EGS P17 Expanding the technical armamentarium to treat complex oesophageal perforations with Endoluminal Vacuum Therapy

Abstract

Abstract Background Endoluminal vacuum therapy (EVT) is increasingly the default treatment modality for oesophageal leaks. If the leak cavity is large or has a dependent element, placement of the endoluminal vacuum device within the leak cavity facilitates healing. However, accessing the leak cavity can be challenging when the oesophageal defect communicating with the leak cavity is small, and it is tempting to default to luminal EVT. This can lead to a EVT failure. We present a case where luminal EVT in the presence of an established leak cavity with a narrow inlet resulted in stagnation of therapy requiring an alternative technical approach. Methods An 80-year-old high-risk female with Boerhaave's syndrome presented with a 4cm esophageal defect and a large mediastinal leak cavity. An ad-hoc endovacuum therapy (EVT) device, consisting of V.A.C granufoam (KCI) attached to a 14Fr nasogastric (NG) tube, was placed in the leak cavity at -125mmHg pressure. The EVT device was replaced every 3-8 days. After 101 days, luminal EVT was adopted due to cavity narrowing. Partial closure of the esophageal defect was achieved, but a persistent mediastinal abscess communicated through a residual pinhole defect. Additional luminal EVT and image-guided drainage couldn't resolve the persistent esophageal fistula, confirmed by contrast-enhanced CT. Results Endoluminal access to the leak cavity was re-established by dilating the fistula using a TTS 12mm radial expansion wire-guided balloon catheter enabling re-establishment of intra-cavity EVT. Having regained access, further intra-cavity EVT using an ad-hoc EVT device fashioned from black granufoam (KCI) sutured to a 10Fr or 12Fr ng tube with 125mmHg negative pressure was applied. The EVT device was changed every 3-6 days. After further 25 days of EVT complete healing was observed. Conclusions Whilst intraluminal EVT has a role in oesophageal leaks associated with small leak cavities which have no dependent element, larger leak cavities require intra-cavity EVT. If access to the leak cavity is challenging due to the small size of the oesophageal defect, endoscopic measures to facilitate endoluminal access to the leak cavity such as dilation of the defect can be safely employed to enable delivery of intra-cavity EVT. This should be considered when endoluminal access to the leak cavity is prevented due to the small size of the defect obviating the need for other more invasive interventions such as surgery.