S2322 Utilization of Endoluminal Vacuum Therapy for a Challenging Lesser Curve Leak

Abstract

INTRODUCTION: Anastomotic leaks can occur in up to 15% of patients undergoing esophagectomy with gastric pull-up. Endoluminal vacuum therapy has become a well-documented technique to treat perforations and anastomotic leaks; however, technical success can vary. We present a case of a lesser curve anastomotic leak after esophagectomy that developed into a large cavity requiring unique techniques for successful endoluminal vacuum therapy. CASE DESCRIPTION/METHODS: A 66-year old male with esophageal adenocarcinoma underwent an Ivor Lewis esophagectomy. On day 20, a CT scan to investigate abdominal pain revealed a lesser curvature staple line leak resulting in an empyema (Figure 1). Chest drainage was performed and a pigtail catheter was maintained to gravity. An EGD was performed given persistent drain output and revealed a 4-cm linear defect into the pleural cavity with substantial debris (Figure 2). Given the size and location, endoluminal vacuum therapy was planned. A 16 Fr nasogastric tube (NGT) was passed nasal to oral and a wound vac sponge was sutured with 3-0 silk to the tip. This was subsequently advanced into the gastric defect and chest cavity and placed to vacuum suction. Given the angulation, a biliary wire was used to maintain visualization. To insert a larger-sized sponge into the cavity, a double-channeled gastroscope was used to simultaneously manipulate two rat tooth forceps. Once a shallow, smaller defect was present, the NGT was transitioned to a 10-mm Jackson-Pratt (JP) silicone flat drain, allowing for easier sponge placement and better approximation. Strict nil per os, antacid therapy, and pigtail chest drainage to bulb suction were key to keep the cavity dry. After 13 exchanges, the defect appeared closed as confirmed with fluoroscopy (Figure 3). DISCUSSION: Endoluminal vacuum therapy is an effective therapy to treat anastomotic leaks after esophagectomy. Several characteristics can alter technical success, and in our case, the angulation at the cavity inlet, linear nature of cavity, and drain management presented challenges. An endoscopically placed wire can be used to maintain visualization of a defect and the use of two rat tooth forceps through a double-channeled gastroscope allows for easier manipulation of the sponge. Bulb suction should be applied to cavity drains for an ideal vacuum effect. The shape and fenestrations of a JP flat drain allow for better positioning into linear defects as they become smaller and apply an evenly distributed gentle vacuum effect.Figure 1.: CT imaging with lesser curvature staple line leak resulting in right posterior pleural space empyema (yellow box).Figure 2.: Initial EGD demonstrating the inlet of the defect (left, black oval) and deep linear cavity (right).Figure 3.: Endoscopic (left, black oval) and fluoroscopy image (right) confirming defect resolution.