Abstract
BackgroundLeaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery.MethodsA piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture. Under general anaesthetic, the foam covered tip is placed endoscopically through the perforation and into any extra-luminal cavity. Continuous negative pressure (125 mmHg) is then applied. Re-evaluation with change of the negative pressure system is performed every 48–72 h depending on the clinical condition. Patients are fed enterally and treated with broad-spectrum antibiotics and anti-fungal medication until healing, assessed endoscopically and/or radiologically, is complete.ResultsSince April 2011, twenty one patients have been treated. The cause of the leak was postoperative/iatrogenic complications (14 patients) and ischaemic/spontaneous perforation (seven patients). Twenty patients (95%) completed treatment successfully with healing of the defect and/or resolution of the cavity and were subsequently discharged from our care. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. In addition, two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. In two patients, E-Vac treatment was complicated by bleeding. The median number of E-Vac changes was 7 (range 3–12), and the median length of hospital stay was 35 days (range 23–152).ConclusionsE-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is now needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered.
Highlights
Presented in the 19th Annual Scientific Meeting of the Association of Upper Gastrointestinal Surgeons, Leeds, 22–23 September 2016.The treatment of upper gastrointestinal tract perforations and postoperative anastomotic leaks remains challenging
The length of stay reflects the long hospitalisation of these patients due to their initial underlying pathology and not the length of the endoluminal vacuum (E-Vac) treatment exclusively
A number of case reports and series of patients treated with E-Vac therapy have been published to date, all supporting the hypothesis that it is a safe and effective technique for managing upper gastrointestinal leaks [8,9,10,11,12,13,14,15,16,17,18,19,20,21,22]
Summary
The treatment of upper gastrointestinal tract perforations and postoperative anastomotic leaks remains challenging. The principles of managing a perforation or anastomotic leak depend on the cause, the size of the defect, the time from the leak to treatment, and the physiological status of the patient. Leaks from the upper gastrointestinal tract often pose a management challenge, when surgical treatment has failed or is impossible. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. Two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. Conclusions E-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered
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