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Perioperative management - VAC Stent

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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Indications

    The VAC-Stent therapy is a suitable treatment method for small to medium-sized defects of the upper gastrointestinal tract, whether they occur spontaneously, postoperatively at an anastomosis, or iatrogenically as a result of an endoscopic or surgical procedure.

    Since the VAC-Stent can only be placed intraluminally, it is important in the case of an extraluminal cavity to check whether the cavity collapses under intraluminal suction. A contaminated cavity only heals if it is optimally drained. For a large and/or contaminated cavity, an endoscopic vacuum therapy with an intracavitary sponge should initially be considered. Once the cavity has become smaller, a switch to a VAC-Stent can be made.

    The technique can be used for:

    • Anastomotic insufficiency after oncological gastroesophageal surgery
       
    • Esophageal fistula
       
    • Spontaneous esophageal perforation in the context of Boerhaave syndrome
       
    • Iatrogenic/endoscopy-related perforations of the esophagus
      • as a result of balloon dilation of strictures or in achalasia
      • during/after EMR/ESD (endoscopic mucosal resection/submucosal dissection)
      • during transesophageal echocardiography
      • during the introduction of feeding tubes and similar procedures
         
    • Trauma, including foreign body ingestion, gunshot wounds, etc.
       
    • Second-line therapy after previous endoscopic treatment with SEMS, EVT, or an Over-the-Scope Clip (OTSC)
       
    • Preventive applications to reduce the rate of anastomotic insufficiency, especially in potentially high-risk anastomoses after a history of chemotherapy or radiochemotherapy for esophageal carcinoma
       
    • Suture insufficiencies along the staple line after bariatric surgery, such as sleeve gastrectomy or Roux-en-Y gastric bypass

    Note 1: The VacStent was originally developed for leaks after esophageal resection but soon found application in patients with leakages after bariatric surgery.

    Note 2: In sleeve gastrectomy, leakages typically occur along the suture line. Staple line leaks are most common in the proximal third of the staple line (in about 85% of cases) and less common in the middle or distal section.

    Recommendation: It is recommended to use the VAC-Stent as early as possible, ideally at the time of diagnosis, to prevent the formation of larger wound cavities and chronic fistulas.

  2. Contraindications

    • Clinically unstable patients requiring emergency surgery for immediate treatment of the septic focus
       
    • Patients with a full stomach and/or severe persistent vomiting with clinical signs of ileus
       
    • Patients requiring full anticoagulation or thrombocytopenia < 20,000/µl
       
    • Defect larger than the available sponge (>5 cm due to sponge length)
       
    • Patients with leaks that are not endoscopically accessible with the VAC stent, e.g., in the case of a stenosis (Ø stent body 14 mm, Ø flange 30 mm)
       
    • Too small distance of the leak to the proximal esophageal sphincter
       
    • Contaminated extraluminal cavity

    Note: In the case of a large and/or contaminated cavity (Ø > 2 cm), the VAC stent is not suitable as sole therapy, especially if there is no further access to the esophagus. Initially, intracavitary EVT should be applied.

    • Significant ischemia of the gastric conduit
       
    • Cavity/fistula with direct contact to large blood vessels or the airways

  3. Preoperative Diagnostics

    Flexible Endoscopy

    • Exploration of the defect/anastomosis, determination of the distance from the anterior tooth row
       
    • Estimation of defect size/depth in relation to the inserted endoscope
       
    • Assessment of the blood supply of the anastomosis region/conduit or interposition
       
    • Assessment of the local inflammatory situation

    Contrast-enhanced computed tomography with water-soluble oral contrast agent (Gastrografin)

    • initially and in the course of treatment to monitor sponge positioning and source control
       
    • Detection of any undrained pleural and mediastinal air and fluid collections as well as accompanying pulmonary complications

  4. Special Preparation

    • Since anastomotic leakages or other esophageal leaks are often associated with the thoracic cavities, pleural effusions should be drained via thoracic drains in these cases
       
    • Upon signs of infection, initiation of antibiotic therapy. In most cases, routine antibiotic prophylaxis with piperacillin/tazobactam is administered for 5 – 7 days
       
    • As long as the VAC stent is in situ, a feeding tube can be placed through the stent if indicated

  5. Informed consent

    • serial endoscopies
    • Continuous transnasal suction, which may occasionally last several weeks.
    • incorrect placement of the stent
    • incomplete expansion of the stent
    • worsening of the defect by the endoscope
    • aspiration during VAC-stent procedures
    • obstruction of the drainage tube/VAC-stent
    • dysphagia due to the stent
    • dislocation of the VAC-stent/inadequate sealing
    • ingrowth of the stent into surrounding tissue
    • incomplete stent removal
    • erosion/ulcer formation at the stent site after removal
    • anastomotic/esophageal stricture
    • gastroesophageal reflux
    • severe therapy-associated complications such as erosion of major vessels or fistulas to the airways (not yet described, but theoretically possible)

  6. Anesthesia

    • Analgesic sedation with propofol and midazolam is sufficient for stable patients

    • General anesthesia is preferred in cases of difficult anatomical conditions or longer procedures

    Note: In recent publications, 27% of patients were treated under general anesthesia with intubation during VAC stent treatment. Analgesic sedation was performed in 73%.

  7. Special instruments

    VAC-Stent®-Set consisting of:

    • Self-expanding fully covered nitinol stent
    • Polyurethane sponge
    • VAC-Stent introduction system
    • Blue suction catheter
    • Removable Luer-Lock connector
    • Y-connector

    Note: The esophagus VACStent® is available in only one size.

    Additionally required:

    • 0.035-inch guide wire
    • Endoscopy unit
    • Possibly transparent distal cap for the endoscope for gentle removal of the stent
    • Possibly imaging system of the C-arm fluoroscope
    • Endoscopic grasping forceps
    • Suction catheter
    • Adjustable medical pump for vacuum treatment
    • 0.9% saline solution

  8. Post-treatment

    • After the placement of the VAC stent, the negative pressure is reduced to 75 mmHg the next day
       
    • To ensure the patency of the suction catheter and prevent ingrowth of the stent, the VAC stent should be flushed three times daily with 20 ml of water through the purple connection
       
    • A proton pump inhibitor (PPI) is considered if the VAC stent covers the cardia area (PPI 40 mg twice daily)

    Nutrition

    On the day of VAC stent placement, strict fasting is generally indicated, followed by a liquid diet the next day and a soft diet subsequently if well tolerated. While the VAC stent is in place, a feeding tube can be placed either endoscopically or blindly through the stent if oral intake is not possible for any reason, such as if the patient is intubated.

    Once the stent treatment is completed, food intake can be gradually increased.

    VAC Stent Replacement

    To avoid damage to the surrounding tissue, the VAC stent should be replaced every 7 days. However, for logistical reasons, this may vary between 5 and 10 days. If the VAC stent is left in place for a longer period, it must be ensured that it is correctly positioned and the vacuum system is functioning properly!

    An early replacement of the VAC stent should be considered, if there are doubts about adequate treatment:

    • Increase in infection parameters
    • Deterioration of the patient's clinical symptoms
    • Other indications of a contaminated cavity, e.g., pus in the thoracic drain

    If there is uncertainty about adequate treatment, a CT scan with oral contrast can be performed to check if the cavity around the stent has collapsed and is adequately sealed by the stent.

    If the collection container fills quickly, stent dislocation should be considered, as it could be gastric fluid or tube feeding.

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