The use of novel modified endoscopic vacuum therapies in the management of a transmural rectal wall defect

Gastrointestinal transmural defects are difficult to manage and are associated with high rates of morbidity and mortality [1] [2]. Endoscopic vacuum therapy (EVT) has developed into a safe and effective tool for intraluminal treatment of these conditions. However, the high cost of the sponge system may limit a wide spectrum of use [2] [3] [4]. In this video, we describe two cost-effective modified EVTs for treatment of transmural defects.

The first technique is performed using an antimicrobial incise drape, gauze, nasogastric tube (NGT), and nylon suture. First, the antimicrobial drape is cut to fit the fenestrated portion of the NGT. Then, several holes are made in the drape. Next, gauze is wrapped around the fenestrated portion of the NGT, and the gauze is then covered by the antimicrobial drape. Finally, the suture is used to fix the gauze and drape to the NGT ([Fig. 1 a]).

Fig. 1 Modified endoscopic vacuum therapy systems. a Gauze and antimicrobial incise drape over a nasogastric tube (NGT). b Two NGTs and a nylon suture.

The second technique requires two NGTs and nylon suture thread. First, we cut the distal end of an 18-Fr NGT, then we place a 12-Fr NGT inside the cut end of the 18-Fr NGT, ensuring that the fenestrated portions of the two NGTs do not align. Finally, the suture is used to fix the NGTs together ([Fig. 1 b]).

A 29-year-old woman with familial adenomatous polyposis who had undergone proctocolectomy 2 years earlier, presented with daily fevers and rectal pain. Computed tomography scan demonstrated a leak at the ileorectal anastomosis with an associated fluid collection ([Fig. 2], [Fig. 3 a]). An end-ileostomy was performed. The patient was then treated with a modified EVT system, followed by four EVT system exchanges ([Video 1]). She was discharged from hospital 28 days after the initial procedure ([Fig. 3 b]).

Fig. 2 Computed tomography scan showing a leak at the ileorectal anastomosis, with an associated fluid collection (arrow).

Fig. 3 Esophagogastroduodenoscopy. a The leak at the ileorectal anastomosis. b Complete healing of the anastomotic leak after 28 days of endoscopic vacuum therapy.

Video 1 Modified endoscopic vacuum therapy in the management of a transmural rectal wall defect.

These novel cost-effective modified EVTs are feasible and appear to be as safe and effective as the traditional sponge EVT system.

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• References

• 1 de Moura DTH, Sachdev AH, Thompson CC. Endoscopic full-thickness defects and closure techniques. Curr Treat Options Gastroenterol 2018; 16: 386-405
• 2 Dos Santos NT, De Moura DTH, Galvão Neto M. et al. Novel laparo-endoscopic hybrid procedure to treat a disconnected Roux limb after bariatric surgery. Endoscopy 2019; 51: E341-E342
• 3 de Moura DTH, Brunaldi VO, Minata M. et al. Endoscopic vacuum therapy for a large esophageal perforation after bariatric stent placement. VideoGIE 2018; 3: 346-348
• 4 de Moura DTH, de Moura BFBH, Manfredi MA. et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11: 329-344