Eso-SPONGE® – Endoluminal vacuum treatment in staple line failure and perforations of the upper GI tract - general and visceral surgery

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  • Technique

    A 55-year-old male patient with squamous cell carcinoma of the distal third of the esophagus had undergone abdominothoracic esophagectomy with gastric conduit reconstruction and end-to-end esophagogastrostomy (manual suture) following neoadjuvant chemoradiotherapy. On postoperative day 5, elevation of the infection markers was noted. Endoscopic follow-up examination revealed staple line failure affecting approximately one-quarter of the anastomotic circumference 25 cm from the dental arch. The leakage cavity behind it was visualized to a depth of about 8 cm. During the same examination, the first Eso-Sponge was inserted into the leakage cavity. The following video demonstrates the second Eso-SPONGE® replacement.

  • Preparation

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    The Eso-SPONGE® treatment set comprises an open-cell polyurethane sponge inserted through an overtube with pusher, rerouted transnasally and then connected to an adjustable medical pump. To prepare for treatment, unpack the components of the set; if necessary, already thread the drainage tube of the sponge through the pusher. Prepare sterile hydrogel, NaCl or Ringer solution, a Ch. 16 gastric tube, and various clamps.

  • Visualizing and placing the overtube into the leakage cavity

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    Prior to Eso-Sponge placement size the wound cavity by flexible endoscopy. Slip the overtube over the endoscope (moisten with lubricant or silicone spray) and introduce the tube under vision to the end of the leakage cavity, with the endoscope serving as a guide. Maintain the overtube in position and carefully withdraw the endoscope.

  • Inserting the sponge

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    With the sponge possibly trimmed to size, wet it with sterile hydrogel (Askina® gel) and introduce it into the overtube. Advance Eso-SPONGE® to the mark with the pusher - the sponge is now at the end of the overtube. Hold the pusher in place and pull back the overtube to the handle of the pusher; this will release the sponge in the leakage cavity. Now remove overtube and pusher together. Check the sponge position with the endoscope and correct, if necessary, with an endoscopic grasper.

  • Transnasal routing

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    Feed a gastric tube or a suction catheter Ch 16 (not included in the set) through the nose and out through the mouth, cutting off the atraumatic tip if necessary. Connect the Eso-SPONGE® drainage tube to the gastric tube in front of the mouth. Pull back together both gastric and drainage tube through the nose. The drainage tube now follows the transnasal route.

  • Connecting the drainage tube to the Y-connector

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    Slight beveling of the Eso-SPONGE® drainage tube may facilitate insertion. If needed, connect two sponges to a Y-adapter and thus operate them with one pump.

  • Connecting to an adjustable medical pump

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    Cut off the Heimlich valve from the tube of the secretion bottle. Connect the filter to the pump (MV-1, MTG GmbH, Sulzbach, Germany) with a Luer-Lock connector and attach the shortened bottle tubing to the filter. Push the Y-connector onto the universal connector of the remaining tubing. Switch on the pump by pressing F and I—the pump is already preset to a constant suction of -125 mmHg. If required, this can be reduced or increased in steps of 5 mmHg (key combination: F and ↑/↓ ). Do not exceed a vacuum of -200 mmHg.

  • Replacing the sponge

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    The system must be replaced every 48 to 72 hours. To that effect, disconnect the Eso-SPONGE® and pump; check the sponge position with the endoscope, if necessary. To pull out the sponge, reroute the Eso-SPONGE® drainage tube through the mouth. Irrigate with NaCl or Ringer solution using the 20 ml syringe and dilator (from the newly opened set). Remove the sponge by pulling it carefully. Re-inspect the leakage cavity with the endoscope and insert a new sponge, if necessary.

  • Final endoscopic evaluation

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    In the case study demonstrated here, the Eso-SPONGE® system was changed a total of 10 times. Total Eso-SPONGE® therapy duration was 25 days. The final endoscopic examination, performed four weeks after the patient was discharged from the hospital, still revealed scarring and retraction at the former leakage cavity and moderate anastomotic stenosis, which, however, allowed easy passage of a standard gastroscope.