Management Of Leaks Research Articles

Glycopyrrolate as an Adjunct in the Management of Anastomotic Leak Following Repair of Esophageal Atresia: A Clinicoradiological Perspective.

Anastomotic leak after primary repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a well-known complication and can represent a challenging clinical scenario. The present study aimed to evaluate the role of glycopyrrolate as an adjunct in the treatment of anastomotic leak after primary repair of EA Vogt type 3b. A retrospective study was carried out in our tertiary care teaching institute from January 2015 to December 2022. Neonates with EA with distal TEF with primary repair who had developed anastomotic leak, managed by the author(s), were studied. The study included patients with major, minor, and radiological leaks. Glycopyrrolate was administered in the dose of 4 μg/kg 8 hourly. The outcomes of the study were either resolution or progression of the leak. There were 21 patients who were managed with glycopyrrolate in addition to the classical treatment of the anastomotic leak following repair of EA with distal TEF. The male: female ratio was 1:1.1. All the cases had anastomotic leaks with either clinically detectable in the chest tube (15) or radiological leak (6). The leaks were detected early in patients with major leak (mean = 3.2 ± 0.84 days) compared to minor leak (mean =4.9 ± 1.29 days). Radiological leaks were detected in all the neonates on postoperative day 7. In five patients with major leak, there was a negligible reduction in the amount of chest tube output, and were subjected to diversion procedures. There were a total of three deaths out of five in this group. In 10 patients with minor leak, there was complete resolution of anastomotic leak in eight patients (80%); there was one patient each with mortality and diversion procedure. The patients with a radiological leak (6) did not show any deterioration, and they were fed 1-5 days after the esophagogram. Glycopyrrolate may be an advantageous postoperative adjunct in the management of minor and radiological leak after tracheoesophageal repair.

Management of chyle leak after whipple surgery

Management of chyle leak after whipple surgery

Endoscopic vacuum therapy: management of upper gastrointestinal anastomotic leaks and esophageal perforations.

Upper gastrointestinal tract (UGT) leaks are associated with severe morbidity and mortality. Endoluminal vacuum (EVAC) therapy is a promising approach for repairing effectively these defects. Our study describes the results obtained from a series of cases treated with EVAC for the management of esophageal anastomotic (EA) leak following esophagectomy for cancer, gastroenteric (GE) anastomoses leak after bariatric surgery and esophageal perforation (EP). We retrospectively analyzed ten patients who had an EA and GE anastomoses leaks and EP treated with EVAC. We described the results of the sample in terms of treatment failure, treatment duration, and number of EVAC replacements. Five patients underwent esophagectomy with neoadjuvant radio-chemotherapy, one patient underwent gastrojejunal bypass bariatric surgery and there were four EP. The median size of mucosal defects was 6,9 mm. The median duration of treatment was thirteen days with 3,6 interventions performed, every three to four days. Treatment success rate was 70%. Treatment failure was 30%: two patients required surgery and in one case an endoluminal prosthesis. EVAC therapy is an appropriate treatment for the management of postoperative fistulas in the UGT. Longer treatments are associated with neoadjuvant chemoradiotherapy and larger fistulas.

Analysis of carbon dioxide disposal methods to reduce greenhouse gases

The practice of capturing, storing and utilizing CO2 is becoming key to developing sustainable energy and industrial solutions. The technology promotes the use of fossil fuels, which remain the predominant source of energy worldwide. The effectiveness of the technology is evident in the reduction of CO2 levels in the atmosphere, a significant contribution to the reduction of global greenhouse gas (GHG) emissions and the fight against climate change. However, a notable concern in the realm of geological storage revolves around the potential leakage of CO2 from storage reservoirs. Carbon dioxide has the capability to migrate from the storage site, reaching both the surface and underground formations. Surface leakage presents health risks to humans, animals, and plants. The solution to this problem requires a detailed approach and should be solved through an inverse problem, in which pressure measurements in monitoring wells will be performed frequently to obtain information about the reservoir and possible leaks. Additionally, there are a number of issues with carbon dioxide leakage during oil and gas extraction, as well as various operations at fields. Emphasizing the monitoring of CO2 leakage, this paper underscores the importance of developing an algorithm designed to proactively prevent CO2 leakage in aquifers and depleted reservoirs. Such an initiative is pivotal in the broader context of mitigating greenhouse gas emissions. The paper offers an overview of methodologies for effective monitoring, management and modeling of CO2 leakage and practical approaches to calculation and assessment, contributing to a more complete understanding of the challenges associated with CO2 storage.

Successful Management of Chyle Leakage Using Thoracic Duct Embolization: A Case Report

Successful Management of Chyle Leakage Using Thoracic Duct Embolization: A Case Report

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament.

Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage. We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage. Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed. The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Neuro-ophthalmic features of patients with spontaneous cerebrospinal fluid leaks.

Increased intracranial pressure is a potential cause of spontaneous cerebrospinal fluid (sCSF) leak. Associated neuro-ophthalmic features have not been well studied, particularly relationships with idiopathic intracranial hypertension (IIH). We hypothesized that neuro-ophthalmic features routinely used in evaluations for IIH can be useful in the investigation of a causal relationship between IIH and sCSF leak. We reviewed the neuro-ophthalmic examination and office-based ophthalmic imaging data of all consecutive patients with sCSF leaks and at least one repair to investigate the clinical and neuro-ophthalmic features of increased intracranial pressure. We conducted a retrospective longitudinal study at a single institution by querying the electronic medical record system for CSF leak Current Procedural Terminology (CPT) codes (G96.00 and G96.01) from June 1, 2019, to July 31, 2022. For patients with a confirmed diagnosis of sCSF leak, demographic information, eye examination results, and ophthalmic imaging details for both eyes were collected. A total of 189 patients with CSF leaks were identified through CPT coding; 159 had iatrogenic or traumatic CSF leaks, and 30 individuals (3 male, 27 female) had confirmed sCSF leaks. The mean age of patients with sCSF leaks was 46 years (range: 29 - 81), with a mean body mass index of 35.2 kg/m2 (range: 18.2 - 54.1). Only 11 of 30 underwent eye examinations (8 before surgical repair and 10 after). The mean pre-repair and post-repair best-corrected visual acuity were 20/30 (range: 20/20 - 20/55) and 20/25 (range: 20/20 - 20/40), respectively (P = 0.188). The mean retinal nerve fiber layer thickness was 99 µm (range: 96 - 104) pre-repair and 97 µm (range: 84 - 103) post-repair (P = 0.195). The mean ganglion cell complex thickness was 84 µm (range: 72 - 94) pre-repair and 82 µm (range: 71 - 94) post-repair (P = 0.500). Humphrey visual field average mean deviation was -5.1 (range: -12.4 - -1.8) pre-repair and -1.0 (range: -10.1 - 2.1) post-repair (P = 0.063). Serial neuro-ophthalmic examinations are recommended for patients with sCSF leaks to screen for signs of current or prior increased intracranial pressure. Larger studies are required to clarify the longitudinal changes in neuro-ophthalmic features, to investigate the incidence of IIH in cases of sCSF leak development or recurrence after surgical repair, and to explore potential causal relationships to guide post-repair management and prevent recurrent leaks. A multicenter consortium is also suggested to develop a standard clinical protocol for comprehensive management of sCSF leaks.

Construction of an Endoluminal Vacuum Using Readily Available Supplies for the Management of Leak After IPAA.

Construction of an Endoluminal Vacuum Using Readily Available Supplies for the Management of Leak After IPAA.

Interventional endoscopy in inflammatory bowel disease: a comprehensive review.

Interventional endoscopy can play a key role in the multidisciplinary management of complex inflammatory bowel disease (IBD) as an adjunct to medical and surgical therapy. The primary role of interventional IBD (IIBD) includes the treatment of Crohn's disease-related stricture, fistula, and abscess. Endoscopic balloon dilation (EBD), endoscopic stricturotomy, and placement of endoscopic stents are different forms of endoscopic stricture therapy. EBD is the most widely used therapy whereas endoscopic stricturotomy has higher long-term efficacy than EBD. Fully covered and partially covered self-expanding metal stents are useful in long and refractory strictures whereas lumen-apposing metal stents can be used in short, and anastomotic strictures. Endoscopic fistula/abscess therapy includes endoscopic fistulotomy, seton placement, endoscopic ultrasound-guided drainage of rectal/pelvic abscess, and endoscopic injection of filling agents (fistula plug/glue/stem cell). Endoscopic seton placement and fistulotomy are mainly feasible in short, superficial, single tract fistula and in those with prior surgical seton placement. Similarly, endoscopic fistulotomy is usually feasible in short, superficial, single-tract fistula. Endoscopic closure therapies like over-the-scope clips, suturing, and self-expanding metal stent should be avoided for de novo/bowel to hollow organ fistulas. Other indications include management of postoperative complications in IBD such as management of surgical leaks and complications of pouchitis in ulcerative colitis. Additional indications include endoscopic resection of ulcerative colitis-associated neoplasia (by endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection), retrieval of retained capsule endoscope, and control of bleeding. IIBD therapies can potentially act as a bridge between medical and surgical therapy for properly selected IBD patients.

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

There is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator. A group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP. The time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077). The performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator.

A novel method for the bronchial occlusion of prolonged air leakage using customized endobronchial plugs.

The management of prolonged air leakage (PAL) is a significant clinical challenge, particularly for patients who are unfit for surgical treatment. The use of endoscopic interventions with occlusive devices has been reported previously; however, local availability and cost may represent potential hurdles, especially in developing countries. In this study, we presented a conical endobronchial plug of our design and evaluated the efficacy of making use of that in the treatment of PAL as a novel method. This retrospective study included a total of 23 patients with PAL who were not suitable for surgery and underwent bronchial occlusion using customized plugs. The responsible bronchi were identified by the balloon occlusion test or by end-tidal carbon dioxide detection. In each case, the plug was grasped at the knot of the tip with forceps and then inserted into the target bronchus with a flexible bronchoscope. Of the 23 patients with intractable pneumothorax, 1 to 3 plugs (median =1) were successfully inserted into the affected bronchi of each patient for bronchial occlusion. Air leakage showed complete cessation in 13 patients (56.5%) and reduction in seven patients (30.4%). A total of 20 patients (87.0%) experienced successful removal of the drainage tube following plug occlusion or presented with additional pleurodesis. Complications included expectoration of the plug (n=1) and fever (n=1); no other severe complications were observed. Bronchial occlusion using customized endobronchial plugs appears to be an effective and simple option for the management of PAL in patients who are not suitable for surgery, especially in developing countries, as the customized plug is a cost-effective alternative.

The Optimal Treatment Strategy for Postoperative Anastomotic Leakage After Esophagectomy: a Comparative Analysis Between Endoscopic Vacuum Therapy and Conventional Treatment.

We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4-142] days vs. 70 [8-604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.

Management of Chyle Leakage after Thyroid Cancer Surgery

Management of Chyle Leakage after Thyroid Cancer Surgery

Endoscopic management of upper gastrointestinal perforations, leakage and fistula

Endoscopic management of upper gastrointestinal perforations, leakage and fistula

Surgical prevention and management of pancreatic leak after pancreatectomy

Surgical prevention and management of pancreatic leak after pancreatectomy

EGS P03 Outcomes from 450 Endoluminal Vacuum Therapy (EVT) Procedures in the Management of Upper Gastrointestinal Leaks and Perforations

Abstract Background Anastomotic leaks and perforations of the upper gastrointestinal (UGI) tract are life-threatening conditions which result in significant rates of morbidity. There is no consensus with respect to how these challenging cases should be optimally managed. Endoluminal vacuum therapy (EVT) is a novel approach for the management of leaks and perforations in the UGI tract. Proponents highlight the benefits of its use particularly in cases where major invasive surgery or re-operation would otherwise usually be required. We present the outcomes from nearly 450 EVT related procedures during the last 5 years. Methods A retrospective analysis of all UGI leaks and perforations managed with EVT between September 2018 and June 2023 was undertaken. This included patients who had undergone cancer resections (oesophagectomy and gastrectomy), bariatric surgery (both within and out with our centre) and those presenting with benign disease (e.g. oesophageal perforation and iatrogenic injury). The setting was a regional tertiary oesophago-gastric and bariatric centre in the North-West of England serving a population of over 3.5 million people. Demographic data, patient and disease factors, nutrition-related data, and outcomes related to EVT were collected. Descriptive and statistical analysis was undertaken. Results 59 patients (43 males; median age 61) underwent 446 EVT related procedures during the study period, of which 52 (88%) were alive at discharge. Median LOS was 43 days. 66% (39/59) cases related to post-operative leak (resection 28, bariatric surgery 11) vs 11/59 spontaneous and 8/59 iatrogenic perforations. Median number of procedures was 6 (IQR 3-11) over a median of 21 days (IQR 11-41). Successful healing was achieved in 86% (51/59) cases. There was no difference in success rate between pathologies (p=0.88), however, iatrogenic perforations required fewer EVT procedures before healing (p=0.00). No adverse events were directly attributable to EVT. Conclusions UGI leaks and perforations represent a heterogeneous group which pose a significant management challenge. Our study suggests that EVT is a safe and effective approach in managing a broad range of different UGI leaks and perforations. EVT opens the possibility of active treatment for patients unsuitable for more invasive surgical intervention. Further study is required to standardise nomenclature, indications and follow-up. Comparisons to other management approaches are required to further explore the benefits for patients, taking into consideration clinical efficacy, impacts on quality of life and cost-effectiveness.

EGS P02 Lessons learnt from 450 Endoluminal vacuum therapy (EVT) procedures in the treatment of upper gastrointestinal perforations and leaks

Abstract Background Endoluminal vacuum therapy (EVT[BA1] ) is a novel, yet relatively well established tool in the management of upper gastrointestinal (UGI) leaks and perforations. Despite a growing body of evidence supporting its use, management strategies and techniques used in the context of EVT are yet to be standardised. Furthermore, the uptake of EVT in the UK is limited to a small number of centres. This project aimed to summarise the key lessons learnt from our initial experience of 450 EVT procedures, to inform others about how this technique can be integrated into regular clinical practice. Methods This study draws on experiential reflections and analysis of a prospective database of 450 EVT procedures in 59 patients in our unit from October 2018 – June 2023. This included patients who had undergone oesophago-gastric (OG) cancer resections, bariatric surgery (index procedures both in the UK and abroad) and those presenting with benign disease (oesophageal perforation and iatrogenic injury). The setting was a regional tertiary OG and bariatric centre in the North West of England serving a cancer and benign population of 3.5 million people and a larger undetermined population for bariatric emergencies. Results 51/59 (86%) patients were successfully managed with 446 EVT procedures. Patient, system and technical factors were identified which when addressed, facilitated expeditious healing of leaks, and enabled active management patients unfit for more invasive interventions. Factors included understanding the indications for using and stopping EVT, control of sepsis, and optimisation of nutrition and glycaemic control. Technical factors included sponge placement, managing foreign material (e.g. redundant sutures and drains) and approaches to managing necrosis. System factors included supporting a training programme, the necessity of a comprehensive team approach and the financial and governance challenges with adopting a novel intervention. Conclusions EVT is as an effective technique in the management of complex UGI leaks and perforations. There are multiple patient, financial, logistical, governance and systems factors that present as challenges to the implementation of this technique into routine practice. An integrated team-based approach is key to adoption of EVT by other centres into their routine practice.

Intractable chylous leak after radical esophagectomy treated with radiotherapy

Postoperative chylous leak after esophagectomy is a rare but potentially life-threatening complication that results in hypovolemia, electrolyte imbalance, malnutrition, and immunologic deficiency. However, the management of postoperative chylous leak remains controversial. Following a diagnosis of esophageal cancer, a 64-year-old man was treated by video-assisted thoracoscopic esophagectomy, laparoscopic gastric tube formation, prophylactically thoracic duct ligation, and reconstruction with esophagogastrostomy at the neck level. Massive postoperative drainage from the thorax and abdomen did not initially meet the diagnostic criteria for chylothorax, which was ultimately diagnosed 3 weeks after the operation. Despite various treatments including total parenteral nutrition, octreotide and midodrine, reoperation (thoracic duct ligation and mechanical pleurodesis), and thoracic duct embolization, the chylous leak persisted. Finally, low-dose radiation therapy was administered with a daily dose of 2 Gy and completed at a total dose of 14 Gy. After this, the amount of pleural effusion gradually decreased over 2 weeks, and the last drainage tube was removed. The patient was alive and well at 60 months postoperatively. Herein, we describe a patient with intractable chylous leak after esophagectomy, which persisted despite conservative treatment, thoracic duct ligation, and embolization, but was finally successfully treated with radiotherapy.

Bio-Inspired Self-Healing, Shear-Thinning, and Adhesive Gallic Acid-Conjugated Chitosan/Carbon Black Composite Hydrogels as Suture Support Materials.

The occurrence of leakage from anastomotic sites is a significant issue given its potential undesirable complications. The management of anastomotic leakage after gastrointestinal surgery is particularly crucial because it is directly associated with mortality and morbidity in patients. If adhesive materials could be used to support suturing in surgical procedures, many complications caused by leakage from the anastomosis sites could be prevented. In this study, we have developed self-healing, shear-thinning, tissue-adhesive, carbon-black-containing, gallic acid-conjugated chitosan (CB/Chi-gallol) hydrogels as sealing materials to be used with suturing. The addition of CB into Chi-gallol solution resulted in the formation of a crosslinked hydrogel with instantaneous solidification. In addition, these CB/Chi-gallol hydrogels showed enhancement of the elastic modulus (G') values with increased CB concentration. Furthermore, these hydrogels exhibited excellent self-healing, shear-thinning, and tissue-adhesive properties. Notably, the hydrogels successfully sealed the incision site with suturing, resulting in a significant increase in the bursting pressure. The proposed self-healing and adhesive hydrogels are potentially useful in versatile biomedical applications, particularly as suture support materials for surgical procedures.

Endoscopic management of colorectal anastomosis refractory leaks: a journey from conventional to inventive approaches

Endoscopic management of colorectal anastomosis refractory leaks: a journey from conventional to inventive approaches