Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations

Abstract

Background Although endoscopic vacuum therapy (EVT) has been successfully used to treat postoperative upper gastrointestinal (UGI) wall defects, its use demands special materials and several endoscopic treatment sessions. Herein, we propose a technical modification of EVT using a double tube (tube-in-tube drain) without polyurethane sponges for the drainage element. The tube-in-tube drainage device enables irrigation and application of suction. A flowchart for standardizing the management of postoperative UGI wall defects with this device is presented.

Methods An EVT modification was made to achieve frequent fistula cleansing, with 3 % hydrogen peroxide rinsing, and the application of negative pressure. A tube-in-tube drain without polyurethane sponges can be inserted like a nasogastric tube or passed through a previously positioned surgical drain. This was a retrospective two-center observational study, with data collected from 30 consecutive patients. Technical success, clinical success, adverse events, time under therapy, interval time from procedure to fistula diagnosis and treatment start, size of transmural defect, volume of cavity, number of endoscopic treatment sessions, and mortality were reviewed.

Results 30 patients with UGI wall defects were treated. The technical and clinical success rates were 100 % and 86.7 %, respectively. Three patients (10 %) had adverse events and three patients (10 %) died. The median time under therapy was of 19 days (range 1–70) and the median number of endoscopic sessions was 3 (range 1–9).

Conclusions This standardized approach and EVT modification using a tube-in-tube drain, with frequent fistula cleansing, were successful and safe in a wide variety of UGI wall defects.

Publication History

Received: 13 April 2021

Accepted after revision: 10 January 2022

Article published online:
04 April 2022

• References

• 1 Loske G, Müller C. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks. Gastrointest Endosc 2009; 69: 601-602
• 2 Virgilio E, Ceci D, Cavallini M. Surgical Endoscopic vacuum-assisted closure therapy (EVAC) in treating anastomotic leakages after major resective surgery of esophageal and gastric cancer. Anticancer Res 2018; 38: 5581-5587
• 3 Halliday E, Patel A, Hindmarsh A. et al. Iatrogenic oesophageal perforation during placement of an endoscopic vacuum therapy device. J Surg Case Rep 2016; 2016: rjw131
• 4 Ooi G, Burton P, Packiyanathan A. et al. Indications and efficacy of endoscopic vacuum-assisted closure therapy for upper gastrointestinal perforations. ANZ J Surg 2018; 88: E257-E263
• 5 Lima MS, Lima G, Pennacchi C. et al. A simple way to deliver vacuum therapy: the tube-in-tube endoluminal vacuum therapy modification. Endoscopy 2021; 53: E317
• 6 Lima MS, Perez CA, Guacho JAL. et al. Endoscopic treatment of rectovesical fistula after colorectal anastomosis: tube-in-tube endoscopic vacuum therapy method. Endoscopy 2021;
• 7 Loske G, Schorsch T, Müller C. Intraluminal and intracavitary vacuum therapy for esophageal leakage: a new endoscopic minimally invasive approach. Endoscopy 2011; 43: 540-544
• 8 Pines G, Bar I, Elami A. et al. Modified endoscopic vacuum therapy for nonhealing esophageal anastomotic leak: technique description and review of literature. J Laparoendosc Adv Surg Tech A 2018; 28: 33-40
• 9 Shim CS, Cho YD, Moon JH. et al. Fixation of a modified covered esophageal stent: its clinical usefulness for preventing stent migration. Endoscopy 2001; 33: 843-848
• 10 Martins BC, Retes FA, Medrado BF. et al. Endoscopic management and prevention of migrated esophageal stents. World J Gastrointest Endosc 2014; 6: 49-54
• 11 Valli PV, Mertens JC, Kröger A. et al. Stent-over-sponge (SOS): a novel technique complementing endosponge therapy for foregut leaks and perforations. Endoscopy 2018; 50: 148-153
• 12 Loske G, Schorsch T, Rucktaeschel F. et al. Open-pore film drainage (OFD): a new multipurpose tool for endoscopic negative pressure therapy (ENPT). Endosc Int Open 2018; 6: E865-E871
• 13 Sena FM, Badurdeen DS, Medeiros RCL. et al. Never lose suction: modified endoscopic vacuum therapy as primary treatment for acute esophagogastric anastomosis fistulas. Gastrointest Endosc 2018; 87: AB511-AB512
• 14 Hegemann G. VIII Absaugen und Drainieren. Allgemeine Operationslehre. Berlin: Springer-Verlag; 1958
• 15 Hu Z, Yin R, Fan X. et al. Treatment of intrathoracic anastomotic leak by nose fistula tube drainage after esophagectomy for cancer. Dis Esophagus 2011; 24: 100-107
• 16 Rausa E, Asti E, Aiolfi A. et al. Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis. Dis Esophagus 2018; 31: doy060
• 17 Pournaras DJ, Hardwick RH, Safranek PM. et al. Endoluminal vacuum therapy (E-Vac): a treatment option in oesophagogastric surgery. World J Surg 2018; 42: 2507-2511
• 18 Yu LL, He ZF, Liu QF. et al. Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection. J Int Med Res 2018; 46: 1528-1536
• 19 Lalezari S, Lee CJ, Borovikova AA. et al. Deconstructing negative pressure wound therapy. Int Wound J 2017; 14: 649-657
• 20 Loske G, Rucktäschel F, Schorsch T. et al. Successful endoscopic vacuum therapy with new open-pore film drainage in a case of iatrogenic duodenal perforation during ERCP. Endoscopy 2015; 47 (Suppl. 01) E577-E578
• 21 Kantowski M, Kunze A, Bellon E. et al. Improved colorectal anastomotic leakage healing by transanal rinsing treatment after endoscopic vacuum therapy using a novel patient-applied rinsing catheter. Int J Colorectal Dis 2020; 35: 109-117