Comparison of endoscopic vacuum therapy with standard care for colorectal anastomotic leakage: a systematic review and meta-analysis

Abstract

Background

This systematic review and meta-analysis aimed to evaluate the effectiveness of endoscopic vacuum therapy (EVT) compared with standard care in managing colorectal anastomotic leakage, a serious complication following colorectal surgery.

Methods

We conducted a literature search across PubMed, Embase, and the Cochrane Library for clinical studies published before October 2024 that compared the outcomes of EVT and standard care for anastomotic leakage, including leakage resolution rates, treatment duration, hospital stay duration, or postoperative complications. The pooled estimates of risk ratio (RR) or mean difference were primarily derived using a fixed-effects model, with a random-effects model used when high heterogeneity was detected.

Results

The analysis included six observational studies (273 patients). EVT was associated with a significantly higher resolution rate compared with standard care (RR 1.18, 95%CI 1.03 to 1.35; P = 0.02). Treatment duration was significantly shorter in the EVT group (mean difference −30.6 days, 95%CI −43.5 to −17.7; P < 0.001), while hospital stay duration showed no significant difference between EVT and standard care (mean difference 1.7 days, 95%CI −4.2 to 7.7; P = 0.57). No statistically significant difference was found in the rate of treatment-related complications between EVT and standard care (RR 1.17, 95%CI 0.52 to 2.80; P = 0.71).

Conclusion

This meta-analysis suggests that EVT has superior effectiveness in terms of leakage resolution rates, as well as a shorter treatment duration compared with standard care for colorectal anastomotic leakage. This study is however constrained by the lack of prospective data, the risk of selection bias, and heterogeneity, requiring cautious interpretation of the findings.

PROSPERO registration: CRD 4873455814.

• References

• 1 Aker M, Askari A, Rabie M. et al. Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort. Int J Surg 2021; 96: 106167
• 2 Chiarello MM, Fransvea P, Cariati M. et al. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40: 101708
• 3 Yang CS, Choi GS, Park JS. et al. Rectal tube drainage reduces major anastomotic leakage after minimally invasive rectal cancer surgery. Colorectal Dis 2016; 18: O445-O452
• 4 Sirois-Giguère E, Boulanger-Gobeil C, Bouchard A. et al. Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option. Dis Colon Rectum 2013; 56: 586-592
• 5 Arezzo A, Miegge A, Garbarini A. et al. Endoluminal vacuum therapy for anastomotic leaks after rectal surgery. Techn Coloproctol 2010; 14: 279-281
• 6 Arezzo A, Verra M, Passera R. et al. Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis 2015; 47: 342-345
• 7 Kuehn F, Janisch F, Schwandner F. et al. Endoscopic vacuum therapy in colorectal surgery. J Gastrointest Surg 2016; 20: 328-334
• 8 Strangio G, Zullo A, Ferrara EC. et al. Endo-sponge therapy for management of anastomotic leakages after colorectal surgery: A case series and review of literature. Dig Liver Dis 2015; 47: 465-469
• 9 Weidenhagen R, Gruetzner KU, Wiecken T. et al. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 2008; 22: 1818-1825
• 10 de Moura DTH, de Moura B, Manfredi MA. et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11: 329-344
• 11 Kühn F, Janisch F, Schwandner F. et al. Comparison between endoscopic vacuum therapy and conventional treatment for leakage after rectal resection. World J Surg 2020; 44: 1277-1282
• 12 Talboom K, Greijdanus NG, Brinkman N. et al. Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series. Techn Coloproctol 2023; 27: 1099-1108
• 13 Weréen A, Dahlberg M, Heinius G. et al. Long-term results after anastomotic leakage following rectal cancer surgery: a comparison of treatment with endo-sponge and transanal irrigation. Dig Surg 2020; 37: 456-462
• 14 Munshi E, Dahlbäck C, Johansson S. et al. Long-term outcomes of endoscopic vacuum therapy and transanal drainage for anastomotic leakage after anterior resection. In Vivo 2022; 36: 2275-2278
• 15 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. PLoS medicine 2021; 18: e1003583
• 16 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
• 17 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
• 18 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
• 19 Luo D, Wan X, Liu J. et al. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res 2018; 27: 1785-1805
• 20 Wan X, Wang W, Liu J. et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014; 14: 135
• 21 Rücker G, Schwarzer G, Carpenter JR. et al. Undue reliance on I(2) in assessing heterogeneity may mislead. BMC Med Res Methodol 2008; 8: 79
• 22 IntHout J, Ioannidis JP, Rovers MM. et al. Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open 2016; 6: e010247
• 23 Mees ST, Palmes D, Mennigen R. et al. Endo-vacuum assisted closure treatment for rectal anastomotic insufficiency. Dis Colon Rectum 2008; 51: 404-410
• 24 Wasmann KA, Reijntjes MA, Stellingwerf ME. et al. Endo-sponge assisted early surgical closure of ileal pouch-anal anastomotic leakage preserves long-term function: a cohort study. J Crohns Colitis 2019; 13: 1537-1545
• 25 Zarnescu EC, Zarnescu NO, Costea R. Updates of risk factors for anastomotic leakage after colorectal surgery. Diagnostics (Basel) 2021; 11: 2382
• 26 Nijssen DJ, Wienholts K, Postma MJ. et al. The economic impact of anastomotic leakage after colorectal surgery: a systematic review. Techn Coloproctol 2024; 28: 55
• 27 Glitsch A, von Bernstorff W, Seltrecht U. et al. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses. Endoscopy 2008; 40: 192-199
• 28 Basiliya K, van Helden EJ, de Jong M. et al. Stent with vacuum therapy for treatment of colonic anastomotic leakage. Endoscopy 2024; 56: E102
• 29 Monino L, Gonzalez JM, Bachmann R. et al. Endoscopic vacuum therapy of anastomotic leaks complicating colorectal surgery. Endoscopy 2023; 55: S264-S265
• 30 Kühn F, Zimmermann J, Beger N. et al. Endoscopic vacuum therapy for treatment of rectal stump leakage. Surg Endosc 2021; 35: 1749-1754
• 31 de Moura DTH, Hirsch BS, Ribas P. et al. Endoscopic vacuum therapy: pitfalls, tips and tricks, insights, and perspectives. Transl Gastroenterol Hepatol 2024; 9: 50
• 32 de Lacy FB, Talboom K, Roodbeen SX. et al. Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates. Br J Surg 2022; 109: 822-831
• 33 van Koperen PJ, van Berge Henegouwen MI, Rosman C. et al. The Dutch multicenter experience of the endo-sponge treatment for anastomotic leakage after colorectal surgery. Surg Endosc 2009; 23: 1379-1383
• 34 Mahendran B, Rossi B, Coleman M. et al. The use of Endo-SPONGE in rectal anastomotic leaks: a systematic review. Techn Coloproctol 2020; 24: 685-694
• 35 Mussetto A, Arena R, Buzzi A. et al. Long-term efficacy of vacuum-assisted therapy (Endo-SPONGE) in large anastomotic leakages following anterior rectal resection. Ann Gastroenterol 2017; 30: 649-653
• 36 Shalaby M, Emile S, Elfeki H. et al. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2019; 3: 153-160