Endoscopic Vacuum Therapy for the Treatment of Anastomotic Leakage after Total Gastrectomy with Esophagojejunostomy

Summary

Here, we present a protocol for endoscopic vacuum therapy (EVT) in the management of anastomotic leaks following total gastrectomy with esophagojejunostomy.

Abstract

Endoscopic vacuum therapy (EVT) offers an effective alternative for the treatment of anastomotic leakage. Current treatment options for leakage include conservative treatment, stent placement, or reoperation. However, conservative treatment often results in slow recovery and is frequently ineffective in severe cases. Stent placement carries risks such as migration or blockage, and both conservative treatment and stents often fail to adequately drain pus or necrotic tissue exudate. Moreover, reoperation is associated with a high risk of surgical complications. EVT employs continuous negative pressure to remove pus and necrotic tissue exudate through natural orifices. This approach also promotes granulation tissue formation at the fistula or leakage site, facilitating the healing process. Clinically, EVT has demonstrated the potential to significantly reduce complications such as infection, bleeding, and anastomotic stenosis. It not only improves patient's outcomes but also minimizes the need for additional invasive procedures and shortens hospital stays. In conclusion, EVT represents a promising and innovative approach for managing complex gastrointestinal leaks.

Introduction

Esophagojejunal anastomotic leakage is a severe and potentially life-threatening complication following total gastrectomy. It not only prolongs hospital stays but also significantly increases medical expenses^1,2,3. The incidence of anastomotic leakage following total gastrectomy ranges from 1% to 14%^4,5,6,7,8.

Traditional treatment methods primarily consist of conservative management, stent placement, and, in some cases, surgical repair⁹. Conservative treatment typically involves nutritional support, anti-inflammatory therapy, and drainage. Covered stents can isolate the abscess cavity from the gastrointestinal lumen. However, both conservative treatment and stent placement often fail to effectively drain pus or necrotic tissue exudate. Although surgical repair directly addresses the leakage site, it carries a high risk of surgical complications. In contrast, EVT has demonstrated superior efficacy by providing continuous drainage of anastomotic leaks or abscess cavities and promoting enhanced healing compared to conservative, stenting, or surgical approaches^10,11.

With advancements in endoscopic technology, Weidenhagen R. et al. first reported the use of EVT in 2008 for the treatment of anastomotic leakage following anterior resection of the rectum¹². This method is derived from vacuum-assisted closure (VAC) technology, commonly used for open wound healing. VAC therapy involves placing an open-cell sponge dressing on the wound, sealing it with adhesive tape, and applying controllable sub-atmospheric pressure. This process reduces chronic edema, enhances local blood flow, and promotes the formation of granulation tissue¹³. EVT combines endoscopic techniques with VAC therapy. Under endoscopic guidance, negative pressure is precisely applied to the fistula or leakage site, effectively removing exudates and bacteria while reducing the source of infection. Additionally, it stimulates tissue cell proliferation and migration, accelerates healing, and lowers the risk of complications^14,15. However, the standard protocol of EVT has been less reported.

Multiple studies have demonstrated the significant advantages of EVT in managing upper gastrointestinal leaks^16,17,18. Pattynama et al. reported a 74% success rate in treating postoperative upper gastrointestinal anastomotic leaks with EVT, achieving closure in 28 of 38 patients¹⁶. In a multicenter retrospective study, Momblán et al. evaluated 102 patients with upper gastrointestinal defects, including 89 anastomotic leaks and 13 perforations, and achieved successful closure in 84 cases (82%)¹⁷. Furthermore, a meta-analysis by do Monte Junior et al. demonstrated that EVT increased leak closure rates by 21%, reduced mortality by 12%, shortened treatment duration by 14-22 days, and decreased adverse events by 24% compared to stent placement for upper gastrointestinal transmural defects¹⁸. These findings underscore the efficacy of EVT in managing upper gastrointestinal defects.

EVT has become a standard treatment for upper gastrointestinal leaks. Its primary clinical indications include anastomotic leaks following oncologic resections of the upper gastrointestinal tract and iatrogenic perforations¹⁹, while contraindications include complete luminal obstruction or lesions that are inaccessible via endoscopy²⁰. The procedure should be performed by endoscopists experienced in advanced endoscopic techniques. EVT involves endoscopic placement of a specialized polyurethane sponge at the site of the anastomotic leak or within the associated abscess cavity. Negative pressure between -100 and -125 mmHg is maintained using a vacuum device throughout the treatment.

In this study, we present a representative case demonstrating the use of EVT for anastomotic leakage. A 74-year-old male underwent total gastrectomy with esophagojejunostomy for esophagogastric cancer (Siewert type III) at another hospital. On postoperative day 7, a computed tomography (CT) scan suggested anastomotic leakage. Despite conservative treatments, including anti-inflammatory therapy, nutritional support, and other measures, no significant improvement was observed. On postoperative day 20, the patient developed anastomotic bleeding and was transferred to our hospital. Upper gastrointestinal radiography confirmed the leakage, showing contrast extravasation from the lower right side of the anastomosis (Figure 1). A repeat CT scan revealed pneumoperitoneum in the abdominal cavity. The patient was subsequently scheduled for EVT.

Protocol

The protocol follows the guidelines of the Human Research Ethics Committee of Nanchong Central Hospital.

1. Preparation

1. Evaluate the size of leakage and abscess by CT, gastrointestinal radiography, or endoscopic examination.
2. Communicate fully with the patient and obtain the patient's informed consent.
3. EVT drainage device (EVTDD):
   1. Select FDA-approved medical-grade open-cell polyurethane ether foam. Shape the foam precisely according to the size and configuration of the leakage or abscess cavity. Use a 6.0 Fr/18 gastric tube as the drainage tube.
   2. Securely wrap the foam around the tube tip and fix it in place with 3-0 polypropylene sutures, ensuring complete coverage of all drainage side holes. Finally, connect the tube end to the negative-pressure drainage system to establish effective drainage (Figure 2).

2. Placement of the EVTDD

1. Administer general anesthesia to the patient.
2. After lubricating the endoscope, insert it into the esophagus through the mouth and advance it toward the abscess cavity. Irrigate the anastomotic leak or abscess cavity with normal saline until the abscess is fully cleared and the saline effluent is clear. The volume of normal saline used for irrigation depends on the size of the anastomotic leak or the volume of the abscess cavity.
3. Place a nasojejunal feeding tube under endoscopic guidance (Figure 3).
4. Use endoscopic forceps to grasp the suture line, which secures the tip of the tube and sponge. Then, push the sponge into the leakage cavity (Figure 4).
5. Confirm the sponge has entered or attached to the abscess cavity under the guidance of endoscopy.
6. Drain the EVTDD tube and nasojejunal feeding tube through the same nasal cavity.
7. Connect the drainage tube to the negative pressure drainage device.
8. Adjust the negative pressure to the appropriate range of -100 to -125 mmHg. Check pressure stability and drainage function every 4-8 h during treatment.
9. Fix the drainage tube and the nasojejunal feeding tube at the patient's nose by taping.

3. Replacement of the EVTDD

1. Replace the EVTDD every 5-7 days by first removing it from the anastomotic leakage site, then from the patient.
2. Observe the healing condition of the leakage site through endoscopy when replacing the EVTDD.
3. Place a new EVTDD as mentioned above.
4. Place contaminated sponges and fluids in autoclave-safe biohazard bags for proper disposal.

4. Postoperative care

1. Keep the drainage tube unobstructed. Record the volume, color, and properties of the drainage contents.
2. Manage complications, including abdominal pain, fever, or bleeding, appropriately.

5. Postoperative follow-up

1. Closely evaluate the treatment effect and adjust the negative pressure as needed. Use CT, contrast gastrointestinal radiography, or endoscopic examination to assess the healing of the leakage.

Results

In this representative case, the patient underwent EVTDD replacement three times. The average procedure time for EVTDD placement was 37 min, and the total hospital stay at the facility was 21 days. No complications were observed during or after the EVT procedures.

During the first EVT procedure, endoscopy revealed a 1 cm × 1.5 cm leakage at the esophagojejunal anastomosis, surrounded by a yellow-white purulent coating, with visible suture lines and vascular clips (Figure 5...

Discussion

EVT plays a crucial role in the treatment of anastomotic leakage, significantly reducing complications and improving patient prognoses²¹. The treatment process involves three main steps. First, the leakage site and any associated abscess cavities are identified preoperatively using CT scans, gastrointestinal radiography, or endoscopic examination. During the procedure, the EVTDD is positioned at the leakage site under direct endoscopic visualization. Finally, the external end of the drainage tube ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Disposable External Suction Connection Tube	Henna Tuoren Best Medical Equipment Co., Ltd.	Type II-2.0
Disposable Negative Pressure Drainage Device	Henna Tuoren Best Medical Equipment Co., Ltd.	Type II-1–2000 mL
Drainage Tube	Yangzhou Huawei Medical Equipment Co., Ltd.	6.0 mm (Fr18)
Endoscope	Olympus	GIF-H170
Endoscopic Forceps	Changzhou JIUHONG Medical Instruments Co., Ltd.	JHY-FB-23-160-O-O
Nasojejunal Feeding Tube	Fresenius kabi AG	CH/FR 15,100 CM
Open-cell Polyurethane Sponge	Guangdong Meiji Biotechnology Co., Ltd.	MJ-03B4
Polypropylene Non - Absorbable Suture	ETHICON	8522H