Efficacy of E-VAC Therapy as Rescue Treatment in Refractory Anastomotic Leak and Perforation after Gastro-esophageal Surgery

21 Jan, 21

Introduction

Anastomotic leak is one of the most feared complications after upper gastrointestinal (UGI) surgery. Endoscopic vacuum therapy (E-VAC) has emerged over the last few years as an alternative to treat leak and perforations.

Aim

To evaluate E-VAC therapy as a rescue treatment in the management of UGI leaks resistant to another treatment.

Patient Profile

Patients who were treated with E-VAC therapy for oesophagal or gastric anastomotic leak and gastric conduit perforation

Methods

A total of 6 patients were treated for the anastomotic leak: 3 cervical, 1 thoracic and 2 abdominal and 1 for perforation of the gastric conduit
6 intracavitary E-VAC and 2 intraluminal E-VAC treatments in 7 patients, with an overall number of 60 procedures were performed
Demographic and clinical data were collected for patients who were treated with E-VAC therapy for oesophagal or gastric anastomotic leak and gastric conduit perforation
Data E-VAC treatment (number of insertions, duration of the treatment and procedure-related complications)

Results

Table 1: Baseline Characteristics

Characteristics	Patients (tot 7)
Age, median	60
ASA
1–2	4
3–4	3
Type of surgery
Total Gastrectomy for cancer	2
Retrosternal esophago-gastroplasty after caustic ingestion	1
Mc Kewon esophagectomy for cancer	2
Ivor Lewis esophagectomy for cancer	2
Site of leak
Cervical esophago-gastric anastomotic leak	3
Thoracic esophago-gastric anastomotic leak	1
Abdominal esophago-jejunal anastomotic leak	2
Intrathoracic gastric tube perforation	1
POD leak detection, median (range)	7 (4–255)
Defect size
< 1 cm	1
1–2 cm	3
> 2 cm	1
Complete dehiscence	2
Abscess size
< 5 cm	1
6–10 cm	4
> 10 cm	2

Complete healing of the leak was achieved in 4 cases of intracavitary (67%) and 1 case of intraluminal (50%) treatment
In patients successfully treated with E-VAC, the median number of procedures was 10 (5–14) with a median treatment duration of 41 days (19–49)
Only one E-VAC-related complication: bleeding successfully managed endoscopically

Table 2: E-VAC treatment details

Patient	Position	N procedure	Treatment duration (days	Complications	Success	Case of Failure	Other treatment
1	Intracavitary	5	19	Bleeding	No	Bleeding	Conservative ^a
2	Intracavitary	8	29	No	Yes
3	Intracavitary	1	4	No	No	Neck pain	Conservative ^a
4	Intracavitary	10	41	No	Yes
5	Intracavitary	14	49	No	yes
6	Intraluminal	3	13	No	No	No local improvement, sepsis	Surgery ^b intracavitary E-VAC
6	Intracavitary	14	46	No	Yes
7	Intraluminal	5	19	No	Yes

^a Conservative treatment: nil per os, naso-gastric tube placed near the defect, antibiotics

^b Surgery: thoracoscopy with closure of the defect, pleural toilette and drain placement

Conclusion

The study demonstrated that E-VAC therapy was found to be safe and effective option for the management of refractory leaks and perforations after UGI surgery, even if it requires longer treatment duration

Reference

Updates Surg (2020). https://doi.org/10.1007/s13304-020-00935-y