Endoscopic vacuum therapy: 2 methods of successful endosponge placement for treatment of anastomotic leak in the upper GI tract

摘要

eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ZWRmNzYxYWJmOWU4MDg2Y2U1OWNkMmYxOGFmZjE1NCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3MzcwMzI3fQ.k44LAagvJ2UhNxWNaxmhaghZCtQ8U4VVM4es_RiyFtcR0ga2ZB5EvSsb5aR9_c7R1ZhwDbIx_oVWndZFudNyKANR9wzGcb5HApDBr2GAGC69pj6688mbn4vdmDEJv0thp7z2UTdqrzstMbd9oLB-nSRD2nY0tMsc4LerA78FjXAysi_eqScLohqWm0RdCWbu31uBab3563DFQvbxDBtloI2GqMrq1y7El-esLAl0mPwUvFffxfcmTYRdI37lsz74d0MNthu-OM-e70e-5yo7lx_J030_W89qbOUQghgn3Nlgvesqzx3D4j5niqSDPiLCihWxphNyn9sOfb8cBkGR2A(mp4, (82.67 MB) Download video Presentation of 2 methods of successful endosponge placement for treatment of anastomotic leak in the upper GI tract. A 74-year-old man presented for evaluation of a gastroesophageal anastomotic leak. The patient’s medical history included distal esophageal adenocarcinoma treated with robotic-assisted esophagectomy with gastric conduit. Its postoperative course was complicated by anastomotic leak, confirmed via esophagram, and right-sided pneumothorax requiring right thoracostomy and chest tube placement. EGD revealed a gastroesophageal leak with a 3-cm aperture and development of postsurgical fluid collection. The patient preferred a nonsurgical treatment of the anastomotic leak with the use of endoscopic vacuum therapy (EVT), which was recommended by a multidisciplinary team including an interventional gastroenterologist, thoracic surgeon, and interventional radiologist. A custom-made sponge connected to an external vacuum device was endoscopically delivered at the surgical anastomosis where the leak was present. The sponge was replaced every 3 to 4 days while granulation tissue developed in the surgical cavity. After 10 sessions of sponge replacement, successful closure was achieved without evidence of any remaining leakage. There was no recurrence of the anastomotic leak on 2 subsequent endoscopic evaluations, and the patient did not require any further interventions. Endoscopic vacuum therapy was performed in this patient using 2 different techniques of endoscopic sponge insertion into the anastomotic leak (Video 1, available online at www.giejournal.org). The first step for both techniques included creation of a vacuum system. We used a nasogastric (NG) tube: 14F, 16F, or 18F (Salem SumpTubes; Cardinal Health, Dublin, Ohio, USA) and a sponge (V.A.C. Granufoam; 3M, St. Paul, Minn, USA). Using scissors, we created a tunnel in the sponge, and the NG tube was inserted with its tip and side holes covered within the sponge, ensuring adequate vacuum. Next, the NG tube was secured to the sponge using a single suture that was sutured in a continuous fashion, descending from the proximal to the distal end of the NG tube. The sponge was then cut into a smaller and cylindrical shape, fitting into the cavity adequately. This also alleviated endoscopic guidance because it reduced friction. Once the vacuum system was created, 2 different methods were used to insert the sponge into the anastomotic leak. In the first method, a small loop of suture left at the tip of the sponge acted as an anchor for grasping forceps. The forceps were used to grasp the suture loop. The endoscope was inserted orally and advanced down to the site of the leak, with the sponge pulled behind. A guidewire was also inserted through the NG tube, helping with sponge insertion into the leak cavity. After release of the suture loop from the forceps, the endoscope was brought behind the sponge, and the sponge and NG tube were then grasped with the forceps and pushed forward into the cavity. This process was repeated until the entire sponge was adequately inserted into the cavity. When pulling the endoscope back, the guidewire was used as a visual and fluoroscopic guide to ensure adequate placement. If the sponge is not easily guided down, a second method can be implemented using an overtube. The overtube was placed on the endoscope and advanced into the cavity. Once the cavity was reached, the