Endoscopy 2021; 53(01): E17-E18
DOI: 10.1055/a-1173-7282
E-Videos

Modified endoscopic vacuum therapy in the management of a duodenal transmural defect

Diogo Turiani Hourneaux de Moura
1  Endoscopy Unit, Gastrointestinal Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Epifânio Silvino do Monte Junior
1  Endoscopy Unit, Gastrointestinal Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Kelly E. Hathorn
2  Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
,
Flaubert Sena de Medeiros
1  Endoscopy Unit, Gastrointestinal Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Christopher C. Thompson
2  Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
,
Eduardo Guimarães Hourneaux de Moura
1  Endoscopy Unit, Gastrointestinal Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
› Author Affiliations
 

Gastrointestinal (GI) transmural defects are associated with high rates of morbidity and mortality [1] [2]. Endoscopic vacuum therapy (EVT) has become a safe and effective tool for intraluminal treatment of these conditions, as it promotes changes in perfusion, microdeformation and macrodeformation of the tissue, and decreases bacterial contamination and local edema to facilitate healing. However, the high cost of the sponge system may limit widespread use of this technique [3]. In this video, we describe a cost-effective modified EVT for the treatment of transmural GI defects ([Fig. 1 a]).

Zoom Image
Fig. 1 Photographs showing: a the modified endoscopic vacuum therapy (EVT) device; b the items required to make the modified EVT device.

The procedure is performed with the use of an antimicrobial incise drape, gauze, a nasogastric tube (NGT), and nylon sutures. First, the antimicrobial drape is cut to match the size of the fenestrated portion of the NGT. Several holes are then made in the drape using a needle. Next, the gauze is wrapped around the fenestrated portion of the NGT and this is covered in the antimicrobial drape. Finally, the suture is used to fix the gauze and drape to the NGT ([Fig. 1 b]).

We report the use of this modified device in a 64-year-old man with cholangiocarcinoma who had undergone right hepatectomy and presented on post-operative day 30 with sepsis and melena. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) scanning showed a transmural duodenal wall defect associated with a fluid collection ([Fig. 2]). Given the patient’s clinical instability, it was decided that surgical therapy should be deferred owing to the high risk of mortality. Therefore, EVT was considered the best option for this patient. The patient was successfully treated with the modified EVT system ([Fig. 3]; [Video 1]), with the first procedure being followed by four EVT system exchanges, and he was discharged from the hospital 24 days after his initial procedure.

Zoom Image
Fig. 2 Endoscopic image showing evidence of an ischemic ulcer in the duodenum with a contained perforation.
Zoom Image
Fig. 3 Endoscopic images during the follow-up esophagogastroduodenoscopies showing progressive healing of the lesion.

Video 1 Video showing how to make the modified endoscopic vacuum therapy device and its use, with subsequent exchanges performed, in the management of a patient with a duodenal transmural defect.


Quality:

This novel cost-effective modified endoscopic vacuum therapy is feasible and appears to be as safe and effective as the traditional sponge EVT system in the right clinical scenario.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

C. C. Thompson is a consultant for Boston Scientific, Medtronic, USGI Medical, Olympus, Apollo Endosurgery, Fractyl, and GI Dynamics; has received research support from USGI Medical, Olympus, Apollo Endosurgery, Aspire Bariatrics, Spatz, and GI Dynamics; and has an ownership interest in GI Windows and EndoTAGSS. E. G. H. de Moura is a consultant for Boston Scientific and Olympus. The remaining authors declare that they have no conflict of interest.


Corresponding author

Diogo Turiani Hourneaux de Moura, MD, PhD
Endoscopy Unit – Gastrointestinal Department
Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
Rua Enéas de Carvalho Aguiar, 255
São Paulo
SP – 05679-065
Brazil   

Publication History

Publication Date:
29 May 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Photographs showing: a the modified endoscopic vacuum therapy (EVT) device; b the items required to make the modified EVT device.
Zoom Image
Fig. 2 Endoscopic image showing evidence of an ischemic ulcer in the duodenum with a contained perforation.
Zoom Image
Fig. 3 Endoscopic images during the follow-up esophagogastroduodenoscopies showing progressive healing of the lesion.