Anatomy - Eso-SPONGE® – Endoluminal vacuum therapy for the treatment of anastomotic insufficiencies and perforations in the upper GI tract

Leaks in the gastrointestinal tract occur after surgical procedures involving anastomosis, but also following endoscopic interventions such as dilations or the removal of precancerous lesions or early carcinomas by means of endoscopic mucosal resection or submucosal dissection. The risk of postoperative leakage increases with the growing use of neoadjuvant treatment concepts in esophageal, gastric and rectal carcinomas.

Esophageal anastomoses are created for reconstruction after esophageal resections and transhiatally extended gastrectomies. The insufficiency rate for esophageal anastomoses is reported in the literature to be between 0 and 30 percent, with mortality rates of up to 50 percent. The main cause of fatal outcomes, in both anastomotic insufficiencies and perforations, is the development of mediastinitis with a most severe septic clinical picture.

Crucial for the prognosis of an oesophageal leak due to anastomotic insufficiency or perforation is the early initiation of adequate therapy. If therapy is begun more than 24 hours after the perforation event, the mortality rate exceeds 20 percent.

Apart from selected cases in which a purely conservative approach with systemic antibiotic administration, tube drainage, and parenteral nutrition is possible, all other treatment strategies aim at closing the defect and providing sufficient drainage of the extraluminal septic focus.

Until around the year 2000, the treatment of anastomotic leaks was purely a surgical domain (suture, re-establishment of the anastomosis, discontinuity resection as a last resort). In the meantime, conservative and interventional-endoscopic therapies have become established. The procedures primarily involve the placement of stents, less commonly the sole therapy with fibrin glue or clips.

The most widespread endoscopic method for treating anastomotic leaks is the placement of self-expanding stents. Both fully covered metal stents and fully covered plastic stents are used. The success rate for treating anastomotic insufficiencies through stent implantation averages around 50 percent.

Advantages of Stent Implantation:

• immediate sealing of the leak
• accordingly rapid oral nutritional build-up
• technically simple

Disadvantages of stent implantation:

• requires not only an endoscopy unit but also a fluoroscopy unit, into which a potentially clinically unstable patient with multiorgan failure and sepsis due to mediastinitis must be transported (repeatedly).
• problematic with larger leaks/dehiscences
• low positional stability of the stent with cervical leaks, in the area of the oesophagogastric junction, and postoperatively after gastric pull-up or colon interposition (lumen incongruence)
• stent-related stenoses and perforations, stent migration, displacement, inadequate sealing, ingrowth of the stent
• simultaneous drainage of the septic focus through the placement of external, percutaneous drains required (usually CT-guided puncture)
• assessment of the anastomosis or leak (usually after 2 – 4 weeks) requires stent removal, as the stent coating does not allow optical control of the leak; possibly requiring re-stenting.