Repair of upper-GI fistulas and anastomotic leakage by the use of endoluminal vacuum-assisted closure

Abstract

Background and aims: GI perforations, leaks, and fistulas are types of full-thickness mural defects that frequently occur as adverse events from GI surgeries such as esophagectomy for malignancy and bariatric surgery. Historically, treatment has entailed a combination of reoperation, percutaneous drainage, and bowel rest. Recently, there has been a changing paradigm in the management of these defects. Endoscopic interventions, including endoclipping and placement of self-expanding metal stents (SEMSs), have been increasingly used with good success. Despite this, some defects remain refractory to these techniques. Endoscopic vacuum-assisted closure (EVAC) is a new, promising endoscopic approach to repairing these 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. EVAC has been shown to be feasible, safe, and effective.

Methods: We present a video series of 3 cases demonstrating the successful application of EVAC for the treatment of anastomotic leakage after esophagectomy and of fistula formation after bariatric surgery.

Results: Two patients experienced anastomotic leakage after esophagectomy for esophageal adenocarcinoma, and 1 patient experienced 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 3 patients' defects did not heal despite SEMS placement; therefore, EVAC was performed. The bariatric surgery patient required 9 sponge exchanges over 35 days, and the 2 esophagectomy patients each required 3 sponge exchanges over 13 days. All 3 patients had resolution of their defects with EVAC. No adverse events occurred, and all patients have had no recurrence for several months.

Conclusions: These cases help to highlight the feasibility, safety, and efficacy of EVAC for the closure of full-thickness GI defects. On the basis of our experience, the use of EVAC should be considered for these complex and refractory cases.

Keywords: EVAC, endoscopic vacuum-assisted closure; OTSC, over-the-scope clip; SEMS, self-expanding metal stent.

Figure 1

Components required to construct vacuum/sponge complex.

Figure 2

Completed vacuum/sponge complex.

Figure 3

Initial defect before endoscopic vacuum-assisted closure in patient 1.

Figure 4

Closure of defect after endoscopic vacuum-assisted closure in patient 1.

Figure 5

Initial defect before endoscopic vacuum-assisted closure in patient 2.

Figure 6

Closure of defect after endoscopic vacuum-assisted closure in patient 2.

Figure 7

Initial defect before endoscopic vacuum-assisted closure in patient 3.

Figure 8

Closure of defect after endoscopic vacuum-assisted closure in patient 3.

Figure 9

Example of vacuum/sponge complex deployed over defect site in the esophagus.