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Vohra I, Gopakumar H, Sharma NR, Puli SR. Efficacy of endoscopic vacuum therapy in esophageal luminal defects: a systematic review and meta-analysis. Clin Endosc 2025; 58:53-62. [PMID: 39385519 PMCID: PMC11837558 DOI: 10.5946/ce.2023.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND/AIMS Endoscopic vacuum-assisted closure (EVAC) is a novel technique used to repair esophageal perforation and leaks. Varying data have been reported on the overall success rate of EVAC. We aimed to conduct a meta-analysis of the available data on the clinical success rate of EVAC. METHODS Electronic databases were searched for publications addressing the efficacy of EVAC in esophageal luminal defects. Pooling was conducted using both fixed and random-effects models. The overall clinical success of EVAC therapy was considered the primary outcome, whereas, overall complication rates, need for adjunct therapy, and mortality were considered secondary outcomes. RESULTS In total, 366 patients were included in the study. On pooled analysis, the mean age was 66 years with 68.32% of patients being men. Overall pooled clinical success rate of EVAC therapy was 87.95%. Upon subgroup analysis, the pooled clinical success rate of postsurgical anastomotic leak and transmural esophageal perforation were found to be 86.57% and 88.89%, respectively. The all-cause hospital mortality was 14% and 4.2% in patients with esophageal perforation and EVAC, respectively. CONCLUSIONS This study demonstrates that EVAC therapy has a high overall clinical success rate, with low mortality. EVAC therapy seems to be a promising procedure with excellent outcomes in patients with luminal esophageal defects.
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Affiliation(s)
- Ishaan Vohra
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Neil R. Sharma
- Parkview Cancer Institute, Advanced Interventional Endoscopy & Endoscopic Oncology (IOSE) Division, GI Oncology Program, Fort Wayne, IN, USA
| | - Srinivas R. Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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Alipouriani A, Lavryk O, Lipman J, Hull T, Liska D, Steele SR, Holubar SD. Ileoanal pouch salvage rates with endoluminal vacuum therapy for early vs late anastomotic leaks. J Gastrointest Surg 2024; 28:1976-1982. [PMID: 39277163 DOI: 10.1016/j.gassur.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/21/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND Anastomotic leaks after ileal pouch-anal anastomosis (IPAA) significantly compromise patient outcomes and increase healthcare resource utilization. The aim of this study was to evaluate the outcomes of endoluminal vacuum therapy (EndoVac) for pouch leaks. We hypothesized that EndoVac for early compared with late leaks was associated with a higher pouch survival rate. METHODS We retrospectively reviewed consecutive pouch anastomotic leaks treated with EndoVac therapy at our institution between 2013 and 2023. Patients were stratified into early (≤30 days) and late (>30 days) leak groups. Anastomotic healing was defined as complete closure of the leak site and resolution of symptoms. Pouch failure was defined as a permanent ileostomy or pouch excision. The probability of pouch survival was estimated using the Kaplan-Meier method. RESULTS A total of 14 patients with IPAA were included: median age, 34 years; 71% were males; and median body mass index, 23.46 kg/m2. The following were the diagnoses made: ulcerative colitis (n = 12) and familial adenomatous polyposis (n = 2). The median (IQR) time from pouch construction to leak was 44.5 (12-192) days; of these, 6 (43%) were early, and 8 (57%) were late. All (100%) leaks were at the anastomosis; all (100%) were diverted at the time of EndoVac therapy: 10 (71%) still diverted, and 4 (29%) rediverted. Patients underwent a median of 5.5 EndoVac changes (3-7) over a 13.5 (6-21) day period from initiation of treatment to cessation of therapy. After EndoVac therapy, healing was observed in 10 (71%) patients; 2 of whom required a minor handsewn anastomotic revision but healed completely, and 4 did not heal; 3 had pouch excision, and 1 underwent redo pouch surgery. Anastomotic healing (66.7% vs 75%, P = .7) and pouch survival (83.3% vs 75%, P = .73) were not significantly different between the early and late leak groups. The overall pouch salvage rate was 78.5%. CONCLUSION EndoVac therapy was effective in achieving high rates of pouch salvage and anastomotic healing in patients with ileoanal pouch leaks, irrespective of the timing of intervention postoperatively. This supports the use of EndoVac as a viable treatment option for both early and late anastomotic leaks.
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Affiliation(s)
- Ali Alipouriani
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, United States.
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Kouladouros K. Applications of endoscopic vacuum therapy in the lower gastrointestinal tract: Tips and tricks and a review of the literature. Best Pract Res Clin Gastroenterol 2024; 70:101927. [PMID: 39053980 DOI: 10.1016/j.bpg.2024.101927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/29/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
Endoscopic vacuum therapy (EVT) is an established technique for the treatment of rectal wall defects and especially anastomotic leaks. A wide range of EVT devices, both handmade and commercially available, allow for their successful placement even in small defects and difficult localizations. Reported success rates range between 85 and 97 %, while periintervenional morbidity is low and major adverse events are very rare. EVT has proven its effectiveness in the lower gastrointestinal tract and is now considered first line treatment for pelvic anastomotic leaks. This narrative review summarizes the current literature on EVT in the lower gastrointestinal tract, focusing on its indications, technical aspects and results, and offers tips and tricks for its clinical applications.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Deng S, Liu K, Gu J, Cao Y, Mao F, Xue Y, Jiang Z, Qin L, Wu K, Cai K. Endoscopic fully covered self-expandable metal stent and vacuum-assisted drainage to treat postoperative colorectal cancer anastomotic stenosis with fistula. Surg Endosc 2023; 37:3780-3788. [PMID: 36690896 PMCID: PMC10156781 DOI: 10.1007/s00464-022-09831-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Digestive tract reconstruction is required after the surgical resection of a colorectal malignant tumor. Some patients may have concomitant anastomotic complications, such as anastomotic stenosis with fistula (ASF), postoperatively. Therefore, we evaluated the efficacy and safety of endoscopic fully covered self-expandable metal stent and homemade vacuum sponge-assisted drainage (FSEM-HVSD) for the treatment of ASF following the radical resection of colorectal cancer. METHODS Patients treated with FESM-HVSD were prospectively analyzed and followed up for ASF following colorectal cancer treatment in our medical center from 2017 to 2021 for the observation and evaluation of its safety and efficacy. RESULTS Fifteen patients with a mean age of 55.80 ± 11.08 years were included. Nine patients (60%) underwent protective ileostomy. All 15 patients were treated with endoscopic FSEM-HVSD. The median time from the index operation to the initiation of FSEM-HVSD was 80 ± 20.34 days in patients who underwent protective ileostomy versus 11.4 ± 4.4 days in those who did not. The average number of endoscopic treatments per patient was 5.70 ± 1.25 times. The mean length of hospital stay was 27.60 ± 4.43 days. FSEM-HVSD treatment was successful in 13 patients, and no patients had any complications. The follow-up time was 1 year. Twelve of 15 (80%) patients achieved prolonged clinical success after FSEM-HVSD treatment, 1 experienced anastomotic tumor recurrence and underwent surgery again, and 1 patient required balloon dilation for anastomotic stenosis recurrence. CONCLUSIONS FSEM-HVSD is an effective, safe, and minimally invasive treatment for ASF following colorectal cancer treatment. This technique could be the preferred treatment strategy for patients with ASF.
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Affiliation(s)
- Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Ke Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Fuwei Mao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Yifan Xue
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Zhenxing Jiang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Le Qin
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022 Hubei China
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Sozutek A, Tas EY, Yener K, Ozcomert J. Endoluminal Vacuum Therapy (EVT) for the Treatment of Rectal Perforation Following Cleansing Enema Application. Cureus 2023; 15:e35939. [PMID: 36911591 PMCID: PMC9997685 DOI: 10.7759/cureus.35939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/11/2023] Open
Abstract
Traumatic rectal injuries (TRIs) are challenging for surgeons because of their high morbidity and mortality. Considering the well-known predisposing factors, enema-associated rectal perforation seems to be the most overlooked entity that leads to devastating rectal injuries. A 61-year-old man with a three-day history of painful swelling around his perirectal area after enema application was referred to the outpatient clinic. CT demonstrated the presence of a left posterolateral rectal abscess compatible with an extraperitoneal rectal injury. Sigmoidoscopy revealed the perforation started 2 cm above the dentate line with a diameter of 10 cm and a depth of 3 cm. Endoluminal vacuum therapy (EVT) and laparoscopic sigmoid loop colostomy was performed. The patient was discharged after removing the system on postoperative Day 10. On his follow-up, the perforation side was totally closed and pelvic abscess was completely resolved two weeks after his discharge. EVT appears to be a simple, safe, well-tolerated and cost-effective therapeutic procedure in the management of delayed extraperitoneal rectal perforations (ERPs) with large defects. To our knowledge, this is the first case that reveals the potency of EVT in the management of a delayed rectal perforation associated with an uncommon entity.
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Affiliation(s)
- Alper Sozutek
- Gastroenterological Surgery, Health Sciences University, Adana City Training and Research Hospital, Adana, TUR
| | - Ekin Y Tas
- Gastroenterological Surgery, Health Sciences University, Adana City Training and Research Hospital, Adana, TUR
| | - Kemal Yener
- Gastroenterological Surgery, Health Sciences University, Adana City Training and Research Hospital, Adana , TUR
| | - Julia Ozcomert
- Gastroenterological Surgery, Health Sciences University, Adana City Training and Research Hospital, Adana, TUR
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Outpatient closure in a late colo-cutaneous postoperative anastomotic leak managed with EVAC in Bucaramanga, Colombia. Case report. Int J Surg Case Rep 2022; 100:107737. [PMID: 36327863 PMCID: PMC9626932 DOI: 10.1016/j.ijscr.2022.107737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction After Hartmann-type colostomy, the adequate selection of some patients allows reversal and closure of the colostomy, however, this reversal is not free of complications. Among complications, anastomotic leaks and fistulae can have functional, economic, and oncological consequences. Complications have been treated with surgery; yet, this management has changed considerably in recent years, moving towards less invasive therapies. Presentation of case This is the report of a 42-year-old man with a history of closed abdominal trauma with perforation of the sigmoid colon managed with a Hartmann-type colostomy. Six months later, he was admitted for a Hartmann reversal procedure without immediate complications. He was assessed again after 4 months observing a small area of erythema and periumbilical edema. EUS was performed without evidence of collections. Colonoscopy evidenced a 7-mm fistulous orifice in the colocolonic anastomosis. The Endo-VAC system was used, performing endoscopically exchanges twice a week following a low-residue diet. The procedure was performed on an outpatient basis and the closure of the leak hole in the colonic anastomosis was achieved in 30 days. Discussion Endoluminal vacuum therapy or EVAC, is an adaptation of the therapy used for negative pressure wound closure. This minimally invasive technique has been used for the treatment of gastrointestinal leaks and fistulae in selected patients and within a hospital setting. Our case presents the use of this technique in a late colocutaneous postoperative leak on an outpatient basis. Conclusion To the best of our knowledge we report the first case of a late colocutaneous anastomotic leak managed with EVAC on an outpatient basis.
Endoluminal vacuum therapy (EVAC) is an adaptation of the therapy used for negative pressure wound closure. We report the first case of a late colocutaneous postoperative fistula managed with EVAC on an outpatient basis. In selected patients, the EndoVac therapy can be performed using easily accessible and low-cost supplies.
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Bemelman WA, Arezzo A, Banasiewicz T, Brady R, Espín-Basany E, Faiz O, Jimenez-Rodriguez RM. Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus. BJS Open 2022; 6:zrac123. [PMID: 36268752 PMCID: PMC9585396 DOI: 10.1093/bjsopen/zrac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons. METHOD Seven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon. RESULTS Thirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks. CONCLUSION Although further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.
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Affiliation(s)
- Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Tomasz Banasiewicz
- Poznan University of Medical Sciences, Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznań, Poland
| | - Richard Brady
- Newcastle Centre for Bowel Disease Research Group, Department of Colorectal Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Eloy Espín-Basany
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron-Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Rosa M Jimenez-Rodriguez
- Unidad de Coloproctología, Department of Surgery, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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de Lacy FB, Talboom K, Roodbeen SX, Blok R, Curell A, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates. Br J Surg 2022; 109:822-831. [PMID: 35640282 PMCID: PMC10364759 DOI: 10.1093/bjs/znac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/10/2022] [Accepted: 04/21/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. METHODS A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. RESULTS Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. CONCLUSION EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.
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Affiliation(s)
- F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Robin Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Anna Curell
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Oncological and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Roel Hompes
- Correspondence to: Roel Hompes, Department of Surgery, Amsterdam UMC, University of Amsterdam, Location AMC, J1A-216, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (e-mail: )
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Vignali A, De Nardi P. Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis. World J Gastroenterol 2022; 28:1394-1404. [PMID: 35582677 PMCID: PMC9048477 DOI: 10.3748/wjg.v28.i14.1394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/07/2021] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.
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Affiliation(s)
- Andrea Vignali
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
- Department of Surgery, Vita-Salute University, Milano 20132, Italy
| | - Paola De Nardi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
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Kühn F, Hasenhütl SM, Hofmann FO, Wirth U, Drefs M, Werner J, Schiergens TS. Endoscopic Vacuum Therapy for Left-Sided Colorectal Anastomotic Leak Without Fecal Diversion. Dis Colon Rectum 2022; 65:421-428. [PMID: 34775405 DOI: 10.1097/dcr.0000000000001959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy for the treatment of rectal anastomotic leak has been shown to be effective and safe. The majority of patients are treated after fecal diversion to avoid further septic complications. OBJECTIVE To report the effectiveness of endoscopic vacuum therapy for rectal anastomotic leak without diversion compared to secondary stoma creation. DESIGN Retrospective cohort analysis. SETTINGS University hospital, single-center. PATIENTS Patients undergoing sigmoid or rectal resection without fecal diversion during primary surgery who were treated with endoscopic vacuum therapy for clinically relevant anastomotic leak. MAIN OUTCOME MEASURES Treatment success (sepsis control, granulation and closure of the leak cavity, and no subsequent interventional or surgical procedure required); treatment duration; complications associated with endoscopic vacuum therapy; outpatient treatment; and restoration of intestinal continuity in diverted patients. RESULTS Fifty-seven patients were included. In 20 patients (35%), endoscopic vacuum therapy was initiated without secondary diversion since the leak was extraperitoneal, and the sponge could be placed into the leak cavity with an adequate seal toward the lumen. In 18 patients (90%), this approach was successful. None of these patients required subsequent diversion in the further course of their disease. In two patients, secondary diversion was necessary due to treatment failure. Balloon dilatation for luminal stenosis was required in two patients. When comparing patient and treatment characteristics of patients with and without a stoma, including treatment success and duration, no significant differences were found. Restoration of intestinal continuity was achieved in 69% of diverted patients. LIMITATIONS Unrandomized, retrospective study design; confounding factors of treatment assignment; low patient numbers and short follow-up of diverted patients; and low statistical power. CONCLUSION In this single-institution study, endoscopic vacuum therapy for rectal anastomotic leak was successful in 90% of patients without diversion with regard to sepsis control, granulation of the leak cavity, avoidance of surgery, and long-term stoma-free survival. See Video Abstract at http://links.lww.com/DCR/B737.TERAPIA ENDOSCÓPICA POR ASPIRACIÓN AL VACÍO EN CASOS DE FUGA ANASTOMÓTICA RECTO-CÓLICA IZQUIERDA SIN OSTOMÍA DE PROTECCIÓNANTECEDENTES:Se ha demostrado que la terapia endoscópica por aspiración al vacío en casos de fuga anastomótica recto-cólica izquierda en el tratamiento de la fuga anastomótica rectal es eficaz y segura. La mayoría de los casos beneficiaron del tratamiento después de la confeción de un ostomía de protección para evitar más complicaciones sépticas.OBJETIVO:Demostrar la efectividad de la terapia endoscópica por aspiración al vacío en casos de fuga anastomótica recto-cólica izquierda sin ostomía de protección comparada con los casos que tuvieron la creación de una ostomía secundaria.DISEÑO:Análisis de cohortes de tipo retrospectivo.AJUSTE:Hospital universitario, unicéntrico.PACIENTES:Aquellos pacientes sometidos a una resección sigmoidea o rectal sin ostomía de protección durante una cirugía primaria, y que fueron tratados con terapia endoscópica por aspiración al vacío en caso de fuga anastomótica clínicamente relevante.PRINCIPALES MEDIDAS DE RESULTADO:Tratamiento exitoso (control de la sepsis, granulación y cierre de la cavidad de la fuga, sin requerir procedimiento quirúrgico o intervención ulteterior); duración del tratamiento; complicaciones asociadas con la terapia endoscópica por aspiración al vacío; tratamiento ambulatorio; restablecimiento de la continuidad intestinal en los pacientes portadores de ostomía.RESULTADOS:Se incluyeron 57 pacientes. En 20 pacientes (35%), se inició la terapia endoscópica por aspiración al vacío sin derivación secundaria, ya que la fuga era extraperitoneal y la esponja podía colocarse en la cavidad de la fuga con un sellado adecuado hacia el lumen. En 18 pacientes (90%), este enfoque fue exitoso. Ninguno de estos pacientes requirió una derivación posterior durante la evolución de la enfermedad. En dos pacientes, fue necesaria una derivación secundaria debido al fracaso del tratamiento. Se requirió dilatación con balón por estenosis luminal en dos pacientes. Al comparar las características de los pacientes y del tratamiento con y sin ostomía, incluido el éxito y la duración del tratamiento, no se encontraron diferencias significativas. El restablecimiento de la continuidad intestinal se logró en el 69% de los pacientes derivados.LIMITACIONES:Diseño de estudio retrospectivo no aleatorio; factores de confusión en la asignación del tratamiento; escaso número de pacientes y seguimiento a corto plazo de los pacientes ostomizados; bajo poder estadístico.CONCLUSIÓN:En este estudio de una sola institución, la terapia al vacío por vía endoscópica en casos de fuga anastomótica rectal fue exitosa en el 90% de los pacientes sin derivación con respecto al control de la sepsis, granulación de la cavidad de la fuga, como se evitó la cirugía y la sobrevida sin ostomía a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B737. (Traducción-Dr. Xavier Delgadillo).
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
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12
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Jagielski M, Piątkowski J, Jarczyk G, Jackowski M. Transrectal endoscopic drainage with vacuum-assisted therapy in patients with anastomotic leaks following rectal cancer resection. Surg Endosc 2022; 36:959-967. [PMID: 33650007 PMCID: PMC8758650 DOI: 10.1007/s00464-021-08359-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgery is the gold standard for the treatment of malignant tumors of the rectum. Intestinal anastomotic leakage remains a serious complication of colorectal surgery. The efficacy and safety of transrectal endoscopic drainage by vacuum therapy in patients with intestinal anastomotic leakage after surgical treatment of middle and distal rectal tumors were assessed. METHODS Prospective analysis of treatment outcomes among patients undergoing surgery for middle and distal rectal tumors at the Department of General, Gastroenterological, and Oncological Surgery of the Ludwik Rydygier Collegium Medicum in Bydgoszcz and Nicolaus Copernicus University in Torun from 2016 to 2019 was conducted. RESULTS Seventy-nine patients with middle and distal rectal tumors underwent laparoscopic resection. Intestinal anastomotic leak was identified in 18 (22.79%) patients [all men, mean age 61.39 (43-86) years] during the postoperative period. Primary protective ileostomy was performed in 8/18 (44.44%) patients. All 18 patients were treated with endoluminal vacuum therapy via transrectal endoscopic drainage. The mean time from surgery to the diagnosis of leakage and initiation of endoscopic treatment was 16 (3-728) days. The mean number of endoscopic procedures per patient was 6 (1-11). The mean duration of endoscopic treatment was 22 (4-43) days. Complications of endotherapy occurred in 2/18 (11.11%) patients treated endoscopically for bleeding from the abscess cavity. Success of endoluminal vacuum therapy was achieved in 17/18 (94.44%) patients. Moreover, 5/18 (27.78%) patients required ileostomy during the endoscopic treatment. The mean follow-up period was 368 (118-724) days. Long-term success of transrectal endoscopic drainage using vacuum-assisted therapy was achieved in 15/18 (83.33%) patients. CONCLUSIONS Endoscopic rectal drainage using vacuum-assisted therapy is an effective and safe minimally invasive treatment in patients with intestinal anastomotic leaks following resection procedures within the middle and distal rectum.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland.
| | - Jacek Piątkowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
| | - Grzegorz Jarczyk
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, 53-59 Św. Józefa St, 87-100, Toruń, Poland
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13
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Endoscopic vacuum therapy for the treatment of colorectal leaks - a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:283-292. [PMID: 34817647 PMCID: PMC8803669 DOI: 10.1007/s00384-021-04066-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND During the last two decades, vacuum-assisted wound therapy has been successfully transferred to an endoscopic treatment approach of various upper and lower gastrointestinal leaks called endoscopic vacuum therapy (EVT). As mostly small case series are published in this field, the aim of our systematic review and meta-analysis was to evaluate the efficacy and safety of EVT in the treatment of colorectal leaks. METHODS A systematic search of MEDLINE/PubMed and Cochrane databases was performed using search terms related to EVT and colorectal defects (anastomotic leakage, rectal stump insufficiency) according to the PRISMA guidelines. Randomized controlled trials (RCTs), observational studies, and case series published by December 2020 were eligible for inclusion. A meta-analysis was conducted on the success of EVT, stoma reversal rate after EVT as well as procedure-related complications. Statistical interferences were based on pooled estimates from random effects models using DerSimonian-Laird estimator. RESULTS Only data from observational studies and case series were available. Twenty-four studies reporting on 690 patients with colorectal defects undergoing EVT were included. The mean rate of success was 81.4% (95% CI: 74.0%-87.1%). The proportion of diverted patients was 76.4% (95% CI: 64.9%-85.0%). The mean rate of ostomy reversal across the studies was 66.7% (95% CI: 58.0%-74.4%). Sixty-four patients were reported with EVT-associated complications, the weighted mean complication rate across the studies was 12.1% (95% CI: 9.7%-15.2%). CONCLUSIONS Current medical evidence on EVT in patients with colorectal leaks lacks high quality data from RCTs. Based on the data available, EVT can be seen as a feasible treatment option with manageable risks for selected patients with colorectal leaks.
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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15
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Althoff A, Baker C, Healy JM. Endoluminal vacuum-assisted closure for penetrating rectal injury in a pediatric patient. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Sürek A, Bozkurt MA, Gemici E, Kocataş A, Ferahman S, Seyhun C, Binboğa S, Aliş H. Treatment of Anastomotic Leaks With EndoVac After Low Anterior Resection in Colorectal Cancers. Surg Laparosc Endosc Percutan Tech 2021; 31:492-496. [PMID: 33538549 DOI: 10.1097/sle.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/28/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Endoscopic drainage should preferably be tried unless the abscess caused by the anastomotic leak is generalized and disseminated into the abdominal cavity. The aim of this study was to evaluate the results of patients treated with EndoVac. PATIENT AND METHODS The medical records of patients who underwent low anterior resection and were treated using the EndoVac therapy system due to the detection of an anastomotic leak were retrospectively evaluated. RESULTS Thirty-three of the patients with detection of anastomotic leaks were treated using EndoVac therapy system. The mean number of application of the EndoVac therapy system was 5.8 (1 to 12) for each patient. Mean duration of hospitalization of the patients was 24.5 (9 to 92) days. Five patients underwent a second operation during the follow-up period after application of the EndoVac therapy system. In our study, the number of patients recovering without the need for additional treatment is 30 (30/33). Our success rate was 90.1%. CONCLUSIONS The EndoVac therapy system is an alternative and helpful system in the treatment of colorectal anastomotic leaks without reoperation needed. It can also prevent permanent stoma.
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Affiliation(s)
- Ahmet Sürek
- General Surgery Department, Bakirköy Dr Sadi KonukTraining and Research Hospital
| | - Mehmet A Bozkurt
- General Surgery Department, Kanuni Sultan Süleyman Training and Research Hospital
| | - Eyüp Gemici
- General Surgery Department, Bakirköy Dr Sadi KonukTraining and Research Hospital
| | - Ali Kocataş
- General Surgery Department, Kanuni Sultan Süleyman Training and Research Hospital
| | - Sina Ferahman
- General Surgery Department, Bakirköy Dr Sadi KonukTraining and Research Hospital
| | | | - Sinan Binboğa
- General Surgery Department, Bakirköy Dr Sadi KonukTraining and Research Hospital
| | - Halil Aliş
- General Surgery Department, İstanbul Aydin University, İstanbul, Turkey
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Kühn F, Janisch F, Schwandner F, Gock M, Wedermann N, Witte M, Klar E, Schiffmann L. Comparison Between Endoscopic Vacuum Therapy and Conventional Treatment for Leakage After Rectal Resection. World J Surg 2020; 44:1277-1282. [PMID: 31965274 DOI: 10.1007/s00268-019-05349-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic leakage after rectal resection represents a severe complication for the patient and requires an early and appropriate management. Endoscopic vacuum therapy (EVT) has become the treatment of choice for anastomotic leakage after rectal resection in several institutions in Germany, and commercially available systems are currently distributed in approximately 30 countries worldwide. However, there is no evidence that EVT is superior to any other treatment for anastomotic leakage after rectal resection. METHODS Twenty-one patients treated with EVT for anastomotic leakage after rectal resection were retrospectively compared to a historical cohort of 41 patients that received conventional treatment. Primary endpoints were death, treatment success and long-term preservation of intestinal continuity. Secondary endpoints were length of hospital stay and duration of treatment. RESULTS There was no difference in mortality (p = 0.624). The intention-to-treat analysis showed a significantly higher success rate of EVT compared to conventional treatment (95.2% vs. 65.9%, p = 0.011). EVT was associated with preservation of intestinal continuity in a significant higher percentage of patients than patients undergoing conventional treatment (86.7% vs. 37.5%, p = 0.001). Conventional treatment tended to a shorter length of hospital stay (31.1 vs. 42.2 days, p = 0.066) but with no difference in overall duration of treatment. Time until closing of a diverting stoma did not differ between groups (10.2 months in the EVT group vs. 9.4 months in the conventional treatment group, p = 0.721). CONCLUSION According to this retrospective study, conventional therapy and EVT are both options for the treatment of anastomotic leakage after rectal resection. EVT might be more effective in terms of definite healing and preservation of intestinal continuity.
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Affiliation(s)
- Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Janisch
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Nicole Wedermann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
- Department of General, Visceral and Thoracic Surgery, Helios Klinikum Aue, Gartenstraße 6, 08280, Aue, Germany.
- Department of Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
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Fang AH, Chao W, Ecker M. Review of Colonic Anastomotic Leakage and Prevention Methods. J Clin Med 2020; 9:E4061. [PMID: 33339209 PMCID: PMC7765607 DOI: 10.3390/jcm9124061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022] Open
Abstract
Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.
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Affiliation(s)
- Alex H. Fang
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Wilson Chao
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Melanie Ecker
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
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Endoscopic vacuum therapy for in- and outpatient treatment of colorectal defects. Surg Endosc 2020; 35:6687-6695. [PMID: 33259019 PMCID: PMC8599392 DOI: 10.1007/s00464-020-08172-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022]
Abstract
Background Evidence for endoscopic vacuum therapy (EVT) for colorectal defects is still based on small patient series from various institutions, employing different treatment algorithms and methods. As EVT was invented at our institution 20 years ago, the aim was to report the efficacy and safety of EVT for colorectal defects as well as to analyze factors associated with efficacy, therapy duration, and outpatient treatment. Methods Cohort study with analysis of prospectively collected data of patients receiving EVT for colorectal defects at a tertiary referral center in Germany (n = 281). Results The majority of patients had malignant disease (83%) and an American Society of Anesthesiologists classification of III/IV (81%). Most frequent indications for EVT were anastomotic leakage after sigmoid or rectal resection (67%) followed by rectal stump leakage (20%). EVT was successful in 256 out of 281 patients (91%). EVT following multi-visceral resection (P = 0.037) and recent surgical revision after primary surgery (P = 0.009) were risk factors for EVT failure. EVT-associated adverse events occurred in 27 patients (10%). Median treatment duration was 25 days. Previous chemo-radiation (P = 0.006) was associated with a significant longer duration of EVT. Outpatient treatment was conducted in 49% of patients with a median hospital stay reduction of 15 days and 98% treatment success. Younger patient age (P = 0.044) was associated with the possibility of outpatient treatment. Restoration of intestinal continuity was achieved in 60% of patients where technically possible with a 12-month rate of 52%. Conclusions In patients with colorectal defects, EVT appears to be a safe and effective, minimally invasive option for in- and outpatient treatment.
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Weréen A, Dahlberg M, Heinius G, Pieniowski E, Saraste D, Eklöv K, Nygren J, Pekkari K, Everhov ÅH. Long-Term Results after Anastomotic Leakage following Rectal Cancer Surgery: A Comparison of Treatment with Endo-Sponge and Transanal Irrigation. Dig Surg 2020; 37:456-462. [PMID: 32829324 DOI: 10.1159/000508935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/19/2020] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Alice Weréen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Göran Heinius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Emil Pieniowski
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Deborah Saraste
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Karolina Eklöv
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, .,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,
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Mahendran B, Rossi B, Coleman M, Smolarek S. The use of Endo-SPONGE ® in rectal anastomotic leaks: a systematic review. Tech Coloproctol 2020; 24:685-694. [PMID: 32377984 DOI: 10.1007/s10151-020-02200-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. METHODS All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. CONCLUSIONS Endo-SPONGE® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.
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Affiliation(s)
- B Mahendran
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK.
| | - B Rossi
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - M Coleman
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - S Smolarek
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
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Kühn F, Zimmermann J, Beger N, Wirth U, Hasenhütl SM, Drefs M, Chen C, Burian M, Karcz WK, Rentsch M, Werner J, Schiergens TS. Endoscopic vacuum therapy for treatment of rectal stump leakage. Surg Endosc 2020; 35:1749-1754. [PMID: 32314078 DOI: 10.1007/s00464-020-07569-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Symptomatic rectal stump leakage (RSL) is a serious complication after discontinuity resection and requires immediate surgical, interventional, or endoscopic therapy. Re-operations are associated with high morbidity and mortality in these mostly very ill patients. Endoscopic vacuum therapy (EVT) has been established for management of anastomotic leakage; however, its effectiveness for RSL treatment has not been analyzed in detail yet. METHODS A retrospective analysis of patients treated with EVT for RSL between 2001 and 2018 analyzing factors predicting therapy success and duration was carried out. RESULTS Fifty-six patients with RSL at a median age of 66 years were included. Of these, 18 patients (32%) had been referred for EVT from external departments or institutions. RSL was associated with a relevant clinical deterioration in all patients, and 55 patients (98%) had been classified as ASA 3 and 4, preoperatively. In 9 patients (16%), additional surgical revision was necessary with initiation of EVT. In 47 patients (84%), EVT was successful and local control of the inflammatory focus was achieved. The median duration of therapy was 20 days. Two patients (4%) suffered from minor EVT-associated bleeding that was endoscopically controlled. Preoperative radiation of the pelvis was significantly associated with EVT failure (P = 0.035), whereas patient age represented a predictive factor for therapy length (P = 0.039). In 12 patients (21%), restoration of intestinal continuity was achieved in the further course. CONCLUSIONS We present the first specific series on EVT for RSL. EVT for RSL was shown to be an effective and safe minimal-invasive treatment option, avoiding surgical revision in the majority of patients.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Julia Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nicola Beger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sandro M Hasenhütl
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Moritz Drefs
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Chen Chen
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maria Burian
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - W Konrad Karcz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
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Chorti A, Stavrou G, Stelmach V, Tsaousi G, Michalopoulos A, Papavramidis TS, Kotzampassi K. Endoscopic repair of anastomotic leakage after low anterior resection for rectal cancer: A systematic review. Asian J Endosc Surg 2020; 13:141-146. [PMID: 31297989 DOI: 10.1111/ases.12733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re-operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over-The-Scope-Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy. METHOD A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed. RESULTS The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70-68.76), the male-to-female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03-6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39-74.90). Vacuum-assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum-assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%). CONCLUSION Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results.
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Affiliation(s)
- Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Veronica Stelmach
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonios Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Popivanov GI, Mutafchiyski VM, Cirocchi R, Chipeva SD, Vasilev VV, Kjossev KT, Tabakov MS. Endoluminal negative pressure therapy in colorectal anastomotic leaks. Colorectal Dis 2020; 22:243-253. [PMID: 31274227 DOI: 10.1111/codi.14754] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
AIM The aim of the present work was to perform an up-to-date review of the literature on endoluminal negative pressure therapy for colorectal anastomotic leak. METHOD An electronic search in PubMed and Google Scholar and a manual search without language restrictions were performed on 25 January 2019. Only original series reporting endoluminal negative pressure therapy in colorectal anastomotic leaks were included. The primary outcome was the success rate (complete closure of the abscess cavity). The secondary outcomes were the rates of complications and stoma closure. RESULTS Nineteen series with a total of 295 cases were analysed. The median distance of the anastomosis from the anal verge and the size of the abscess were 5.65 cm (4.9-10) and 6.0 cm (5-8.1) respectively. In 84.5% (78%-91%) the stoma was created at the first intervention. Neoadjuvant therapy was performed in 48.6% (3%-60%). Median 7 sponges (2-34) were used with median negative pressure 150 mmHg (125-700) for a median of 31 days (14-127). The success rate was 85.4% (80%-91%) with ileostomy closure in 72.6%. Complications were observed in 19% (13%-25%): abscesses 11.5% and anastomotic stenosis 4.4%. Laparotomy was required in 15% of the complications. The stoma was the only significant predictor for the success of the therapy (0.007, SE 0.004, P = 0.040). CONCLUSIONS The initial experience looks promising with an 85% success rate, which precludes risky re-resections with redo anastomosis or Hartmann's procedure. Despite the good initial results, definitive conclusions cannot be drawn because of the small sample size and the lack of high-quality comparative studies.
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Affiliation(s)
- G I Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - V M Mutafchiyski
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - R Cirocchi
- Department of Surgery and Surgical Science, University of Perugia, Perugia, Italy
| | - S D Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
| | - V V Vasilev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - K Ts Kjossev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - M S Tabakov
- Clinic of Abdominal Surgery, MHAT 'Sv. Ivan Rilski', Sofia, Bulgaria
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Endoscopic vacuum therapy with instillation (iEVT) - a novel endoscopic concept for colorectal anastomotic leak and perianal complications. Wideochir Inne Tech Maloinwazyjne 2020; 15:560-566. [PMID: 33294070 PMCID: PMC7687668 DOI: 10.5114/wiitm.2020.93204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/11/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Anastomotic leaks remain the most fearful complications. Aim We present a novel endoscopic salvage therapy known as endoscopic vacuum therapy with instillation (iEVT) as a combination of standard endoscopic vacuum therapy (EVT) and negative pressure wound therapy with instillation (iNPWT). Material and methods A case series of 6 consecutive patients treated with iEVT is presented. A Redon drain and a central venous catheter were introduced within polyurethane foam used as a self- made device for iEVT and antimicrobial solution was instilled. Results A total of 6 patients with the mean age of 29.5 ±8.9 were treated with iEVT. The mean number of iEVT sessions was 5.8 ±2.3. The mean time of iEVT management was 20.7 ±8.8 days. Locally, a reduction in purulent discharge and defect's dimension with contraction were revealed confirmed with imaging studies. Conclusions iEVT is a very encouraging, novel method for complicated perianal diseases and anastomotic leak.
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Ge PS, Thompson CC. The Use of the Overstitch to Close Perforations and Fistulas. Gastrointest Endosc Clin N Am 2020; 30:147-161. [PMID: 31739961 PMCID: PMC6885379 DOI: 10.1016/j.giec.2019.08.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.
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Affiliation(s)
- Phillip S. Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA,Corresponding author. twitter: @MetabolicEndo (C.C.T.)
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27
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Schiffmann L, Wedermann N, Schwandner F, Gock M, Klar E, Kühn F. Neoadjuvant radio-chemotherapy prolongs healing of anastomotic leakage after rectal resection treated with endoscopic vacuum therapy. Therap Adv Gastroenterol 2019; 12:1756284819877606. [PMID: 31579099 PMCID: PMC6759710 DOI: 10.1177/1756284819877606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/27/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Neoadjuvant radiochemotherapy (nRCT) is an important component in the treatment of advanced rectal cancer. Endoscopic vacuum therapy (EVT) has become the treatment of choice for anastomotic leakage after rectal resection in many institutions in Germany. Published case series report on average success and stoma reversal rates of more than 80%. However, so far, there is no distinct report on the potential influence of nRCT on EVT. METHODS A total of 11 patients treated with EVT for anastomotic leakage after nRCT and rectal resection were retrospectively compared with a cohort of eight patients with rectal anastomotic leakage without neoadjuvant treatment. Primary endpoints were death, treatment success, and long-term preservation of intestinal continuity. Secondary endpoint was the duration of treatment. Statistical analysis was performed using Statistical Package for Social Science (SPSS) version 23.0. RESULTS There was no difference in mortality (0%), success rate (90.9% versus 100%, p = 0.381), or long-term preservation of continuity (63.6% versus 62.5%, p = 0.960). After nRCT, patients showed a significant longer duration of EVT (31.1 days versus 15.9 days, p = 0.040) which was associated with a significantly higher number of sponge applications (9.6 versus 5.0, p = 0.042). CONCLUSIONS In our analysis, EVT showed success in over 90% of patients with anastomotic leakage after rectal resection for colorectal cancer, regardless of neoadjuvant treatment. However, in case of anastomotic leakage, nRCT seems to be associated with the need for a significant longer duration of EVT.
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Affiliation(s)
| | - Nicole Wedermann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
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de Moura DTH, de Moura BFBH, Manfredi MA, Hathorn KE, Bazarbashi AN, Ribeiro IB, de Moura EGH, Thompson CC. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11:329-344. [PMID: 31205594 PMCID: PMC6556487 DOI: 10.4253/wjge.v11.i5.329] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Ahmad N Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
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Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2019; 3:153-160. [PMID: 30957061 PMCID: PMC6433422 DOI: 10.1002/bjs5.50124] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. METHODS A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. RESULTS Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. CONCLUSION EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.
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Affiliation(s)
- M. Shalaby
- Department of General Surgery, Colorectal Surgery UnitMansoura UniversityMansouraEgypt
- Department of General SurgeryRome Tor Vergata UniversityRomeItaly
| | - S. Emile
- Department of General Surgery, Colorectal Surgery UnitMansoura UniversityMansouraEgypt
| | - H. Elfeki
- Department of General Surgery, Colorectal Surgery UnitMansoura UniversityMansouraEgypt
- Department of Surgery, Colorectal Surgery UnitAarhus UniversityAarhusDenmark
| | - A. Sakr
- Department of General Surgery, Colorectal Surgery UnitMansoura UniversityMansouraEgypt
| | - S. D. Wexner
- Department of Colorectal SurgeryCleveland Clinic FloridaWestonFloridaUSA
| | - P. Sileri
- Department of General SurgeryRome Tor Vergata UniversityRomeItaly
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30
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Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA. Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Affiliation(s)
- R E Clifford
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK.
| | - H Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - N Govindarajah
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - D Vimalachandran
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - P A Sutton
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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Treatment of Complicated Anal Fistula by an Endofistular Polyurethane-Sponge Vacuum Therapy: A Pilot Study. Dis Colon Rectum 2018; 61:1435-1441. [PMID: 30399049 DOI: 10.1097/dcr.0000000000001233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment of supra- and transsphincteric anal fistulas remains a clinical challenge because current treatment results are variable and potentially endanger sphincter function. OBJECTIVE Based on positive results of endoluminal polyurethane-sponge vacuum therapy in the upper and lower GI tract, a new system for endofistular vacuum therapy was developed for anal fistulas to utilize vacuum therapy to remove the endofistular pseudoepithelium and to induce granulation in the fistula tract. DESIGN This study is based on a prospective case series. PATIENTS Seven patients with complicated anal fistulas (3 associated with Crohn's disease and 4 of cryptoglandular origin) longer than 4 cm were treated. Initially, the fistula was curettaged and the first endofistular vacuum therapy sponge was positioned in the fistula tract. The inner fistula opening was closed by suture. A 125 mm Hg constant vacuum was applied to the sponge, and the endofistular vacuum therapy sponge was changed a median of 3 (3-5) times after each 48 to 72 hours of constant vacuum therapy. After final removal, the fistulas were reevaluated every other week for 3 months. MAIN OUTCOME MEASURE The main outcome measured was the closure of the fistula. RESULTS All patients tolerated the therapy well and no adverse events were observed. Fistula tract closure was demonstrated within 4 weeks after the termination of vacuum therapy. One patient with cryptoglandular fistula developed a recurrence within the follow-up of 3 months. LIMITATIONS This was an observational study that had no control arm. CONCLUSION In this pilot case series, the results are encouraging. Because endoluminal vacuum therapy would be a new and sphincter-sparing therapy, this concept warrants further investigation in controlled trials.
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Lim LY, Dolgunov D, Tan NCH, Chong CS. How to do a self-assembled endosponge in the management of low colorectal anastomotic sinus. ANZ J Surg 2018; 88:1200-1201. [PMID: 30198098 DOI: 10.1111/ans.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/08/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Li Yan Lim
- Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Dmitrii Dolgunov
- Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Nigel Chun Han Tan
- Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, Department of Surgery, University Surgical Cluster, National University Health System, Singapore
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Shelygin YA, Nagudov MA, Ponomarenko AA, Alekseev MV, Rybakov EG, Tarasov MA, Achkasov SI. [Meta-analysis of management of colorectal anastomotic leakage]. Khirurgiia (Mosk) 2018:30-41. [PMID: 30199049 DOI: 10.17116/hirurgia201808230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.
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Affiliation(s)
- Yu A Shelygin
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Nagudov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - A A Ponomarenko
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M V Alekseev
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - E G Rybakov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Tarasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - S I Achkasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
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Loske G, Schorsch T, Rucktaeschel F, Schulze W, Riefel B, van Ackeren V, Mueller CT. Open-pore film drainage (OFD): a new multipurpose tool for endoscopic negative pressure therapy (ENPT). Endosc Int Open 2018; 6:E865-E871. [PMID: 29978007 PMCID: PMC6031437 DOI: 10.1055/a-0599-5886] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 03/05/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic negative pressure therapy (ENPT) has been developed to treat gastrointestinal leakages. Up to now, ENPT has usually been performed with open-pore polyurethane foam drains (OPD). A big disadvantage of the OPDs is their large diameter. We have developed a new, small-bore open-pore film drainage (OFD). Herein we report our first experience in a case series of 16 patients. PATIENTS AND METHODS OFD is constructed with a drainage tube and a very thin double-layered open-pore drainage film (Suprasorb CNP, Drainage Film, Lohmann & Rauscher International, Germany). The distal end of the tube is wrapped with only one layer of film. OFD is placed into the gastrointestinal leakage site with common endoscopic techniques. The tube is connected to an electronic vacuum device and continuous negative pressure of -125 mmHg applied. RESULTS From 2013 to 2016, 16 patients were treated with the new OFD device. In 10 patients, transmural intestinal defects (4 esophageal, 4 rectum/colon, 1 duodenal, 1 pancreatic cyst) were closed with ENPT in median time of 12 days (range 3 - 34 days). Five of the 10 patients were treated solely with OFD devices. In five patients ENPT started with ODP and changed to OFD when the cavity was shrunken to a channel with a small opening. In four patients postoperative gastric reflux was eliminated for 5 to 16 days. CONCLUSIONS Small-bore OFD opens up promising new treatment options within ENPT. OFD can be used in endoscopic closure management of intestinal leakages in the upper and lower gastrointestinal tract. Gastric reflux can be eliminated in an active manner. OFD can be inserted nasally. OFD may be an adequate substitute for OPD, especially when placement of the larger OPD is difficult.
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Affiliation(s)
- Gunnar Loske
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany,Corresponding author Dr. med. Gunnar Loske, MD Katholisches Marienkrankenhaus Hamburg gGmbHDepartment for General, Abdominal, Thoracic and Vascular SurgeryAlfredstrasse 9 Hamburg 22087Germany+49 (0)40 2546 1400
| | - Tobias Schorsch
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany
| | - Frank Rucktaeschel
- Westküstenklinikum Heide, Department for Internal Medicine, Gastroenterology, Hemato-Oncology, Nephrology and Endocrinology, Heide, Germany
| | - Wolfgang Schulze
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany
| | - Burkhard Riefel
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany
| | - Vera van Ackeren
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany
| | - Christian Theodor Mueller
- Katholisches Marienkrankenhaus Hamburg gGmbH, Department for General, Abdominal, Thoracic and Vascular Surgery, Hamburg, Germany
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Assessment of MMP-2/-9 expression by fluorescence endoscopy for evaluation of anastomotic healing in a murine model of anastomotic leakage. PLoS One 2018; 13:e0194249. [PMID: 29566031 PMCID: PMC5863981 DOI: 10.1371/journal.pone.0194249] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/27/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Disturbance of intestinal wound closure leads to insufficient anastomotic healing and is associated with considerable morbidity following colorectal resections. Matrix metalloproteinases (MMPs) play a crucial role in regulation of wound closure. Here fluorescence endoscopy was evaluated for assessment of MMP-2/-9 expression during failed intestinal anastomotic healing. METHODS Distal colonic anastomoses were performed as a model for disturbed healing in 36 Balb/c mice. Healing was evaluated endoscopically, macroscopically, and histologically after 1, 3 and 5 days. For detection of MMP-2/-9 expression fluorescence endoscopy (FE) was used following i.v.-administration of a Cy5.5-labeled MMP-2/-9 specific tracer. FE was complemented by quantification of the fluorescence signal using the MS-FX PRO Optical Imaging System. An overall leakage score was calculated and correlated with the results of FE. RESULTS With increasing incidence of anastomotic leakage from POD1 (17%) to POD5 (83%) the uptake of the MMP tracer gradually increased (signal-to-noise ratio (SNR), POD1: 17.91 ± 1.251 vs. POD3: 30.56 ± 3.03 vs. POD5: 44.8 ± 4.473, P<0.0001). Mice with defective anastomotic healing showed significantly higher uptake compared to non-defective (SNR: 37.37± 3.63 vs. 26.16± 3.635, P = 0.0369). White light endoscopy and FE allowed evaluation of anastomotic healing and visualization of mucosal MMPs in vivo. Using FE based detection of MMPs in the anastomosis, an overall positive predictive value of 71.4% and negative predictive value of 66.6% was calculated for detection of anastomotic leakage. CONCLUSION During disturbed anastomotic healing increased expression of MMP-2/-9 was observed in the anastomotic tissue. Fluorescence endoscopy for detection of MMP-2/-9 during the healing process might be a promising tool for early identification of anastomotic leakage.
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Katz E, White I, Shpitz B, Ghinea R, Avital S. Different approaches for Endo-SPONGE ® insertion to treat rectal anastomotic leaks. Tech Coloproctol 2018; 22:231-233. [PMID: 29480425 DOI: 10.1007/s10151-018-1764-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/21/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Ephraim Katz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ian White
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Baruch Shpitz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronen Ghinea
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shmuel Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, Festen S, van der Zaag EJ, Tanis PJ, Bemelman WA. Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc 2017; 32:315-327. [PMID: 28664443 PMCID: PMC5770507 DOI: 10.1007/s00464-017-5679-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/19/2017] [Indexed: 12/13/2022]
Abstract
Introduction Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of anastomotic leakage after pre-treatment with the Endosponge® therapy. Methods In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed. Results Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient. Conclusion Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
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Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - G D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - L P S Stassen
- Department of Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands
| | | | - D Hess
- Department of Surgery, Antonius Zorggroep, Sneek, The Netherlands
| | - S van Dieren
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - E J van der Zaag
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Falco N, Fontana T, Tutino R, Raspanti C, Mascolino A, Melfa I, Scerrino G, Salamone G, Gulotta G. Complication of endoscopic tattooing: a case report of covered perforation. G Chir 2017; 37:74-8. [PMID: 27381693 DOI: 10.11138/gchir/2016.37.2.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Laparoscopy is considered a good approach in treatment of colorectal neoplastic diseases; the endoscopic tattooing is then recommended (Evidence Level III and grade of recommendation A) to mark a lesion or a polypectomy site for intraoperative identification. We describe the case of perforation after tattoing treated conservatively. CASE REPORT 63 years old woman, underwent colonoscopy for lipoma tattooing with India ink SPOT® solution kit and saline test. Immediately after the procedure the patient has been referred the appearance of colic epi-mesogastric pain and fever; Computed Tomography (CT) without MDC identified an irregular thickening of transverse colon with some microbubbles compatible with focal peritonitis. Initial paralytic ileus was present too. The blood count and metabolic panel examinations reveal a neutrophil leucocytosis (WBC: 11.000/mmc, 80% neutrophils). RESULTS On the base of WSES sepsis severity score and recent literature patient was treated conservatively with total parenteral nutrition, and intravenous antibiotic therapy. After the resolution of fever and reactivation of peristalsis. The discharge occurred after six days with no early complications. CONCLUSION India ink tattooing with SPOT® solution kit and saline test represent the first choice. It is a feasible technique although perforation is a possible complication. It may need an immediately surgical operation but in most cases a conservative management is a good and safe tool even if surgery may be attempted too.
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Sevim Y, Celik SU, Yavarifar H, Akyol C. Minimally invasive management of anastomotic leaks in colorectal surgery. World J Gastrointest Surg 2016; 8:621-626. [PMID: 27721925 PMCID: PMC5037335 DOI: 10.4240/wjgs.v8.i9.621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/06/2016] [Accepted: 07/20/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
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