Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks: How to Deal with the Challenges (with Video)

Abstract

Anastomotic leaks after gastrointestinal surgery have an important impact on surgical outcomes because of the high morbidity and mortality rates. Multiple treatment options exist requiring an individualized patient-tailored treatment plan after multidisciplinary discussion. Endoscopic vacuum therapy (EVT) is a novel treatment option that is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. EVT has a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient. To the unexperienced, the EVT technique may be prone to several hurdles which may deter endoscopists from using it and depriving patients from a potentially life-saving therapeutic option. The current review highlights the possible difficulties of the EVT procedure and aims to provide some practical solutions to facilitate its use in daily clinical practice. Personal tips and tricks are shared to overcome the pre-, intra- and post-procedural hurdles. An instructive video of the procedure helps to illustrate the technique of EVT.

Keywords: anastomotic leak; endoscopic vacuum therapy; practical review; upper gastrointestinal tract.

Figure 1

Total gastrectomy with an oesophagojejunal anastomosis complicated by an anastomotic leak. (A) Pre-procedure evaluation by CT scan (white arrows: hydroaeric collection; white star: anastomotic leak). (B) Pre-procedure endoscopic evaluation with inspection of the anastomotic leak. (C) Pre-procedure endoscopic evaluation of the extramural cavity.

Figure 2

Fluoroscopic evaluation of the depth and the orientation of an extramural collection after endoscopic contrast injection in a patient with an anastomotic leak of an oesophagojejunal anastomosis.

Figure 3

Placement of two sponges in a large-sized extramural collection (80 × 70 mm).

Figure 4

(A) Oesophageal stricture 6 months after intraluminal EVT treatment of partial anastomotic dehiscence. Notice the presence of medication tablets proximal to the post-EVT anastomotic stricture. (B) Endoscopic balloon dilatation of a post-EVT oesophageal stricture.

Figure 5

Difficult introduction of the overtube on the endosope into the collection. (A) Introduction of the endoscope into a collection, thus complicating an anastomotic oesophagogastric leak. The angulated tip of the endoscope does not allow advancement of the overtube into the collection. (B) Introduction of the overtube is not possible over the angulated endoscope tip in a patient with an anastomotic leak and extramural collection at the level of the oesophagojejunal anastomosis.

Figure 6

(A) Clean granular aspect of healing tissue in an extraluminal cavity after removal of the EVT sponge. (B) Diffuse intracavity bleeding after removal of the EVT sponge.