Endoscopic vacuum therapy for treatment of upper gastrointestinal anastomotic leakages: first experience

Abstract

Background: Surgical interventions on the esophagus belong to the group of "high risk" operations, as they can lead to such formidable complications as insolvency, bleeding and the formation of postoperative fistulas and strictures. The results of systematic analysis of the largest series of clinical cases published in the last 20 years show the incidence of postoperative anastomotic leakage about 3% after open and 2.1% after laparoscopic surgery without significant differences determined by the type of surgical access. However, analysis of the cumulative world experience shows the average incidence of anastomotic leakage at the level of 7-8%. These reports suggest that postoperative mortality rates in this patient group reach 30% and have no significant improvement toward reduction. Aggressive approaches to the treatment of patients with traditional surgical interventions lead to an increase in mortality from 20 to 64%, which determines the use of minimally invasive technologies as a priority. Since 2006, a new method of endoscopic vacuum therapy in management of anastomotic leaks has become available in clinical practice. Methods and materials: From March 2015 to March 2018, anastomotic leakage of the esophagus was diagnosed in 12 patients (5 women, 7 men), including 9 patients with failure of esophagogastric anastomosis, 3 patients with failure of esophagojejunal anastomosis. The average age was 67.5 years. Size of anastomotic perforation ranged from 0.8 to 3 cm. Strategy of treatment for all patients include adequate nutritional support by enteral feeding through the nasogastric tube, parenteral administration of combined nutrients, enterostomy, or a combination of several methods. Early antibiotic therapy is necessary for the prevention and treatment of already developed mediastinitis and septic complications. The complications were detected on the 1-7 days after surgery. Anastomotic leak was confirmed by radiological and endoscopic methods. Endoscopic vacuum therapy was performed on the day of leakage detection (2-4 days after the surgery). Thus no additional sanation and draining interventions were required due to early diagnosis and adequate drainage of the anastomosis area. Polyurethane spongy system, slightly smaller diameter or corresponding to the diameter of the esophagus, was mounted on a thermoplastic gastric probe and installed at the level of the perforation. Immediately after installation, the system was connected to a vacuum aspirator with a pressure of 100 - 125 mm Hg. Replacement of the system was carried out every 3-13 days. To fully close the insolvency, it took from 1 to 7 procedures. The decision to complete the therapy was carried out based on the results of endoscopic and X-ray examination in the absence of data for the presence of fistula. Results: Totally 57 procedures were performed: the number of replacements - 4 (1-7), the interval between procedures - 6 days (3- 13 days), the duration of treatment - 13 days (1-66 days). The success rate was 75%. There were three lethal outcomes, including two due to progressive cardiovascular failure with positive dynamics of local treatment. One patient died of the multiple organ failure. Conclusions: Endoscopic vacuum therapy is considered to be valuable and cost-effective method of treatment of anastomotic leaks and perforations of the upper GI tract.