Combined Endoscopic Transanal Vacuum-Assisted Rectal Drainage: A Novel Therapy for Colorectal Anastomotic Leak after TME for Cancer

Abstract

Introduction: Low colorectal and colo-anal anastomosis leakage after anterior resection of rectum occurs in up to 24% of cases. Leak is the main cause of morbidity and mortality in postoperative period and can result in a permanent stoma in up to 25% of cases. Loop ileostomy or colostomy does not reduce the percentage of fistulas, but reduces flow rate. Conservative management imply long times to heal. Endosponge® system (B. Braun Aesculap AG, Germany) was recently acquired in clinical practice. This system accelerates healing process through vacuum creation, removal of fluids and edema, infection control, local increase of blood flow and stimulation of granulation tissue formation. The device consists of a cylindrical polyurethane sponge, with 400 to 600 micron pores, standard dimension of 7 cm, which can be cut to fit the estimated size of the abscess cavity. The drain tube is connected to a Redyrob Trans Plus®bottle which exerts a constant suction during the therapy. Materials and Methods: From November 2012 and March 2014 four patients were treated with Endosponge® system, all of them underwent operation of anterior resection of rectum for cancer and developed anastomotic leakage during postoperative course. All patients had loop ileostomy, none presented signs of sepsis. The Endosponge® system was then placed endoscopically. In all cases, after the first placing, the authors utilized sterile foam dressing from negative pressure wound therapy kit, tailored to better fill the abscess cavity and connected with Redyrob Trans Plus?bottle. Device changes were performed every 5 - 7 days, according to the size of the cavity and the amount of secretions produced. The treatment was started during hospitalization first and then continued as outpatient. Results: There was no mortality. The amount of secretions was related to the initial size and the degree of contamination of the abscess cavity. Antibiotic therapy was discontinued after an average of 21 days, with a range between 14 and 32 days. Complete healing was achieved in a median of 82 days (30 to 148) in all patients with good functional results, no further surgery was required. Conclusions: The results of therapy with Endosponge® seem encouraging. Success of therapy is higher if initiated as soon possible after the intervention and is also related to the size of dehiscence and abscess cavity. In cases with large abscesses, it is not clear whether this new treatment leads to reduction in healing time, however, can prevent the packaging of a (often definitive) colostomy. Further studies will be able to select patients who will most benefit from the procedure.