2128 Successful Treatment of Large Cavity Esophageal Disruptions With Transluminal Washout and Endoscopic Vacuum Therapy

Abstract

INTRODUCTION: Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy (EVT) has proven to be a feasible, safe therapy for management of esophageal wall defects, but there is limited data on the effiacy of EVT for large and severe collections. We demonstrate that large and even multiple collections could be managed by EVT with serial endoscopic debridement and washout. CASE DESCRIPTION/METHODS: We describe a retrospective single-center analysis of two patients who underwent EVT for significant esophageal disruptions. Patient 1 developed esophageal perforation from Boerhaave Syndrome with a 2 cm disruption and 10.7 cm cavity, and Patient 2 developed postoperative anastomotic leak after Ivor-Lewis Esophagectomy with two separate disruptions: a 2 cm proximal disruption with a 4 cm mediastinal cavity and 14 cm gastric pull up disruption with a cavity encompassing the entire central and lower right thorax. EVT was accomplished with the use of a standard upper video endoscope, nasogastric (NG) tube and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal/ thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. DISCUSSION: Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross sectional diameter was 10.7 cm. The average number of EVT procedures performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. In conclusion, endoscopic washout and debridement followed by EVT can be effective for large, even multiple, thoracic and/or mediastinal contaminations following esophageal perforation and gastroesopagheal anastamotic dehiscence and leaks in appropriately-selected patients. Our technique involving EVT coupled with serial washout and debridement has the potential to change the current approach to the management of severe mediastinal or thoracic contamination from anastomotic dehiscence and other types of esophageal disruptions.