Endoscopic ‘suction room’ to treat complex enteral stump leaks after upper gastrointestinal surgery

Abstract

Leaks/dehiscence of the enteral stump associated with infected peri-enteric collections after upper gastrointestinal surgery are a life-threatening adverse event, not usually endoscopically treatable.

We describe a new endoscopic approach to treat complex entero-cutaneous fistulas (CECF) by creating a “suction room” through placement of multiple stents (enteral, biliary and/or pancreatic) and a large nose-enteral suction tube inside the enteral stent maintained on a continuous negative aspiration suction.
Between January 2016 and December 2019, six consecutive patients referred to our unit with CECF of the enteral stump after failed redo surgeries underwent creation of a “suction room.” In five patients, enteral, biliary and pancreatic stents were positioned before a nose-to-stent or nose-to-collection large 18 Fr tube placement. In one patient, a pancreatic stent was not placed. Technical and clinical success were achieved in all patients. Mean and median times of aspiration were 49 and 27 days, respectively, with a mean hospital stay of 56 days after the endoscopic procedure. Stents were successfully removed. Mean post-procedural follow-up was 17.3 months.

Endoscopic creation of the “suction room” offers the unique possibility of treating complex entero-cutaneous fistulas in surgically altered sites, which are difficult to manage with standard endoscopic methods.

Publication History

Received: 13 August 2020

Accepted: 11 November 2020

Article published online:
19 February 2021

• References

• 1 Loske G. Endoscopic negative pressure therapy of the upper gastrointestinal tract. Chirurg 2019; 90: 1-6
• 2 Babu B, Finch J. Current status in the multidisciplinary management of duodenal fistula. Surgeon 2013; 11: 158-164
• 3 Cozzaglio L, Coladonato M, Biffi R. et al. Duodenal fistula after elective gastrectomy for malignant disease: an Italian retrospective multicenter study. J Gastrointest Surg 2010; 14: 805-811
• 4 Mutignani M, Dioscoridi L, Dokas S. et al. Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: a novel effective rescue procedure. World J Gastrointest Endosc 2016; 8: 533-540
• 5 Wahl P, Lammer F, Conen D. et al. Septic complications after injection of N-butyl-2-cyanoacrylate: report of two cases and review. Gastrointest Endosc 2004; 59: 911-916
• 6 Mutignani M, Forti E, Larghi A. et al. Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy. Endoscopy 2019; 51: 1146-1150
• 7 Mutignani M, Forti E, Pugliese F. et al. New endoscopic technique for uncontrollable bilious vomiting after gastrojejunal surgical bypass. Endoscopy 2017; 49: E225-E226
• 8 Newton NJ, Sharrock A, Rickard R. et al. Systematic review of the use of endo-luminal topical negative pressure in oesophageal leaks and perforations. Dis Esophagus 2017; 30: 1-5
• 9 Watkins JR, Farivar AS. Endoluminal therapies for esophageal perforations and leaks. Thorac Surg Clin 2018; 28: 541-554