscopic treatment option for leaks of the upper gastrointestinal tract. However, our data could not show the expected advantage of orally feeding the patients during the treatment with the VACStent® in its current form. Efficacy of VACStent® compared to EVT or SEMS needs to be investigated in a further study. ClinicalTrials.gov Identifier: NCT03962179.
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Affiliation(s)
- Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Julia Scherdel
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Isabel Rieck
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Florian Lorenz
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Dratsch
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Robert Kleinert
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Gebauer
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
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Postoperative Leckagen im Gastrointestinaltrakt – Diagnostik und Therapie. DER GASTROENTEROLOGE 2022; 17:47-56. [PMID: 35035584 PMCID: PMC8744584 DOI: 10.1007/s11377-021-00584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
Postoperative Leckagen nach Ösophagus‑, Magen- oder Kolon- bzw. Rektumchirurgie stellen schwerwiegende chirurgische Komplikationen mit einer hohen Morbidität und Mortalität dar. Leckagen werden zumeist durch eine Kombination aus klinischer Beobachtung, Infektionsparametern sowie endoskopischen und schnittbildgebenden Verfahren diagnostiziert. Die Therapie ist bei intraperitonealen Leckagen chirurgisch, bei retroperitonealen bzw. mediastinalen Leckagen in einem interdisziplinären Setting überwiegend interventionell endoskopisch. Hier stehen der Defektverschluss durch die Abdichtung mittels selbstexpandierender gecoverter Stents mit gleichzeitiger externer extraluminaler Drainage sowie der Defektverschluss mit simultaner innerer Drainage und endoskopischer Unterdrucktherapie als vorrangige Methoden zur Verfügung.
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Jung DH, Huh CW, Min YW, Park JC. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022; 95:281-290. [PMID: 34555386 DOI: 10.1016/j.gie.2021.09.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates. METHODS Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract. RESULTS Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself. CONCLUSIONS EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.
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Affiliation(s)
- Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Cheal Wung Huh
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Reimer S, Seyfried F, Flemming S, Brand M, Weich A, Widder A, Plaßmeier L, Kraus P, Döring A, Hering I, Hankir MK, Meining A, Germer CT, Lock JF, Groneberg K. Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study. Surg Endosc 2022; 36:9169-9178. [PMID: 35852622 PMCID: PMC9652162 DOI: 10.1007/s00464-022-09400-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 06/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) is an effective treatment option for leakage of the upper gastrointestinal (UGI) tract. The aim of this study was to evaluate the clinical impact of quality improvements in EVT management on patients' outcome. METHODS All patients treated by EVT at our center during 2012-2021 were divided into two consecutive and equal-sized cohorts (period 1 vs. period 2). Over time several quality improvement strategies were implemented including the earlier diagnosis and EVT treatment and technical optimization of endoscopy. The primary endpoint was defined as the composite score MTL30 (mortality, transfer, length-of-stay > 30 days). Secondary endpoints included EVT efficacy, complications, in-hospital mortality, length-of-stay (LOS) and nutrition status at discharge. RESULTS A total of 156 patients were analyzed. During the latter period the primary endpoint MTL30 decreased from 60.8 to 39.0% (P = .006). EVT efficacy increased from 80 to 91% (P = .049). Further, the need for additional procedures for leakage management decreased from 49.9 to 29.9% (P = .013) and reoperations became less frequent (38.0% vs.15.6%; P = .001). The duration of leakage therapy and LOS were shortened from 25 to 14 days (P = .003) and 38 days to 25 days (P = .006), respectively. Morbidity (as determined by the comprehensive complication index) decreased from 54.6 to 46.5 (P = .034). More patients could be discharged on oral nutrition (70.9% vs. 84.4%, P = .043). CONCLUSIONS Our experience confirms the efficacy of EVT for the successful management of UGI leakage. Our quality improvement analysis demonstrates significant changes in EVT management resulting in accelerated recovery, fewer complications and improved functional outcome.
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Affiliation(s)
- Stanislaus Reimer
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany.
| | - Sven Flemming
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Markus Brand
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Weich
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Anna Widder
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Lars Plaßmeier
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Peter Kraus
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Anna Döring
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Ilona Hering
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Mohammed K Hankir
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Johan F Lock
- Department of General-, Visceral-, Transplant-, Vascular- and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Kaja Groneberg
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
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Livingstone I, Pollock L, Sgromo B, Mastoridis S. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc 2021; 54:787-797. [PMID: 34781418 PMCID: PMC8652150 DOI: 10.5946/ce.2021.240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022] Open
Abstract
Esophageal wall defects, including perforations and postoperative leaks, are associated with high morbidity and mortality and pose a significant management challenge. In light of the high morbidity of surgical management or revision, in recent years, endoscopic vacuum therapy (EVT) has emerged as a novel alternative treatment strategy. EVT involves transoral endoscopic placement of a polyurethane sponge connected to an externalized nasogastric tube to provide continuous negative pressure with the intention of promoting defect healing, facilitating cavity drainage, and ameliorating sepsis. In the last decade, EVT has become increasingly adopted in the management of a diverse spectrum of esophageal defects. Its popularity has been attributed in part to the growing body of evidence suggesting superior outcomes and defect closure rates in excess of 80%. This growing body of evidence, coupled with the ongoing evolution of the technology and techniques of deployment, suggests that the utilization of EVT has become increasingly widespread. Here, we aimed to review the current status of the field, addressing the mechanism of action, indications, technique methodology, efficacy, safety, and practical considerations of EVT implementation. We also sought to highlight future directions for the use of EVT in esophageal wall defects.
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Affiliation(s)
| | | | - Bruno Sgromo
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sotiris Mastoridis
- Oxford Oesophagogastric Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Hayami M, Klevebro F, Tsekrekos A, Samola Winnberg J, Kamiya S, Rouvelas I, Nilsson M, Lindblad M. Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience. Dis Esophagus 2021; 34:6046267. [PMID: 33367786 DOI: 10.1093/dote/doaa122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.
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Affiliation(s)
- Masaru Hayami
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Johanna Samola Winnberg
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Kamiya
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Preemptive Endoluminal Vacuum Therapy to Reduce Morbidity after Minimally Invasive Ivor Lewis Esophagectomy: Including a Novel Grading System For Postoperative Endoscopic Assessment of GI-Anastomoses. Ann Surg 2021; 274:751-757. [PMID: 34334639 DOI: 10.1097/sla.0000000000005125] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Preemptive endoluminal vacuum therapy (pEVT) is a novel concept to reduce postoperative morbidity and has the potential to disrupt current treatment paradigms for patients undergoing esophagectomy. SUMMARY BACKGROUND DATA Endoluminal vacuum therapy is an accepted treatment for anastomotic leakage (AL) after esophagectomy. METHODS Retrospective analysis of patients undergoing minimally invasive Ivor Lewis esophagectomy (MILE) with pEVT between 11/2017 and 10/2020. The sponge was removed endoscopically after 4-6 days, and anastomosis and gastric conduit were assessed according to a novel endoscopic grading system. Further management was customized according to endoscopic appearance and clinical course. Endpoints were postoperative morbidity and AL rate, defined according to the Clavien-Dindo (CD) and International Esodata Study Group classifications. RESULTS PEVT was performed in 67 consecutive patients, 57 (85%) were high-risk patients with an ASA score >2, WHO/ECOG score >1, age >65 years, or BMI >29 kg/m2. Thirty patients experienced textbook outcome, and overall minor (≤CD IIIa) and major (≥CD IIIb) morbidity was 40.3% and 14.9% respectively. 30-day-mortality was 0%. Forty-nine patients (73%) had uneventful anastomotic healing after pEVT without further endoscopic treatment. The remaining 18 patients (27%) underwent prolonged EVT with uneventful anastomotic healing in 13 patients (19%), contained AL in 4 patients (6%), and one uncontained leakage (1.5%) in a case with proximal gastric conduit necrosis, resulting in an overall AL rate of 7.5%. CONCLUSIONS PEVT is an innovative and safe procedure with a promising potential to reduce postoperative morbidity after MILE and may be particularly valuable in highly comorbid cases.
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Lange J, Dormann A, Bulian DR, Hügle U, Eisenberger CF, Heiss MM. VACStent: Combining the benefits of endoscopic vacuum therapy and covered stents for upper gastrointestinal tract leakage. Endosc Int Open 2021; 9:E971-E976. [PMID: 34079885 PMCID: PMC8159583 DOI: 10.1055/a-1474-9932] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/22/2021] [Indexed: 01/17/2023] Open
Abstract
Background and study aims Endoscopic treatment has markedly improved the high morbidity and mortality in patients with upper gastrointestinal tract leakage. Most procedures employ either covered self-expanding metal stents (SEMS) or endoscopic vacuum therapy (EVT), both with good clinical success but also with concomitant significant shortcomings inherent in each technique. A newly developed device, the VACStent, combines the fully covered SEMS with a polyurethane sponge cylinder anchored on the outside. This allows endoluminal EVT while keeping the intestinal lumen patent. The benefit is prevention of stent migration because the suction force of the sponge-cylinder immobilizes the VACStent on the intestinal wall, while at the same time, the attached external vacuum pump suctions off any secretions and improves healing with negative-pressure wound treatment (NPWT). Patients and methods In this pilot study, the first patients to receive the VACStent were assessed. Outcomes included the applicability and stability of the VACStent system together with the clinical course. Results Three patients with different clinical courses were managed with the VACStent. The first patient suffered anastomotic leakage following subtotal esophagectomy and was successfully treated with two postoperative VACStents for 12 days. The second patient received a covered SEMS for 14 days for acute Boerhaave syndrome. Due to persistent leakage, management was converted to EVT. Seven days, later a VACStent was inserted to allow oral nutrition while the leak finally closed. In the third patient, a LINX Reflux Management System had to be removed for erosion, leaving the gastroesophageal junction (GEJ) with a full-thickness gap. After VACstent insertion, successful closure was achieved within 4 days. Conclusions These clinical cases demonstrate the applicability and efficacy of the VACstent in management of esophageal and anastomotic leakage. With its vacuum sponge, the stent fosters wound healing while the covered SEMS keeps the passage patent for nutrition.
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Affiliation(s)
- Jonas Lange
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Arno Dormann
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - Dirk Rolf Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Ulrich Hügle
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - Claus Ferdinand Eisenberger
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Markus Maria Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
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Buttar NS. Minimally invasive endoscopic approaches to manage postsurgical leaks: time to recognize the finger in the dike. Gastrointest Endosc 2021; 93:1300-1303. [PMID: 33712226 DOI: 10.1016/j.gie.2020.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/31/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Navtej S Buttar
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Bonavina L. Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:907. [PMID: 34164541 PMCID: PMC8184442 DOI: 10.21037/atm.2020.03.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
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Loeck J, von Lücken HJ, Münscher A, Müller CT, Loske G. Endoscopic negative pressure therapy (ENPT) in head and neck surgery: first experiences in treatment of postoperative salivary fistulas and cervical esophageal perforations. Eur Arch Otorhinolaryngol 2021; 278:4525-4534. [PMID: 33715018 DOI: 10.1007/s00405-021-06709-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/18/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Iatrogenic cervical esophageal perforations (CEP) and postoperative salivary fistulas (PSF) are some of the complications requiring treatment in head and neck surgery. Conservative, surgical and endoscopic therapeutic techniques are used. Both CEP and PSF are potentially life-threatening complications and require intensive treatment. Endoscopic negative pressure therapy (ENPT) is an innovative endoscopic surgical procedure for the treatment of transmural intestinal defects throughout the gastrointestinal tract (GIT). In this retrospective study, we demonstrate its application in head and neck surgery. MATERIALS AND METHODS In ENPT, open-pore drains are placed endoscopically in the wound area. The drains can be inserted in an intraluminal position spanning the length of the defect (intraluminal ENPT), or through the defect into the extraluminal wound cavity (intracavitary ENPT). An electronic suction pump applies and maintains a continuous negative pressure of - 125 mmHg over a period of several days. The endoscopic drains are changed at regular intervals every few days until stable intracorporeal wound healing by secondary intention or defect closure is achieved. Between 06/2008 and 05/2019 ten patients (f = 3, m = 7; 46-78 years old) were treated with ENPT for CEP or PSF. Five patients had postoperative wound defects with consecutive PSF after total laryngectomy or floor of mouth resection. In five patients iatrogenic CEP was found following endoscopic procedures. RESULTS In all patients treated with ENPT, healing of the perforation defect or fistula was achieved (cure rate 100%). The median treatment duration was 13.7 days (range 4-42 days). No relevant treatment-associated complications were observed. CONCLUSION ENPT is a new, minimally invasive method for treating PSF and CEP.
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Affiliation(s)
- Jonathan Loeck
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany.
| | - Hans-Jürgen von Lücken
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany
| | - Adrian Münscher
- Department of Otorhinolaryngology, Head and Neck Surgery, Katholisches Marienkrankenhaus gGmbH, Alfredstrasse 9, 22087, Hamburg, Germany
| | - Christian Theodor Müller
- Department of General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
| | - Gunnar Loske
- Department of General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus gGmbH, Hamburg, Germany
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Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A. Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 2021; 21:72. [PMID: 33593301 PMCID: PMC7885467 DOI: 10.1186/s12876-021-01651-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).
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Affiliation(s)
- Chengcheng Christine Zhang
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Lukas Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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