Keywords
leaks - endoscopic vacuum therapy - complications - perforation
Postoperative anastomotic site leaks continue to pose a significant challenge, regardless
of advancements in surgical techniques. The incidence of anastomotic site leaks ranges
from 11.4 to 21.2% following esophagectomy and from 2.8 to 8.4% after colorectal resections.[1]
[2] Traditionally, percutaneous drainage of collections, surgical repair with buttressing,
excision of the esophageal conduit, colonic interposition, clipping for small leaks,
and supportive measures such as antibiotics and nutrition via feeding tubes or parenteral
nutrition are commonly utilized for post-esophagectomy leaks.[1] Similarly, fecal diversion and stoma are commonly used to treat post-colorectal
surgical leaks.[2] Endoscopic vacuum therapy is a minimally invasive, effective, and cost-effective
treatment for post-surgical leaks. This technique involves the use of open-pored polyurethane
foam, which is connected to a portable vacuum device via a flexible tube and inserted
into the cavity under endoscopic guidance.[3]
[4] Endoscopic vacuum therapy generates continuous negative pressure at the leak site,
enhancing local tissue perfusion and decreasing tissue edema. The continuous aspiration
of pus, secretions, and necrotic debris cleanses the wound surface and stimulates
granulation tissue formation, facilitating wound healing by secondary intention.[5]
Loske et al conducted a study utilizing endoscopic vacuum sponge therapy for various
types of leaks, including anastomotic leaks following esophagectomy or gastrectomy
(n = 5), iatrogenic esophageal perforations (n = 2), esophageal wall necrosis (n = 1), Boerhaave syndrome (n = 1), and perforations due to esophageal cancer (n = 1). The therapy involved one to seven sessions of sponge changes at intervals ranging
from 2 to 7 days. The average duration of therapy was 12 days. Patients received nutrition
via percutaneous gastrostomy or an enteral feeding tube. All but one survived, with
healing of defects occurring without stricture formation or functionally significant
scar formation. A continuous high-intensity vacuum of 125 mmHg was applied.[6] Reimer et al conducted a quality-improvement study involving 156 patients over a
period of 10 years. Anastomotic site leaks occurred in 64.1% of patients (n = 100). Additional indications included primary perforation at 6.4%, postoperative
preventative therapy at 9.6%, and iatrogenic perforation at 19.8%. The patients were
divided into two periods (periods 1 and 2), and the outcomes were compared. They reported
that more than 90.9% of patients in period 2 had complete leak resolution, compared
to 79.9% in period 1, and that 70% in period 2 did not require any additional surgical
procedures or percutaneous drain insertion. In period 2, endoscopic vacuum therapy
was utilized as the primary treatment for leaks, with early endoscopy (within 6 hours)
employed for leak diagnosis, along with lavage and endoscopic removal of necrotic
material, and supplementary endoscopic closure techniques. Adverse events were reported,
including bleeding in 3 cases, bronchial fistula in 9 cases, and strictures in 17
cases.[7]
Richter et al conducted a multicenter study involving the treatment of 69 patients
with anastomotic leaks and 33 patients with perforations using endoscopic vacuum therapy.
The anastomotic leak group demonstrated a closure rate of 91%, compared to 79% for
perforations. Complications reported in the study included abscess (4%), fistula (9%),
bleeding (6%), peritonitis (1.5%), pneumonia (13%), mediastinitis (13%), pleural empyema
(7.3%), sepsis (10.1%), renal failure (7.3%), and acute respiratory distress syndrome
(4.4%). In 45% of the patients, additional thoracic drainage and lavage were required.
The study identified that the presence of mediastinitis and the distance of the defect
from the dental arch were significantly associated with the failure of endoscopic
vacuum therapy.[8] A recent systematic review of endoscopic vacuum therapy for esophageal leaks demonstrated
a high success rate and low complication rates among treated patients.[9] Vacuum therapy has been successfully utilized for leaks following colorectal surgery,
analogous to its application in esophageal leaks. Kühn et al conducted a prospective
study that collected data from over 281 patients undergoing colorectal surgery who
experienced leaks. A significant proportion (83%) underwent surgical intervention
for malignancy. A significant proportion experienced leakage from the anastomotic
site following rectal or sigmoid colon resection (67%), while 20% exhibited leakage
from the rectal stump. Endoscopic vacuum therapy was effective in 91% of cases. The
median duration was 25 days. Prior chemoradiation correlated with an extended treatment
duration. Multivisceral resection and surgical revision following primary surgery
are linked to an increased risk of therapeutic failure. Approximately 50% of the patients
received outpatient treatment, resulting in a 15-day reduction in hospital stay. Complications
reported included anastomotic stenosis in 10 patients, rectovaginal fistulas in 7
patients, and bleeding in 4 patients. The majority of studies employed pressures between
100 and 125 mmHg.[10] The study conducted by Sundaram et al demonstrated that the healing of upper gastrointestinal
leaks can be accomplished at significantly reduced pressures of 25 to 30 mmHg. This
study was the first large case series from India, demonstrating the efficacy and safety
of low-pressure modified low-cost endoscopic vacuum therapy in patients with anastomotic
leaks. The high pressures have the potential to cause chest discomfort in patients
with poor lung compliance and to increase the risk of lung infections, demanding a
low pressure approach; however, more evidence is needed for wider adoption of this
technique.[4]
[11] Kühn et al. conducted a systematic review and meta-analysis of studies employing
endoscopic vacuum therapy for colorectal leaks. The average success rate was 81.4%
(95% confidence interval: 74.0–87.1%), with complications occurring in 12.1% of cases.
Current evidence regarding endoscopic vacuum therapy for colorectal leaks is insufficient
due to a lack of high-quality data.[12]
Commentary
Post-surgical anastomotic site leaks present a significant challenge that necessitates
a multidisciplinary approach.[1] The diversion of secretions, alternative nutritional routes, drainage of collections
via drain placement, and surgical buttressing or disconnection procedures have historically
resulted in significant morbidity and mortality.[2]
[3] Minimally invasive, cost-effective, safe, and efficient endoscopic vacuum therapy
presents a promising option for patients experiencing post-surgical leaks in the upper
and lower gastrointestinal tract, as well as those with Boerhaave syndrome and esophageal
necrosis.[5]
[9]
[10] Endoscopic vacuum therapy, when combined with appropriate nutritional supplementation
and percutaneous drainage of collections, can facilitate the healing of leaks and
cavities through secondary intention.[5] Vacuum therapy equipment is readily available and comprises an open-pore polyurethane
sponge, fenestrated tubes of 12 French, 14 French, or 16 French (depending on secretion
thickness), suture material, a suction machine, and an overtube for insertion.[4]
[5]
[6]
[7] In the majority of instances, vacuum therapy results in defect closure in conjunction
with percutaneous drainage of collections, endoscopic lavage of the cavity to remove
necrotic debris and pus, and placement of over-the-scope clips for residual defects.[4]
[5]
[6]
[7]
[8]
[9]
[10] Endoscopic sponge placement involves holding the sponge in place using foreign body
forceps and guiding it into the cavity with an endoscope. Periodic sponge replacement
is essential because its pores become saturated, resulting in loss of suction. Most
studies utilize high-pressure suction[5]
[6]
[7]
[8]
[9]
[10]; however, low pressures may also demonstrate effectiveness.[4] In addition, outpatient treatment is an option, particularly for colorectal leakage.[10] Research indicates complications such as bleeding, fistulization—particularly rectovaginal
fistula formation—stricture formation, empyema, pneumothorax, sepsis, and respiratory
distress in certain patients. Overall, vacuum therapy appears to be successful and
safe in treating post-surgical leakage. It is also employed to treat Boerhaave syndrome
and esophageal perforations with an acceptable success rate.[6]
In conclusion, endoscopic vacuum therapy demonstrates safety and efficacy as a minimally
invasive approach for managing post-surgical gastrointestinal leaks, esophageal perforation,
or rupture. Further studies are necessary to evaluate the appropriate selection of
patients, optimal pressures, sponge size, catheter size, and to compare these factors
with other modalities such as clip closure, clip–loop closure, and fully covered self-expandable
stents to establish its position within the treatment algorithm.
