Isolation techniques for gastrointestinal tract defects: Two case reports

Abstract

BACKGROUND

Gastrointestinal (GI) tract injuries and defects form a heterogeneous group of conditions often presenting with fistula formation. Management depends on factors such as defect number, anatomical location, and patient status, requiring a therapy that addresses multiple etiopathogenic factors.

CASE SUMMARY

We present two cases of patients who underwent total gastrectomy for gastric malignancy. A combined therapeutic approach was employed, based on isolating the injury site with local vacuum-assisted closure (VAC) therapy and simultaneous enteral nutrition. This method facilitated successful healing and enabled the identification of previously undetected defects not recognized by conventional diagnostics.

CONCLUSION

The combination of injury site isolation, local VAC therapy, and enteral feeding proved to be safe, effective, and easily adaptable to standard surgical practice. This approach may expand surgical options in the treatment of GI tract injuries and defects.

Key Words: Gastric cancer; Acute pancreatitis; VAC therapy; Anastomotic leakage; Fistulas; Enteral nutrition; Case report

Core Tip: The treatment of gastrointestinal tract defects and fistulas remains a complex challenge without a standardized approach, due to the highly variable and often unique nature of injuries. Our experience highlights a novel method combining isolation of the affected gastrointestinal segment with local vacuum-assisted therapy while maintaining enteral nutrition. This approach not only facilitates early detection and dynamic monitoring of fistulas but also promotes faster healing by preventing contact with gastrointestinal contents and preserving mucosal integrity through continued enteral feeding. By applying this method in oncologic patients undergoing similar surgeries, we demonstrate its feasibility, safety, and potential to significantly improve clinical outcomes. Further exploration of segmental isolation may expand therapeutic options for various abdominal pathologies.

INTRODUCTION

Defects of the gastrointestinal (GI) tract wall represent a heterogeneous group of conditions that can result in the formation of external or internal fistulas, often complicated by mediastinitis, peritonitis, or sepsis. Mortality associated with these complications varies widely, ranging from 10% to 60% of cases[1]. Treatment effectiveness depends on multiple factors, among which the interval between the onset of symptoms and the identification of the defect plays a critical role. This period can be highly variable: From 1 to 58 months in oncological cases, and from 5 to 30 days in benign conditions[2]. Such variability is largely attributable to the broad spectrum of clinical manifestations, ranging from purulent-septic presentations to bleeding and emphysematous changes in the subcutaneous tissue.

The patient’s immune status is another key determinant of outcomes. However, earlier recognition of complications and the prompt initiation of targeted therapy consistently correlate with better results. Endoscopic investigations, including video esophagoscopy and bronchoscopy, together with radiographic studies, remain the cornerstone of diagnostic evaluation. These modalities should be employed complementarily, as infiltrative changes in the esophagus or airways can obscure small fistulous tracts during endoscopy. Similarly, fluoroscopy with water-soluble contrast agents may fail to detect subtle defects[3]. As such, accurate visualization and confirmation of GI fistulas remain significant diagnostic challenges.

Current guidelines advocate minimally invasive treatments for fistulas, such as clipping, endoscopic suturing, fibrin glue application, and the placement of various types of covered stents (plastic, metallic, or self-expandable). Despite this trend, there is no universally accepted standardized treatment algorithm, reinforcing the necessity for individualized, multifactorial approaches[4].

Among the available modalities, endoluminal vacuum therapy (EndoVAC) is the most extensively studied for the treatment of non-malignant GI fistulas. Its major advantage lies in providing continuous aspiration of pathological exudate, thus accelerating fistula healing under negative pressure conditions. However, EndoVAC therapy is not universally effective. Reported success rates are around 85%, predominantly among patients with postsurgical fistulas (e.g., after esophagectomy, gastrectomy, or proximal gastrectomy) or fresh iatrogenic injuries[5,6]. Several limitations to EndoVAC therapy have been identified, including the lack of a clearly defined optimal range for negative pressure—especially the upper limit—which may contribute to additional esophageal wall trauma[7,8]. Moreover, EndoVAC is associated with high treatment costs, an increased risk of stricture formation, the need for frequent system exchanges, and a necessary shift to parenteral nutrition.

Importantly, with existing treatment strategies, the defect area often remains exposed to external influences from the gastrointestinal environment, potentially delaying healing and increasing infection risk. Additionally, prolonged parenteral nutrition not only significantly increases healthcare costs but also leads to several complications, including intestinal mucosal atrophy, dysbiosis, increased susceptibility to infections, and metabolic disturbances such as hyperglycemia and hyperlipidemia. Impaired immune function and the absence of essential nutrients and trophic factors—critical for mucosal regeneration—further compromise patient outcomes.

Considering the advantages and limitations of existing therapies, an ideal approach to managing GI wall defects and fistulas should combine the creation of an isolated environment with controlled negative pressure to enhance healing, while simultaneously preserving the ability to maintain enteral nutrition. Such a strategy may significantly improve tissue repair, minimize complications associated with prolonged parenteral nutrition, and ultimately lead to better clinical outcomes. The principle of gastrointestinal tract isolation and creation of therapeutic conditions has previously been successfully utilized by us for various pathologies[9,10].

CASE PRESENTATION

Chief complaints

Two male patients—aged 74 and 70 years—were admitted in August and September 2024, respectively, with similar symptoms. Both presented with progressive dysphagia, vomiting, generalized weakness, anemia, and unintentional weight loss.

History of present illness

Both patients underwent preoperative endoscopic evaluation, confirming gastric cancer. The first patient was diagnosed with moderately differentiated adenocarcinoma; the second, with well-differentiated adenocarcinoma. Contrast-enhanced computed tomography (CT) showed no regional lymphadenopathy or distant metastases in either case. Following review by a multidisciplinary tumor board, both cases were staged as IIA. In September 2024, the patients underwent video-assisted laparoscopic total gastrectomy with D2 Lymphadenectomy and Roux-en-Y reconstruction, including stapled side-to-end esophagojejunostomy.

History of past illness

Both patients had a known history of arterial hypertension. The second patient had additionally undergone partial gastrectomy 40 years earlier for peptic ulcer disease (Billroth II reconstruction, Hofmeister–Finsterer modification), which introduced significant anatomical and technical challenges for the current surgical procedure.

Personal and family history

Neither patient reported a personal or family history of malignancy.

Physical examination

In the first patient, the immediate postoperative course was complicated by acute traumatic pancreatitis, confirmed by an elevated serum amylase level (605 U/L), as well as intestinal failure syndrome and small bowel paresis. A subhepatic drain was maintained to evacuate peripancreatic fluid. On postoperative day 12, the drain output became enteric in nature. Fistulography revealed a leak from the duodenal stump, consistent with a Grade IV fistula according to the Clavien-Dindo classification. An emergency reoperation was performed, which included laparotomy, intra-abdominal decontamination, and placement of a vacuum-assisted closure (VAC) system. Serial abdominal debridement was carried out every 3-4 days.

In the second patient, enteric drainage was noted on postoperative day 8 from a surgically placed drain located adjacent to the esophagojejunal anastomosis.

Laboratory examinations

Both patients exhibited leukocytosis and elevated inflammatory markers, consistent with an ongoing infectious process.

Imaging examinations

In the first case, oral contrast-enhanced CT revealed contrast extravasation distal to the esophagojejunostomy. Endoscopy identified two distinct fistulous tracts: One located 8 cm distal to the anastomosis at the Roux limb, and another originating from the duodenal stump. Both fistulas communicated with a subhepatic abscess cavity (Figure 1A).

Figure 1 Endoscopic view of the fistulas of Patient 1. A: Lower fistulous tract with a channel; B: Openings of the upper fistulous tract above the anastomosis; C: Result after 10 days of therapy, with a residual cavity formed.

In the second case, oral contrast fluoroscopy demonstrated extravasation from the jejunal stump, which was confirmed endoscopically.

MULTIDISCIPLINARY EXPERT CONSULTATION

A multidisciplinary team comprising surgeons, endoscopists, and anesthesiologists convened to evaluate treatment options. It was agreed to initiate therapy with the PandiCath^® system (Figure 2), which allows isolation of the affected gastrointestinal segment while preserving enteral nutrition.

Figure 2 PandiCath^®. 1: Channel for inflating balloons 5 and 8; 2: Main channel for fluid infusion, passive drainage, and shunting of the proximal and distal sections of the organ; 3: Manipulation channel connected to a controlled negative pressure pump, ensuring outflow from the isolated area or administration of medications; 4: Perforation openings above the isolated area; 5 and 8: Inflatable isolation balloons positioned above and below the defect area; 6: Opening of the manipulation channel (3), located between the balloons, allowing for biological material collection; 7: Protrusions around opening 6, preventing adhesion of the mucous layer; 9: Distal opening of channel 2.

PandiCath^® device description and placement considerations

PandiCath^® comprises two low-pressure, water-inflatable balloons spaced 16.5 cm apart along a flexible catheter, creating a sealed intraluminal segment for targeted interventions such as vacuum-assisted therapy and contrast instillation for real-time verification of device positioning and assessment of the fistulous tract. The balloons are connected via a shared inflation channel that equalizes internal pressure, thereby minimizing interference with bowel motility. Placement is guided endoscopically or fluoroscopically to ensure precision and safety. Balloon volumes range from 40-100 mL, adjusted endoscopically based on anatomy to ensure effective sealing without compromising perfusion. To minimize potential pressure injury, balloons are deflated once or twice daily. A continuous negative pressure of -80 mmHg supports drainage and healing. The device typically remains in place for 3-4 days, with routine clinical and endoscopic monitoring. Contraindications include bowel ischemia, uncontrolled coagulopathy, or anatomical limitations. Repositioning or replacement is done as needed.

FINAL DIAGNOSIS

Both patients

Gastric adenocarcinoma, stage IIA.

Patient 1 complications

Postoperative acute traumatic pancreatitis, Grade IV duodenal and esophagoenteric fistulas, and severe purulent peritonitis.

Patient 2 complications

Grade III anastomotic fistula involving the jejunal stump.

TREATMENT

Under endoscopic guidance, the PandiCath^® system was positioned to fully isolate the esophagojejunostomy between the two balloons. Injection of contrast medium into the isolated segment confirmed the presence and location of the fistulas, as well as proper device positioning.

In the first patient, contrast administration additionally revealed a previously undetected proximal fistulous tract located above the anastomosis (Figure 1B). Localized VAC therapy was initiated in both patients through the PandiCath^® system.

In the first case, additional scheduled debridement procedures were performed to manage the duodenal stump fistula and associated peritonitis. Complete closure of all GI defects was confirmed endoscopically in this patient after 10 days of therapy (Figure 1C). In the second patient, fistula closure was confirmed by control fistulography after three days of treatment (Figure 3). Both patients were discharged in satisfactory condition.

Figure 3 Fluoroscopy of the anastomosis area three days after the start of therapy of Patient 2. The arrow indicates traces of contrast medium and air in the jejunal stump anastomosed according to Roux, with no contrast leakage detected.

OUTCOME AND FOLLOW-UP

After 8 months of follow-up on May 22, 2025, patient was interviewed and examined. They reamed asymptomatic, with no evidence of dysphagia or cancer recurrence.

DISCUSSION

The treatment of gastrointestinal tract defects and fistulas remains a significant clinical challenge, for which standardized, one-size-fits-all solutions are rarely feasible. The underlying causes, predisposing factors, and clinical contexts of such injuries are highly variable, and often unique, making it difficult to design and implement large-scale, randomized multicenter trials with homogeneous patient cohorts, well-defined inclusion criteria, and standardized outcome measures. As reflected in the global literature, most available evidence consists of individual case reports or small multi-institutional case series, which, while informative, still represent aggregated anecdotal data. Our report is noteworthy in that it describes two patients with nearly identical esophagogastric anastomotic defects treated concurrently using the same therapeutic approach.

Global experience indicates that the key to successful treatment of GI defects and injury is a multidisciplinary approach and flexibility in selecting additional therapeutic strategies. However, the proposed method offers several important advantages. First, it allows for both the identification of the defect and dynamic monitoring of its healing process. Second, isolating the damaged area prevents fistula passage from coming into contact with the gastrointestinal contents, promoting its closure. Local VAC therapy within the isolated area effectively removes mucopolysaccharide mucus, fibrin, and bacterial flora, reducing the fistula cavity and accelerating healing. A significant additional advantage of this method is the preservation of enteral feeding, which is critical for maintaining the patient's nutritional status. Enteral nutrition protects enterocytes, stimulates intestinal motility, and normalizes microcirculation in the gastrointestinal tract walls[11,12].

CONCLUSION

The proposed method, which combines isolation of the injury site with localized VAC therapy and simultaneous enteral nutrition, has demonstrated both safety and effectiveness in the diagnosis and treatment of gastrointestinal wall defects. It is also straightforward to implement in routine clinical practice. While it is challenging to fully isolate the method’s effects from other factors influencing outcomes in the presented cases, we believe this multimodal approach holds significant promise in the management of complex abdominal pathologies. In particular, it may offer valuable therapeutic benefit in cases of esophageal burns, gastrointestinal hemorrhage, and trauma resulting from high-kinetic-energy injuries. Further studies involving larger patient cohorts are warranted to validate and optimize the safety and efficacy of this treatment strategy.