Endoluminal Negative Pressure Wound Therapy (E-NPWT) for anastomotic leakage after rectal resection

Abstract

REVIEWAbstract-Background: Local management of anastomotic leakage after rectal cancer resection has traditionally consisted of rinsing and drainage. Transanal endoluminal application of NPWT (E-NPWT or endo-VAC or endo-sponge) is an interesting novel concept that has been explored in a few studies and case series over the last decade. We report herein our institutional experience over a three year period during which E-NPWT was the local treatment of choice for all cases with anastomotic leakage after rectal resection.Patients and Methods: This study retrospectively evaluated the clinical charts of 147 consecutive patients who underwent anterior rectal resection from 2011-2013. A postoperative anastomotic leak occurred in eight (5%) patients from two straight anastomoses, one side-to-end construction, and five colonic pouches. All patients had undergone curative anterior resection with diverting ostomy. Transanal debridement and application of a trimmed foam were performed by rigid or fexibel endoscopy and started without delay after confirmation of diagnosis in seven patients 8-15 days postoperatively. In one patient E-NPWT began after failed fibrin-glue treatment 6 weeks later. The foams were connected to a standard vacuum pump with the pressure set at -70mmHg in a continuous mode. E-NPWT was maintained for a median period of 10 (5-25) days. The treatment intervals were typically 2-3 days.Results: Complete healing was achieved in three cases during E-NPWT. In the remaining five patients, the defect reduced in size to allow further spontaneous healing. This occurred twice. One persistent sinus was successfully sealed with fibrin glue. One persisting recto-vaginal fistula required surgical closure. One large defect secondary to ischemic pouch necrosis required secondary pouch explantation and permanent colostomy. The overall ileostomy reversal rate was 75%.Conclusion: E-NPWT is feasible and without severe side effects. Early initiation prevents septic progression and results in a high closure rate in patients with pelvic leakage. Although complete healing is not achieved in recto-vaginal fistulas or ischemic necrosis of the neorectum, E-NPWT may play a potential role in bridging and damage control.