Pre-emptive active drainage of reflux (PARD) in Ivor-Lewis oesophagectomy with negative pressure and simultaneous enteral nutrition using a double-lumen open-pore film drain (dOFD)

Abstract

Background: Postoperative reflux can compromise anastomotic healing after Ivor-Lewis oesophagectomy (ILE). We report on Pre-emptive Active Reflux Drainage (PARD) using a new double-lumen open-pore film drain (dOFD) with negative pressure to protect the anastomosis.

Methods: To prepare a dOFD, the gastric channel of a triluminal tube (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over 25 cm. The ventilation channel is blocked. The filmcoated segment is placed in the stomach and the intestinal feeding tube in the duodenum. Negative pressure is applied with an electronic vacuum pump (- 125 mmHg, continuous suction) to the gastric channel. Depending on the findings in the endoscopic control, PARD will either be continued or terminated.

Results: PARD was used in 24 patients with ILE and started intraoperatively. Healing was observed in all the anastomoses. The median duration of PARD was 8 days (range 4-21). In 10 of 24 patients (40%) there were issues with anastomotic healing which we defined as "at-risk anastomosis". No additional endoscopic procedures or surgical revisions to the anastomoses were required.

Conclusions: PARD with dOFD contributes to the protection of anastomosis after ILE. Negative pressure applied to the dOFD (a nasogastric tube) enables enteral nutrition to be delivered simultaneously with permanent evacuation and decompression.

Keywords: Anastomosis; Drainage; Endoscopic vacuum therapy; Endoscopy; Nasogastric tube; Prophylaxis.

Fig. 1

Showing the dOFD, a open-pore drainage-element (DE) coated with a 25 cm long strip of the open-pore double-layered thin film. Intestinal feeding tube (iT) The film is fixed with a suture coiled around the length of the tube. b detail of the DE segment. c Detail of the proximal end of the dOFD. Proximal opening of the gastric tube (G) to which negative pressure is applied. Proximal end of feeding tube (iT) with mandrin. Ventilation tube is blocked with a clamp (B)

Fig. 2

Illustration of the dOFD used and a NGT. The drains were cut open so that the transverse profile can be seen. The dOFD was wrapped with the open-pore double-layered film (oF). The oF has countless small pores on the surface, all of which are interconnected. The individual channels are integrated into one tube: Ventilation channel (V), this is blocked; intestinal feeding channel (iT); and the gastric channel (G(Vac)), to which the vacuum is applied and which is in suction contact with the oF. On the right, an 18 French NGT with large lateral perforations (LP) can be seen

Fig. 3

Schematic illustration of the PARD method. A Without a nasogastric tube postoperative reflux will flood the anastomotic region after ILE. B For PARD method, a thin double-lumen open-pore film drain (dOFD) is inserted through the nose. The 25 cm long open-pore drainage film element of the gastric tube is placed in the stomach. The intestinal feeding tube is directed into the duodenum. C With an electronic vacuum pump (VAC − 125) negative pressure of − 125 mmHg is applied to the gastric channel. Continuous negative pressure suction results in the permanent evacuation of the gastric conduit and decompression of the anastomotic region. Enteral feeding is possible via the feeding tube

Fig. 4

Demonstrates a dOFD after removal. Typically, the drainage-element is found to be saturated with green bile descending from distal drainage-element (dDE) to the proximal (pDE). The pores of the membrane in the pDE are blocked with swallowed bronchial mucus or gastric slime. In the dDE pores are patent and drainage is working

Fig. 5

Endoscopic impressions of at-risk anastomoses (ARA) that healed using the PARD method

Fig. 6

In patient No. 8 we found an incomplete ischaemia of the oral gastric conduit and anastomosis (a). During prolonged PARD for 19 day the necrosis was rejected, and secondary wound healing took place (b)