Endoscopic Vacuum Therapy (EVT) for Persistent Duodenal Stump Dehiscence After Upper Gastrointestinal Surgery in Selected Patients: A Tertiary Referral Center Case Series

Abstract

Introduction: The usefulness of endoscopic vacuum therapy (EVT) in the setting of postoperative gastrointestinal leaks is widely described. On this basis, we would like to focus a specific application of EVT: the dehiscence of the duodenal stump after upper gastrointestinal surgery. Standard EVT is not applicable in these cases because of technical limitations (length of overtube and devices). However, vacuum stimulates the healing of leaks and fistulas through granulation tissue’s formation and would be effective also in this setting. Materials and Methods: Between October 2019 and January 2020, 7 consecutive patients (4 M, 3 F, 62±9 y old) affected by duodenal stump’s dehiscence were endoscopically treated by the placement of a large-bore (14 to 18 Ch) suction tube across the wall’s defect into the peritoneal cavity. Continuous aspiration at −80/−100 mm Hg was applied. Clinical success was established both by fluoroscopic check injecting contrast medium from the tube to verify the fistula’s closure and by abdominal computed tomography scan to exclude residual fluid collections. Results: Technical and clinical success were achieved in all the patients. The suction tube was maintained in site for 12±5 days in continuous aspiration. The drainage’s output became null in 2±1 days without any intra-abdominal residual fluid collection. The principle of this technique is to let the duodenal walls’ stump to collapse on the intraluminal part of the tube (with subsequent mucosal intussusception into the holes of the tube itself) creating a sort of vacuum-packed barrier to interrupt the outflow of enteric materials into the fistula’s path. It guarantees the fistula’s closure by the gradual formation of granulation tissue. Conclusions: The present technique offers a safe and viable endoscopic alternative to treat duodenal stump’s leaks after upper gastrointestinal surgery.

Delayed duodenal stump fistula after laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer: A case report

“…[4,6] The endoscopic approach involves techniques such as endoscopic stitching, stapling, biological glue, diversion with stent, and endoscopic vacuum-assisted closure. [14] The mean interval of DSF after gastrectomy is 6.6-9 days. [5,7] A case report which reported a delayed DSF after 45 days of initial surgery had explained it was caused by increased backpressure on the afferent limp and duodenal stump due to obstruction of the distal jejunum.…”

“…[ 4 , 6 ] The endoscopic approach involves techniques such as endoscopic stitching, stapling, biological glue, diversion with stent, and endoscopic vacuum-assisted closure. [ 14 ]…”

Endoscopic negative pressure therapy for duodenal leaks

“…A limited aspect of duodenal/jejunal ENPT is the length of the probe and the safe position into the duodenum. For this reason, Mutagnini et al described the successful use of non-coated nasojejunal probes in seven patients with duodenal stump insufficiencies and suction with a negative pressure between 80 and 100 mmHg ( 23 ). This article was not included to the review because OPSD was not used.…”

Comments on „Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations”

“…We read with great interest the article by de Lima et al on the application of endoscopic vacuum therapy (EVT) to upper gastrointestinal perforations [1]. We have experienced and previously published the technique in the same setting (for postoperative esophageal leaks) [2] and for chronic duodenal leaks [3], and would like to discuss a few points on the basis of our expertise. First, the timing of the treatment is not clearly defined.…”