Prevention of reflux after esophagectomy with endoscopic negative pressure therapy using a new double-lumen open-pore film drainage with an intestinal feeding tube
19 September 2017 (online)
Reflux after Ivor Lewis esophagectomy has a deleterious effect on anastomotic wound healing and is a risk for pulmonary aspiration . We report endoscopic negative pressure therapy, using a novel double-lumen open-pore film drainage method, for prevention of postoperative reflux.
A 70-year-old patient underwent Ivor Lewis esophagectomy because of carcinoma of the distal esophagus (pT2pN0), having undergone laryngectomy because of carcinoma of the larynx 5 years previously. On postoperative day 4, rising inflammatory parameters led to endoscopy in order to check the anastomosis, in accordance with our treatment algorithm . We found biliary gastric reflux flooding the intrathoracic anastomosis ([Fig. 1]). The anastomotic tissue was seen to be green-colored and the staple line of the stomach showed signs of inflammation ([Fig. 2]).
We decided to evacuate the stomach with endoscopic negative pressure therapy, using an innovative double-lumen drainage system that incorporated open-pore film material. Our goal was to eliminate the postoperative reflux that was compromising the anastomotic healing.
We adapted a triluminal tube (Freka Trelumina, CH/Fr 16/9, 150 cm; Fresenius, Germany) using open-pore film (Suprasorb CNP Drainagefolie; Lohmann and Rauscher, Germany). All the openings of the gastric channel of the triluminal tube were wrapped around once with a length of the open-pore film. The film was fixed using suture thread. The ventilation lumen of the tube was blocked with a clamp ([Fig. 3], [Video 1]). The small-bore tube was inserted nasally and pushed, so that finally the intestinal feeding channel was positioned in the duodenum ([Video 1]) and the film-wrapped part of the tube was positioned in the stomach ([Fig. 4]).
Video 1 The construction of a double-lumen open-pore film drainage (OFD) device and the course of endoscopic negative pressure therapy (ENPT) for preventing gastric reflux after Ivor Lewis esophagoectomy.
Application of negative pressure with an electronic device (setting – 125 mmHg, continuous, intensity 10; KCI V.A.C. Freedome, KCI USA Inc., San Antonio, Texas, USA) resulted in permanent collapse of the stomach and complete drainage of the reflux. Simultaneously, intestinal nutrition was started along the feeding channel. The open-pore film drainage was changed once after 3 days of treatment ([Fig. 5]). Infection signs at the staple line and green colored imbibition at the anastomosis had disappeared. Endoscopic negative pressure therapy was ended after a period of 10 days. Follow-up endoscopy 7 days after the end of therapy showed complete healing ([Video 1]).
Double-lumen open-pore film drainage combined with the intestinal feeding tube enables full enteral nutrition and complete gastric drainage, simultaneously. The active prevention of reflux with double-lumen open-pore film drainage is an easy method of supporting anastomotic healing after esophageal resection.
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