Endoscopic Vacuum-assisted Closure Research Articles

Management of esophageal anastomotic leaks, a systematic review and network meta-analysis.

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.

Modified Endoscopic Vacuum Assisted Closure (E-VAC) is a novel minimally invasive technique for treating esophageal pleural fistulas

BackgroundSurgical pathologies of the esophagus in the pediatric age are not unusual. However, when they appear, they are not complications-free. These include anastomotic dehiscence or pleural fistulas. Classically they are treated clinically, and this treatment is associated with complications such as mediastinitis, pleural effusion, sepsis, and death. We propose treating esophageal dehiscence using a negative pressure system placed endoscopically. This minimally invasive procedure can be used as definitive treatment or bridging therapy for surgical correction. MethodsThis is a retrospective longitudinal multicenter study from January 2018 to January 2022 in five medical centers, three located in Colombia and two in Mexico. The patients had esophageal dehiscence or pleural fistula diagnosed by contrast leakage in postoperative esophagogram or endoscopy and treated with an endoscopic negative pressure system, with a 30-day follow-up after the diagnosis. We analyze the time of placement, pressure and E-VAC (Endoscopic- Vacuum Assisted Closure) replacements, as well as the efficacy and inherent complications. ResultsWe present nine patients diagnosed with esophageal dehiscence or pleural fistula treated with endoscopic VAC. The oldest was 14-years old and the youngest was 2-day-old. Six patients were diagnosed with esophageal atresia, either type III or type I. The other three patients had gastric volvulus, short esophagus, and embryonic esophageal remnants. The most frequent initial surgical procedures were the correction of esophageal atresia and esophageal-jejunal anastomosis. The esophageal dehiscence or pleural fistula was diagnosed by esophagogram with hydrosoluble contrast. Four patients had E-VAC as initial therapy; the remaining five used it after expectant management failed. Fistula closure took an average of 13 days, with fewer than three VAC changes required. Two of the nine patients presented with subsequent anastomotic stenosis, which was treated with endoscopic dilation using a balloon dilation. ConclusionsUsing the E-VAC system in esophageal and pleural fistulas is effective in all our patients. It also shortens hospitalization and treatment time when performed as the first management line. We recommend using E-VAC at a pressure of 50 - 125 mmHg and preferably of the continuous type. System changes are indicated when there are suction problems, system clogging, or E-VAC migration when relocation is impossible. The other methods described do not use the transparent dressing, so it must be completely changed at each control. Level evidenceIV

Comparison of long-term quality of life outcomes between endoscopic vacuum therapy and other treatments for upper gastrointestinal leaks.

While endoscopic vacuum assisted closure (EVAC) therapy is a validated treatment for gastrointestinal leaks, its impact on long-term quality of life (QoL) is uncertain. The purpose of this study was to evaluate the impact of successful EVAC management on long-term QoL outcomes. An institutional review board approved prospectively maintained database was retrospectively reviewed to identify patients undergoing treatment for gastrointestinal leaks between June 2012 and July 2022. The Short-Form 36 (SF-36) survey was used to assess QoL. Patients were contacted by telephone and sent the survey electronically. QoL outcomes between patients who underwent successful EVAC therapy and those who required conventional treatment (CT) were analyzed and compared. A total of 44 patients (17 EVAC; 27 CT) completed the survey and were included in our analysis. All included patients had foregut leaks with sleeve gastrectomy being the most common sentinel operation (n = 20). The mean time from the sentinel operation was 3.8years and 4.8years for the EVAC and CT groups, respectively. When evaluating long-term QoL, the EVAC group scored higher in all QoL domains when compared to the CT group with physical functioning (87.3 vs 69.3, p = 0.04), role limitations due to physical health (84.1 vs 45.7, p = 0.02), energy/fatigue (60.0 vs 40.9, p = 0.04), and social functioning (86.2 vs 64.1, p = 0.04) reaching statistical significance. Overall, patients who achieved organ preservation via successful EVAC therapy scored higher in all domains with role limitations due to physical health (p = 0.04) being statistically significant. In a multivariable regression analysis, increased age and a history of prior abdominal surgery at the time of the sentinel operation were patient characteristics that negatively impacted QoL outcomes. Patients with gastrointestinal leaks successfully managed by EVAC therapy have better long-term QoL outcomes when compared to patients undergoing other treatments.

Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series

PurposeComparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR.MethodsThis retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up.ResultsOverall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008).ConclusionProactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.

Modified Endoscopic Vacuum-Assisted Closure (EVAC) for Esophageal Perforation: a Promising and Simplified Technique — Report of Three Patients

Modified Endoscopic Vacuum-Assisted Closure (EVAC) for Esophageal Perforation: a Promising and Simplified Technique — Report of Three Patients

Bariatric endoscopy: from managing complications to primary metabolic procedures.

Obesity is a worldwide epidemic and is the second leading cause of preventable death. The approach to treating obesity involves a multidisciplinary approach including lifestyle interventions, pharmacological therapies, and bariatric surgery. Endoscopic interventions are emerging as important tools in the treatment of obesity with primary and revisional bariatric endoscopic therapies. These include intragastric balloons, aspiration therapy, suturing and plication, duodenal-jejunal bypass liners, endoscopic duodenal mucosal resurfacing, and incisionless magnetic anastomosis systems. Endoscopic interventions have also demonstrated efficacy in treating complications of bariatric surgery. Approaches include stenting, endoscopic internal drainage, and endoscopic vacuum-assisted closure. This review aimed to discuss the current endoscopic procedures used as primary and revisional bariatric therapy including those used for managing bariatric surgical complications.

Endoscopic vacuum therapy significantly improves clinical outcomes of anastomotic leakages after 2-stage, 3-stage, and transhiatal esophagectomies

BackgroundAnastomotic leakages after esophagectomies continue to constitute significant morbidity and mortality. Intrathoracic anastomoses pose a high risk for mediastinitis, sepsis, and death, if a leak is not addressed timely and appropriately. However, there are no standardized treatment recommendations or algorithms as for how to treat these leakages.MethodsThe study included all patients at the University Hospital Regensburg, who developed an anastomotic leakage after esophagectomy with gastric pull-up reconstruction from 2007 to 2022. Patients receiving conventional treatment options for an anastomotic leakage (stents, drainage tubes, clips, etc.) were compared to patients receiving endoscopic vacuum-assisted closure (eVAC) therapy as their mainstay of treatment. Treatment failure was defined as cervical esophagostomy formation or death.ResultsIn total, 37 patients developed an anastomotic leakage after esophagectomy with a gastric pull-up reconstruction. Twenty patients were included into the non-eVAC cohort, whereas 17 patients were treated with eVAC. Treatment failure was observed in 50% of patients (n = 10) in the non-eVAC cohort and in 6% of patients (n = 1) in the eVAC cohort (p < 0.05). The 90-day mortality in the non-eVAC cohort was 15% (n = 3) compared to 6% (n = 1) in the eVAC cohort. Cervical esophagostomy formation was required in 40% of cases (n = 8) in the non-eVAC cohort, whereas no patient in the eVAC cohort underwent cervical esophagostomy formation.ConclusioneVAC therapy for leaking esophagogastric anastomoses appears to be superior to other treatment strategies as it significantly reduces morbidity and mortality. Therefore, we suggest eVAC as an essential component in the treatment algorithm for anastomotic leakages following esophagectomies, especially in patients with intrathoracic anastomoses.

Endoscopic vacuum-assisted closure therapy for leakage of the lower gastrointestinal tract: multicenter experiences.

Background and study aims Only a few studies are available regarding endoscopic vacuum-assisted closure (E-VAC) therapy for the post-surgery leakage of the lower gastrointestinal tract. Patients and methods In this multicenter German study, we retrospectively analyzed patients treated with E-VAC therapy due to post-surgery leakage of the lower gastrointestinal tract from 2000-2020 at Hannover Medical School, University Medical Center Schleswig-Holstein, Campus Luebeck, and Robert Koch Hospital Gehrden. Results Overall, 147 patients were included in this study. Most patients had undergone tumor resections of the lower gastrointestinal tract (n = 88; 59.9 %). Median time to diagnosis of leakage was 10 days (interquartile range [IQR] 6-19). Median duration of E-VAC therapy was 14 days (IQR 8-27). Increase of C-reactive protein (CRP) levels significantly correlated with first diagnosis of leakage ( P < 0.001). E-VAC therapy led to closure or complete epithelialization of leakage in the majority of patients (n = 122; 83.0 %) and stoma reversal was achieved in 60.0 %. Stoma reversal was significantly more often achieved in patients with CRP levels ≤ 100 mg/L at first diagnosis compared to patients with CRP levels > 100 mg/L (78.4 % vs. 52.7 %; P = 0.012). Odds ratio for failure of stoma reversal was 3.36 in cases with CRP values > 100 mg/L ( P = 0.017). In total, leakage- and/ or E-VAC therapy-associated complications occurred in 26 patients (17.7 %). Minor complications included recurrent E-VAC dislocations and subsequent stenosis. Overall, 14 leakage- or E-VAC-associated deaths were observed most often due to sepsis. Conclusions E-VAC therapy due to post-surgery leakage of the lower gastrointestinal tract is safe and effective. High levels of CRP are a negative predictor of E-VAC therapy success.

Esophageal Dilation in Children: A State of the Art Review.

Esophageal dilations in children are performed by several pediatric and adult professionals. We aim to summarize improvements in safety and new technology used for the treatment of complex and refractory strictures, including triamcinolone injection, endoscopic electro-incisional therapy, topical mitomycin-C application, stent placement, functional lumen imaging probe assisted dilation, and endoscopic vacuum-assisted closure in the pediatric population.

Endoscopic vacuum-assisted surgical closure (EVASC) of anastomotic defects after low anterior resection for rectal cancer; lessons learned

BackgroundEndoscopic vacuum-assisted surgical closure (EVASC) is an emerging treatment for AL, and early initiation of treatment seems to be crucial. The objective of this study was to report on the efficacy of EVASC for anastomotic leakage (AL) after rectal cancer resection and determine factors for success.MethodsThis retrospective cohort study included all rectal cancer patients treated with EVASC for a leaking primary anastomosis after LAR at a tertiary referral centre (July 2012—April 2020). Early initiation (≤ 21 days) or late initiation of the EVASC protocol was compared. Primary outcomes were healed and functional anastomosis at end of follow-up.ResultsSixty-two patients were included, of whom 38 were referred. Median follow-up was 25 months (IQR 14–38). Early initiation of EVASC (≤ 21 days) resulted in a higher rate of healed anastomosis (87% vs 59%, OR 4.43 [1.25–15.9]) and functional anastomosis (80% vs 56%, OR 3.11 [1.00–9.71]) if compared to late initiation. Median interval from AL diagnosis to initiation of EVASC was significantly shorter in the early group (11 days (IQR 6–15) vs 70 days (IQR 39–322), p < 0.001). A permanent end-colostomy was created in 7% and 28%, respectively (OR 0.18 [0.04–0.93]). In 17 patients with a non-defunctioned anastomosis, and AL diagnosis within 2 weeks, EVASC resulted in 100% healed and functional anastomosis.ConclusionEarly initiation of EVASC for anastomotic leakage after rectal cancer resection yields high rates of healed and functional anastomosis. EVASC showed to be progressively more successful with the implementation of highly selective diversion and early diagnosis of the leak.Graphical abstract

Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How?

The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.

Endoscopic Vacuum-assisted Closure in a Patient with an Overtube-induced Esophageal Perforation

An esophageal perforation is one of the most fatal clinical events, with a mortality rate of up to 21%. This may arise postoperatively or post-endoscopically. In the past, surgical treatment, such as an esophagectomy, was performed these cases. However, the procedure was challenging and had a high risk of postoperative complications. Recently, advancements in endoscopic techniques have been made, and endoscopic procedures became a common treatment modality for patients with esophageal perforation, even in those with underlying diseases. Among the endoscopic procedures, endoscopic vacuum-assisted closure (E-VAC) has been known to be safe and effective. We present the case of a 64-year-old female with advanced liver cirrhosis and an overtube-induced esophageal perforation during esophageal variceal ligation. She was successfully treated with E-VAC.

Management of post-operative pancreatic fistulas following Longmire\u2013Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy

BackgroundPylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT.MethodsWe included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed.ResultsPGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT.ConclusionsEVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.

APPLICATION OF MINIMUM INVASIVE TECHNIQUE ENDOSCOPIC VACUUM – ASSISTED CLOSURE FOR THE TREATMENT OF ESOPHAGEAL ANASTOMOTIC LEAKAGE: THE FIRST CASE AT HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Background: Today, the treatment of anastomotic leakage is still a challenging issue associated with high morbidity and mortality, especially esophageal surgery. Endoscopic vacuum-assisted closure (EVAC) is a technique that uses negative pressure wound therapy to treat fistula endoscopically. Recently, endoscopic approaches have been applied with a high success rate. An endo-SPONGE connected to a nasogastric tube under endoscopic guide into a fistula cavity. This procedure facilitates healing, obtains source control, and aid in reperfusion of the adjacent tissue with debridement. Case report: We report a post-thoracoscopicesophagectomy case of a 74-year-old man who successfully treated anastomotic leakage using EVAC. Result: This is the first case report of applying this new technique in our country and achieving successful outcomes

Endoscopic vacuum assisted closure (E-VAC) of upper gastrointestinal leakages

Objectives Endoscopic vacuum-assisted closure (E-VAC) of leaks of the upper gastrointestinal tract is an increasingly applied endoscopic technique. Data on indication, clinical success, complications and prognostic factors are still sparse. Methods Patients treated with E-VAC between 2012 and 2019 at a tertiary referral center have been retrospectively analyzed. Results Overall, 116 patients treated with E-VAC were identified. Indication for E-VAC placement was postoperative leakage in 94/116 (81%), iatrogenic perforations 7/116 (6%) and others 15/116 (13%). In 92/116 (79%) of the patients E-VAC therapy showed successful wound closure. The first E-VAC after detection of insufficiency was significantly more often placed intracavitary in patients with E-VAC failure (p = .031). There was a trend for longer intensive care unit treatment for patients with E-VAC failure (p = .069). Complications occurred significantly more often in patients with E-VAC failure (p = .009). Platelet count was significantly higher in patients with E-VAC success at day of insufficiency detection (257/Thsd/µL (interquartile range [IQR], 185–362) vs. 195 (IQR, 117–309); p = .039). Platelet count (375 Thsd/µL (IQR, 256–484) vs. 190 (IQR, 129–292)), hemoglobin (9.5 g/dL (IQR, 8.8–10.1) vs. 8.7 g/dL (IQR, 8.15-9.35)) and C-reactive protein level (79 mg/L (IQR, 39.7-121.9) vs. 152 mg/L (IQR, 73.7-231)) at day 14 differed significantly. The 30 days mortality rate was 33.3% (8/24) in E-VAC failure compared with 2.2% in patients with E-VAC success (p = .001). Conclusions E-VAC is an emerging highly effective interventional endoscopic technique for gastrointestinal wound closure even in highly selected patients.

Endoscopic vacuum assisted closure of gastrocutaneous fistula after sleeve gastrectomy combined with fibrin sealant

Treatment of gastrointestinal fistulas after staple line leaks is difficult and non-invasive procedures such as endoclips, stents or endoscopic vacuum assisted closure (E-VAC) are sometimes not adequate. Fibrin sealants (FS) may promote healing, although today are used mainly to prevent anastomosis dehiscence within digestive tract. The authors present a 37-year-old female patient who developed a chronic gastrocutaneous fistula after sleeve gastrectomy for severe obesity treated successfully with a combination of E-VAC and a fibrin sealant. Long term peritoneal drainage, total parenteral nutrition, and antibiotic therapy for the next six weeks failed to close the leakage. Ultimately the fistula was closed after 6 changes of E-VAC and final implementation of a fibrin sealant. The duration of treatment was 81 days, including 34 days of E-VAC treatment and FS application. Complete closure of the fistula was visualized on gastroscopy six weeks after the treatment.

Endoscopic Vacuum Therapy to Seal Recalcitrant Esophageal Leak After Esophageal Surgery in Children

Postoperative esophageal leak is a serious adverse event that occurs in up to 20% following esophageal surgery. Increasingly, endoscopy is utilized to manage leaks refractory to surgical washout and drainage including endoscopic vacuum-assisted closure (EVAC) using negative pressure therapy to achieve source control and granulation. In this report, successful use of this endoscopic strategy to seal a persistent leak after esophageal diverticulectomy is described. A two-year-old male born with esophageal atresia and tracheoesophageal fistula underwent primary anastomosis on the first day of life. Two years later, he presented symptomatic from a diverticulum at the anastomosis and underwent diverticulectomy complicated by esophageal leak at the diverticulectomy site. Despite multiple surgical interventions to seal the leak and obtain source control, the esophageal leak persisted. A multidisciplinary team of surgeons, gastroenterologists, and radiologists determined in consensus with the family of the patient to proceed with EVAC beginning with intracavitary placement of a dressing sponge secured on a nasoesophageal tube. After six endoscopic sessions, the esophageal leak was determined to be closed on endoscopic and fluoroscopic imaging. The patient was ultimately discharged home nine days after removal of the endoscopic vacuum. The leak site remained closed on fluoroscopic esophagram studies performed 6 months later. Negative pressure therapy successfully closed a refractory esophageal leak in a child resulting from diverticulectomy. Future investigations should employ larger series to compare the efficacy, tolerance, and duration of therapy needed to close leaks from EVAC versus stenting.

Efficacy of Endoscopic Vacuum-Assisted Closure Treatment for Postoperative Anastomotic Leak in Gastric Cancer.

Background/AimsEndoscopic vacuum-assisted closure (EVAC) has been attempted as new nonsurgical treatment for anastomotic leakage. We aimed to evaluate the clinical outcomes of EVAC and compare its efficacy with the self-expandable metallic stent (SEMS) for postgastrectomy leakage.MethodsBetween January 2007 and February 2018, 39 patients underwent endoscopic treatment for anastomotic leakage after gastric cancer surgery. Of them, 28 patients were treated with SEMS, seven with EVAC after SEMS failure, and four with EVAC. We retrospectively compared the clinical characteristics and therapeutic outcomes between EVAC (n=11) and SEMS (n=28).ResultsThe median follow-up duration was 17 months (interquartile range, 9 to 26 months) in both groups. In comparison of clinical characteristics between two groups, only the median size of the leak was larger in the EVAC group than in the SEMS group (2.1 cm vs 1.0 cm; p<0.001). All EVAC cases healed successfully; however, two cases (7.1%) failed to heal in the SEMS group. Anastomotic stricture occurred one case (9.1%) in EVAC and four cases (14.3%) in SEMS within 1 year after endoscopic treatment. The median treatment duration of EVAC was shorter than that of SEMS (15 days vs 36 days; p<0.001). Median weight loss after therapy was similar in both groups (8.0 kg in EVAC vs 9.0 kg in SEMS; p=0.356).ConclusionsEVAC can be effective endoscopic treatment for postgastrectomy anastomotic leakage. Substantial leakage could be an important clinical factor for considering EVAC as a treatment option. Large randomized controlled trials are needed to confirm the efficacy of EVAC.

Long-Term Results after Anastomotic Leakage following Rectal Cancer Surgery: A Comparison of Treatment with Endo-Sponge and Transanal Irrigation

Objective: We aimed to evaluate long-term results in patients from regular health care treated with endoscopic transanal closure system, that is, endoscopic vacuum-assisted closure system (EVAC) compared to transanal irrigation. Methods: In this retrospective, medical chart-based, observational study, we included patients with anastomotic leakage after low anterior resection for rectal cancer from 3 Stockholm hospitals 2006–2016 and compared time to first stoma closure in a Kaplan-Meier model and the proportion of patients who were stoma-free at end of follow-up. Results: Anastomotic leakage was found in 81 patients who were followed up in median 5.9 years (min–max: 0.53–13). EVAC was used on 14 (17%) patients and transanal irrigation on 34 (42%) patients. The remaining 33 (41%) patients either got a permanent colostomy or were treated only with antibiotics and percutaneous drainage. Treatment with EVAC or transanal irrigation led to similar rates of stoma closure, both when comparing all patients, and when comparing patients with similar defects. At the end of follow-up, 43% of patients treated with EVAC and 50% of patients treated with repeated irrigation were stoma-free (p = 0.75). Conclusions: We found no evidence of better outcomes in patients treated with EVAC. The study was, however, limited by small sample size.

Management of Intrathoracic and Cervical Anastomotic Leakage after Esophagectomy for Esophageal Cancer: A Systematic Review

Anastomotic leakage (0–30%) after esophagectomy is a severe complication and is associated with considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy have the best clinical outcome, based on the currently available literature. A systematic literature search was performed in Medline, Embase, and Web of Science until April 2017. All studies reporting on the specific treatment of cervical or intrathoracic anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Mortality rates of intrathoracic anastomotic leakages in the treatment groups were as follows: conservative (14%), endoscopic stent (8%), endoscopic drainage (8%), endoscopic vacuum-assisted closure system (0%), and surgery treatment group (50%). Mortality rates of cervical anastomotic leakages in the treatment groups were as follows: conservative (8%), endoscopic stent (29%), and endoscopic dilatation (0%). Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting a specific treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. In the absence of robust evidence-based treatment guidelines, we suggest customized treatment depending on sequelae of the leak and clinical condition of the patient. PrDepartment of Surgery, Radboudumc, P.O.B. 9101/618 NLactical advices are provided. Registration number PROSPERO: CRD42016032374 .