Repair of upper gastrointestinal fistulas and anastomotic leakage utilizing endoluminal vacuum-assisted closure.
Watson A, and Zuchelli T. Repair of upper gastrointestinal fistulas and anastomotic leakage utilizing endoluminal vacuum-assisted closure. Gastrointest Endosc 2018; 87(6):AB123.
Gastrointestinal (GI) perforations, leaks, and fistulas are types of full-thickness mural defects that can result in significant morbidity and mortality. These defects frequently occur as complications from GI surgeries such as esophagectomy and bariatric surgery. Historically, treatment of these complications has entailed a combination of reoperation, percutaneous drainage, antimicrobial therapy, and bowel rest. More recently, there has been a changing paradigm in the management strategy of these defects. Minimally-invasive endoscopic interventions including endoclipping and placement of self-expanding metal stents (SEMS) have been reported to achieve high rates of successful closure and are associated with improved outcomes. Despite these encouraging results, some defects remain refractory to these techniques. Endoscopic vacuum-assisted closure (EVAC) is a new promising endoscopic approach for repairing upper GI defects. EVAC works through applying continuous, controlled negative pressure at the defect with the use of an endoscopically-placed polyurethane sponge connected to an electronic vacuum device. The sponge is exchanged every 3-5 days until healing of the defect, which also allows for interval examination of the site. EVAC utilizes the general principle of negative pressure wound therapy that continuous suction and drainage allows for decreased bacterial contamination and local edema while promoting perfusion and granulation tissue formation. We present a video series of three cases demonstrating the successful application of EVAC for the treatment of anastomotic leakage after esophagectomy and of fistula formation after bariatric surgery. Two patients developed anastomotic leakage after esophagectomy for esophageal adenocarcinoma and one patient developed a chronic gastric fistula after roux-en-y gastric bypass. The gastric bypass patient's fistula failed to resolve with over-the-scope-clip placement and all three patients' defects did not heal despite SEMS placement. Therefore, EVAC was performed for these refractory cases. The bariatric surgery patient required nine sponge exchanges over 35 days and the two esophagectomy patients required three sponge exchanges over 13 days. All three patients had resolution of their defects, which were confirmed by esophagram. No complications occurred and all patients have not had recurrence for several months. These cases help to highlight the feasibility, safety, and efficacy of EVAC for the closure of full-thickness GI defects. Based on our experience, the use of EVAC should be considered for these complex and refractory cases.