Reflux after Ivor Lewis esophagectomy has a deleterious effect on anastomotic wound
healing and is a risk for pulmonary aspiration [1 ]. We report endoscopic negative pressure therapy, using a novel double-lumen open-pore
film drainage method, for prevention of postoperative reflux.
A 70-year-old patient underwent Ivor Lewis esophagectomy because of carcinoma of the
distal esophagus (pT2pN0), having undergone laryngectomy because of carcinoma of the
larynx 5 years previously. On postoperative day 4, rising inflammatory parameters
led to endoscopy in order to check the anastomosis, in accordance with our treatment
algorithm [2 ]. We found biliary gastric reflux flooding the intrathoracic anastomosis ([Fig. 1 ]). The anastomotic tissue was seen to be green-colored and the staple line of the
stomach showed signs of inflammation ([Fig. 2 ]).
Fig. 1 Biliary gastric reflux (Rf) is flooding the anastomosis in the esophagus (Eso) of
a 70-year-old patient who has undergone Ivor Lewis esophagectomy.
Fig. 2 Retroverted view shows the green-colored anastomosis (A), inflammation at the gastric
staple line (Stl), and the endoscope (E).
We decided to evacuate the stomach with endoscopic negative pressure therapy, using
an innovative double-lumen drainage system that incorporated open-pore film material.
Our goal was to eliminate the postoperative reflux that was compromising the anastomotic
healing.
We adapted a triluminal tube (Freka Trelumina, CH/Fr 16/9, 150 cm; Fresenius, Germany)
using open-pore film (Suprasorb CNP Drainagefolie; Lohmann and Rauscher, Germany).
All the openings of the gastric channel of the triluminal tube were wrapped around
once with a length of the open-pore film. The film was fixed using suture thread.
The ventilation lumen of the tube was blocked with a clamp ([Fig. 3 ], [Video 1 ]). The small-bore tube was inserted nasally and pushed, so that finally the intestinal
feeding channel was positioned in the duodenum ([Video 1 ]) and the film-wrapped part of the tube was positioned in the stomach ([Fig. 4 ]).
Fig. 3 Double-lumen open-pore film drainage (OFD) device with intestinal feeding channel
(IC), adapted from a triluminal tube by means of open-pore film (oF). The (ventilation)
lumen (V) is blocked with a clamp (bl).
Video 1 The construction of a double-lumen open-pore film drainage (OFD) device and the course
of endoscopic negative pressure therapy (ENPT) for preventing gastric reflux after
Ivor Lewis esophagoectomy.
Fig. 4 The tube (t), with the open-pore film drainage (OFD) section placed in the stomach
distal to the anastomosis (A), for simultaneous endoscopic negative pressure therapy
to drain biliary reflux, and intestinal feeding via the duodenum.
Application of negative pressure with an electronic device (setting – 125 mmHg, continuous,
intensity 10; KCI V.A.C. Freedome, KCI USA Inc., San Antonio, Texas, USA) resulted
in permanent collapse of the stomach and complete drainage of the reflux. Simultaneously,
intestinal nutrition was started along the feeding channel. The open-pore film drainage
was changed once after 3 days of treatment ([Fig. 5 ]). Infection signs at the staple line and green colored imbibition at the anastomosis
had disappeared. Endoscopic negative pressure therapy was ended after a period of
10 days. Follow-up endoscopy 7 days after the end of therapy showed complete healing
([Video 1 ]).
Fig. 5 Change of open-pore film drainage device (OFD) after 3 days of endoscopic negative
pressure therapy. The stomach is empty, no biliary reflux is seen, and the green coloration
of the anastomosis (A) has disappeared. S, suture.
Double-lumen open-pore film drainage combined with the intestinal feeding tube enables
full enteral nutrition and complete gastric drainage, simultaneously. The active prevention
of reflux with double-lumen open-pore film drainage is an easy method of supporting
anastomotic healing after esophageal resection.
Endoscopy_UCTN_Code_TTT_1AO_2AJ
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