Successful Closure of Upper GI Leaks by Endoscopic Vacuum Therapy

Abstract

Endoscopic Vacuum Therapy (EVT) is a novel approach in the management of GI perforations and leaks. We report 3 cases of post-surgical leaks that failed previous endoscopic therapy but were closed by EVT. In all cases, a wound vacuum sponge (KCI-V.A.C. GranuFoam) was affixed to the distal end of a 12 or 16Fr NG tube (Covidien) with 2-0 sutures and endoscopically guided to the defect. The sponge was then placed either intracavitarilly or intraluminally. In case 1, a 58 year old man developed a 15mm duodenal leak after surgical resection of a 20cm retroperitoneal hemangiopericytoma. The sponge/NG tube was inserted nasally over a guidewire, endoscopically guided into the duodenal perforation using a snare, and secured with hemoclips. The NG tube was kept at low continuous suction (30 mm Hg) and was replaced once over a 28-day period, ultimately resulting in leak closure. Patient was discharged tolerating oral diet with CT showing resolution of fluid collections. In case 2, a 62 year old woman with gastric adenocarcinoma developed a persistent 0.6cm anastomotic leak after total gastrectomy and esophago-jejunal anastomosis. EVT was employed intracavitarilly with NG tube kept at low continuous suction (30mm Hg) for 7 days, leading to leak closure. After sponge removal, the patient was discharged tolerating full liquid diet with imaging confirming leak resolution. In case 3, a 48 year old woman with history of lap band placement underwent gastric bypass surgery with development of a small abscess and esophageal leak. EGD showed a leak 2cm above the GE junction. An OTSC, one partially covered and, later, one fully covered esophageal metal stent were placed. Repeat EGD showed a persistent 4mm opening near the OTSC with radiographic evidence of leak. The EVT sponge/NG tube was placed intraluminally over the leak. The NG tube was kept on low continuous suction (30mmHg) and replaced once over a 17-day period. After removal of the sponge, the patient was discharged on full liquid diet. Follow-up CT demonstrated resolution of the leak and the abscess. EVT is a promising approach to the management of upper GI luminal defects. The appeal of the technique lies in its minimally invasive nature, ease of use, and cost effectiveness. Our cases support EVT's reported efficacy and provides evidence for its role as a viable alternative to surgical closure, OTSC, or metal stent placement in the repair of upper GI perforations/leaks2123_A Figure 1. The vacuum sponge affixed to the distal end of a NG tube2123_B Figure 2. The sponge/NG tube placed intracavitarilly within the defect