Laparoendoscopic mediastinal vacuum therapy of a gastric perforation through the diaphragm

Endoscopically guided endoluminal vacuum therapy using polyurethane sponges has become an established method for treating rectal anastomotic leaks [1] and is now increasingly also used in the upper gastrointestinal tract [2] [3] [4]. We report on transhiatal placement of an Endo-Sponge (Braun Medical, Melsungen, Germany) into the mediastinum using the Gastrotrokar described in an earlier paper [5].

A 54-year-old man was referred by the emergency doctor after a 2-day history of thoracolumbar pain on violent coughing. Immediate intubation was necessary because the patient presented a complete picture of sepsis. A laparoscopic fundoplication had been performed 6 years earlier due to gastroesophageal reflux disease.

Gastroscopy revealed a satisfactory fundoplication. However, a transhiatal perforation of the fundus was observed ([Fig. 1]). The necrosis cavity, which was located para-aortally in the mediastinum, was measured during computed tomography (CT) as 5.4 × 5 × 3.2 cm. Free intra-abdominal air and subcutaneous emphysema were found ([Fig. 2]). Transesophageal endoscopic placement of an Endo-Sponge was not possible, because of the need for a maximally retroflexed scope position.

Fig. 1 Transhiatal perforation of the fundus. a Image showing: entry into the mediastinal necrosis cavity (1); fundoplication cuff (2); endoscope (3). b View into the necrosis cavity.

Fig. 2 Computed tomography (CT) scan showing air within the abdomen (1), air in the lower mediastinum (2), and subcutaneous emphysema (3).

A Gastrotrokar (Storz, Tuttlingen, Germany) was introduced through a 20-Fr percutaneous endoscopic gastrostomy (PEG) tube (Fresenius Kabi AG, Bad Homburg, Germany) into the body of the stomach. The Endo-Sponge introduced transesophageally into the stomach using an overtube was then introduced easily into the cavity using a laparoscopic forceps ([Figs. 3] and [4]). The Endo-Sponge tube was drained through the PEG tube and kept under continuous negative pressure of 125 mmHg using a negative pressure therapy system (KCI, USA Inc., San Antonio, Texas, USA). Broad-spectrum antibiotics (cefuroxime and metronidazol) were delivered.

Fig. 3 The laparoendoscopic rendez-vous maneuver for placement of Endo-Sponge drainage of the mediastinal necrosis cavity (with the Gastrotrokar).

Fig. 4 Retroflex view of: a Endo-Sponge (1a) in the mediastinal cavity, showing the 3-mm laparoscopic forceps (2) and entry into the mediastinal necrosis cavity (3); b Endo-Sponge (1b) in the gastric lumen, with the Endo-Sponge tube (4).

After 48 h, the patient showed marked improvement both clinically and in laboratory test values. The patient was extubated. The Endo-Sponge was replaced on days 2 and 8, cleansing the wound and reducing the cavity by 50 % ([Fig. 5]), so treatment was withdrawn on day 14. Complete reduction of the necrosis cavity was found on removal of the PEG tube after 21 days ([Fig. 6]). Subsequently, the patient had no difficulty swallowing.

Fig. 5 The mediastinal cavity on day 8. The cavity is clean and has reduced in size by about 50 %.

Fig. 6 The completely healed mediastinal cavity with formation of scar tissue, on day 21.

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References

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