Successful closure of esophagogastric anastomotic leak using endoscopic vacuum therapy

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Abstract

A clinical case of a 67-year-old female patient with esophagogastric anastomotic leakage after proximal gastrectomy for cancer of the cardiac portion is presented. The complication manifested itself as acute right-sided pleural empyema on the 12th day after the surgery. After the pleural cavity drainage and primary sanitation of the empyema, endoscopic installation of a vacuum system equipped with an open-pore sponge was chosen as a technique for closing the anastomotic defect. This system was operating for 10 days, gradually reducing the amount of the exudate discharged. There was no need to replace the drainage, since endoscopic examination revealed good regeneration in the area of the anastomotic defect. Intensive therapy, along with drainage and sanitation of sources of inflammation, ensured stabilization of the patient’s general condition and healing of the anastomosis. This clinical observation demonstrates the effectiveness of endoscopic vacuum therapy in treatment of esophageal anastomotic leaks and the prospect of its use in difficult cases associated with defects and fistulas of the gastrointestinal tract.

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Introduction

Esophagogastric anastomotic leak is a severe complication observed in 11.4–20 % of cases after esophageal resection [1–3]. Despite studies aimed at improving anastomotic healing, the leak rate has not significantly decreased [4]. Although recent trends show a reduction in the frequency of esophagogastric anastomotic dehiscence, mortality remains consistently high, reaching 30–60 % [3; 5]. The treatment of such patients is particularly challenging due to the development of severe secondary complications [6; 7]. Reoperative surgery is technically difficult, and in 30 % of cases, the anastomotic defect cannot be repaired; attempts to restore its integrity often prove unsuccessful, leading to new complications and sometimes necessitating multiple surgical interventions [6]. Therefore, surgeons are justified in pursuing a conservative approach based on minimally invasive endoscopic techniques. Currently, the most promising method is endoscopic vacuum therapy (EVT), which positively influences the wound healing process [7]. The variability in treatment approaches for esophagogastric anastomotic leaks reflects the complexity of choosing an optimal strategy, making the search for the most effective treatment for severe complications a pressing issue.

Clinical Case

A 67-year-old female patient, admitted to the Department of Thoracic and Abdominal Oncology at the Perm Regional Clinical Hospital, underwent subtotal proximal gastrectomy with double-row end-to-end esophagogastric anastomosis via an abdominal approach on June 1, 2023, for adenocarcinoma of the gastric cardia pTis N0, pL0, pV0, Pn0. On postoperative day 12, despite initial stable recovery, the patient developed sudden collapse with loss of consciousness, initially attributed to her pre-existing Parkinson’s disease. She was transferred to the intensive care unit, where acute right-sided pleural empyema secondary to esophagogastric anastomotic leak was revealed. Thoracentesis and pleural cavity drainage were performed, with 1000 mL of turbid exudate evacuated. After hemodynamic stabilization, video-assisted pleural cavity sanitation was planned to determine further treatment strategy.

Surgery performed on June 14, 2023: video-assisted thoracoscopy, sanitation and drainage of the right pleural cavity. The empyema cavity containing infected fibrin was visualized, and 200 mL of turbid serous exudate was removed. The lung was aerated, while the parietal pleura appeared hyperemic, thickened and edematous. A 1 cm defect was identified in the posterior mediastinum on the mediastinal pleura with gastric content leakage. A tubular drain was placed along the esophagus to the defect and another drain to the pleural dome. An inferior longitudinal tracheostomy was applied. Esophagogastroduodenoscopy (EGD) revealed a 1.3 cm anastomotic leak along the anterior semicircle 34 cm from the incisors. A drain equipped with a porous sponge was placed at the anastomotic site and connected to a vacuum aspiration system. The endoscopic vacuum therapy sponge was customized according to the defect size with diameter of 2.5 cm and length of 7 cm to overlap the defect edges by 3 cm (Figure). A gastric tube was placed inside the sponge without reaching its distal end and fixed with through-and-through sutures to the tube. A 1.5 cm loop was created from the distal suture for system grasping and placement at the level of the anastomotic defect parallel to the endoscope. The vacuum system was connected with a continuous negative pressure source of 110 mmHg.

 

Fig. Gastric tube equipped with an open-pore polyurethane sponge

 

After the surgery, the patient’s condition was extremely severe due to acute pleural empyema and bilateral pneumonia. Mechanical ventilation was performed. For 10 days, the vacuum system drainage from the esophagus produced 20-50 ml of foul-colored gastric contents, gradually decreasing to minimal volume. The vacuum system was disconnected, the sponge-equipped tube was removed, and EGD revealed the esophagogastric anastomosis lined with granulation tissue without visual evidence of transmural wall defect; a jejunal feeding tube was placed for enteral nutrition.

As the volume of exudate from the right pleural cavity decreased, the drains were removed on postoperative day 18. Chest imaging revealed bilateral pneumonia, while bronchoscopy showed grade 1-2 diffuse endobronchitis. The patient remained in extremely severe condition due to respiratory failure and multiple organ dysfunction. Antibiotic therapy, symptomatic treatment, correction of water-electrolyte and metabolic imbalances, and nutritional support via enteral and parenteral feeding were continued. On postoperative day 64 (August 15), the patient was transferred to a specialized department for further treatment. After contrast radiography of the esophagus and stomach confirmed unobstructed esophageal patency with no contrast leakage, oral intake was permitted. The patient was discharged in satisfactory condition 89 days postoperatively. Follow-up examinations at 3 and 6 months after discharge confirmed continued outpatient monitoring at the local facility with treatment for comorbidities and unrestricted oral nutrition.

Results and Discussion

Back in 1973, N.N. Kanshin proposed a method of wound drainage using special drains that allowed simultaneous wound irrigation and vacuum aspiration [8]. The author emphasized that “creating controlled vacuum facilitates cavity collapse and drainage of tissue fluid from the perifocal inflammation zone, thereby inhibiting absorption of toxic products and reducing edema that adversely affects tissue blood supply and oxygenation.” A monograph on the treatment of unformed intestinal fistulas described an obturator equipped with a foam sponge for fistula aspiration [9].

Since the 1990s, vacuum therapy has been widely used for treating patients with chronic wounds, including colorectal anastomotic leaks [10]. Following the rapid adoption of this method, G. Loske proposed two EVT options for managing upper gastrointestinal anastomotic leaks: with intraluminal and/or intracavitary placement of drains equipped with porous sponges [11].

In the Russian literature, several publications have demonstrated the use of EVT in patients with anastomotic leaks of the upper gastrointestinal tract, reporting an efficacy rate ranging from 80 % to 100 % [12–15]. It has been noted that the endoscopic treatment technique requires significant experience and skill on the part of endoscopists, as well as coordinated efforts among surgeons, anesthesiologists, and intensivists to ensure intensive care during the perioperative period, monitor the performance of the vacuum system, and perform drainage replacement. The porous sponge may cause bleeding from the wound edges and mucosa, and distal or proximal dislocation of the drainage system is possible. Cases of post-procedure cicatricial stricture formation have been described, with an incidence rate of up to 40 % [12].

We opted for the intraluminal approach, as the leakage into the pleural cavity had been preliminarily drained under thoracoscopic guidance. Moreover, advancing a porous drain through the anastomotic defect poses a risk of additional trauma in the area of dehiscence.

Most authors emphasize the necessity of placing a feeding tube alongside the vacuum system; however, considering the potential adverse effects and the uncertainty of the final outcome in the presence of a defect at the esophagogastric junction, a staged introduction of feeding tube placement was chosen as the wound healing progressed positively. Nutritional support was provided via parenteral nutrition.

Most publications recommend replacing the vacuum system every 3–5 days. However, considering the patient’s extremely severe condition and the gradual decrease in aspirate volume, it was decided to postpone drainage replacement until maximal reduction of the discharge. After 10 days, the vacuum system was removed; no mucous coating was observed on the sponge surface, and its pores remained open and permeable to fluid. Upon detecting good regeneration of the anastomotic defect, repeated placement of the sponge drain was avoided. An irrigator was inserted into the jejunum for enteral tube feeding, which is an important component of managing such complications. After confirming closure of the defect by contrast radiography of the esophagus and stomach, oral feeding was restored.

Conclusions

Endoscopic vacuum therapy is effective for healing esophagogastric anastomotic leaks accompanied by purulent-septic complications. This method deserves attention, further refinement, and implementation into clinical practice.

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About the authors

M. V. Repin

Ye.A. Vagner Perm State Medical University

Author for correspondence.
Email: max_repin@inbox.ru
ORCID iD: 0000-0002-0686-2619

DSc (Medicine), Professor of the Department of Surgery with a Course of Cardiovascular Surgery and Invasive Cardiology

Russian Federation, Perm

D. V. Trushnikov

Perm Regional Clinical Hospital

Email: max_repin@inbox.ru
ORCID iD: 0000-0002-1071-7115

Endoscopist, Chief Freelance Endoscopy Specialist of the Ministry of Health of the Perm Region

Russian Federation, Perm

D. A. Tronin

Perm Regional Clinical Hospital

Email: max_repin@inbox.ru
ORCID iD: 0009-0003-7733-9854

Endoscopist

Russian Federation, Perm

I. N. Shchetkina

Perm Regional Clinical Hospital

Email: max_repin@inbox.ru
ORCID iD: 0009-0006-3714-0615

Deputy Chief Physician for Surgery

Russian Federation, Perm

E. E. Sablin

Perm Regional Clinical Hospital

Email: max_repin@inbox.ru
ORCID iD: 0000-0003-4347-9106

Surgeon

Russian Federation, Perm

References

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