Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection

Abstract

Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).

Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study

“…The comparison of leakage management between periods 1 and 2 highlight the impact of the local quality improvement intervention: The lower threshold for postoperative endoscopy instead of radiologic imaging lead to a trend towards earlier postoperative diagnosis of leakage (8 vs. 11 days). This early time-point in period 2 corresponds well to the 8 days reported in recent studies for postoperative leakage after oncologic UGI surgery [17,18]. Notably, no changes in leakage diameter or presence of sepsis on diagnosis of leakage were observed in our analysis.…”

“…Thus, the duration of leakage until EVT was significantly shortened and the .010* number of leakage interventions prior to EVT were reduced to a minimum. An analogous approach was reported from Heidelberg University Hospital, where postoperative leakage management was switched to primary EVT in 2015 [17].…”

“…Thus, the duration of leakage until EVT was significantly shortened and the number of leakage interventions prior to EVT were reduced to a minimum. An analogous approach was reported from Heidelberg University Hospital, where postoperative leakage management was switched to primary EVT in 2015 [ 17 ]. The earlier diagnosis of leakages and the abandonment of revisional surgery reduced the incidence of mechanical ventilation by 50% in our analysis, which likely prevents additional pulmonary complications and long-term ICU stay.…”

Possibilities of modern technologies in the treatment of injuries and fistulas of the esophagus

“…По некоторым данным, задержка в лечении более 24 часов приводит к трехкратному увеличению летальности. Однако единичные сообщения о благоприятных исходах у пациентов, поступивших в поздние сроки, позволяют предположить, что результат лечения зависит от развития инфекционных осложнений, степени изменений стенки пищевода и медиастинальной клетчатки [9,10].…”

Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis

“…It consists of intra- or extra-luminally placed polyurethane foam connected via a tube to a vacuum device applying continuous negative pressure with the aim of cleaning the anastomotic site, promoting shrinkage of the para-anastomotic cavity ( Supplementary Figure S2A,B ). EVT is widely spreading as a treatment of post-esophagectomy/gastrectomy leaks, being increasingly preferred to stenting, as it is an effective and less-complicated approach; a recent prospective trial by Zhang et al showed an 89% closure rate of post-esophagectomy intra-thoracic leakages, with a 5.4% rate of adverse events [ 14 ].…”