2177 Endoscopy-Directed Overtube-Assisted Vacuum Therapy of a Colo-Rectal Anastomotic Leak

Abstract

INTRODUCTION: Colorectal anastomotic leak is a feared and potentially catastrophic complication of colorectal surgery. It presents an increase morbidity and mortality risk, hospital stays, cost and potential for repeat procedures. We present a case of development of an anastomotic leak managed with an overtube-assisted endoscopic vacuum therapy (EVT) under direct endoscopic visualization. CASE DESCRIPTION/METHODS: 51 year old woman with a rectal cancer status post neoadjuvant therapy, low anterior resection (7 cm from the anal verge) and diverting loop ileostomy presented with a complaint of abdominal pain at 3 weeks post-op. A gastrograffin enema revealed contrast extravasation into the pre-sacral space confirming a colorectal anastomotic leak. The endoscopic exam revealed dehiscence of an end-to-end anastomosis at 7 cm from the anal verge, with a 2-cm defect that led to the pre-sacral cavity, measuring 6 × 4 cm in size. A polyurethane sponge was cut to the dimension of the cavity and sutured to a 16-Fr NG tube. A short overtube was placed into the opening of the cavity. The sponge was advanced through the overtube, under direct visualization, with a scope behind it. The tube was connected to a vacuum system for continued negative pressure at 175 mmHg. The procedure was repeated at a three-day interval. Over 7 sessions, the primary defect was completely sealed, reduced to 10% with diffuse granulation tissue formation. Serial barium enemas following treatment showed no evidence of extravasation or concern for persistent leak. On subsequent takedown of the ileostomy the patient was able achieve normal bowel function. DISCUSSION: Endoscopic treatment of anastomotic leaks has been proposed as an alternative to operative management in clinically stable patients with non-generalized peritonitis. Modalities include SEMS, pigtail stent placement and EVT . EVT was first described in 2008, which is proven to heal mucosal defects are placed at repeat intervals to allow for slow closure of the defect, with a higher success rate of 79% compared to other endoscopic modalities. No delivery system currently exists here in the states, allowing for the ease deployment of the sponge device. This case demonstrate that a short overtube (typically used for foreign body removal) can be used as a deployment device and highlights this unique way of advancing the sponge into the cavity using the scope as a pusher, allowing for direct visualization of the deployment.