Anatomy - Eso-SPONGE® – Endoluminal vacuum treatment in staple line failure and perforations of the upper GI tract - general and visceral surgery
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Transmural esophageal defects
Gastrointestinal tract leakage develops after anastomotic surgical procedures as well as following endoscopic interventions, such as dilation or ablation of precancerous lesions and early cancer, involving endoscopic mucosal resection or submucosal dissection. The risk of postoperative leakage is on the rise because of the increased use of neoadjuvant treatment regimens in esophageal, gastric and rectal cancers.
In esophageal resection and extended transhiatal gastrectomy, reconstruction requires an esophageal anastomosis. The failure rate reported in the literature for esophageal anastomoses ranges from 0% to 30%, with mortality rates of up to 50%. The leading cause of mortality in both staple line failure and perforation is developing mediastinitis with severe clinical sepsis.
The prognosis of esophageal leakage in both staple line failure and perforation largely depends on early initiation of adequate treatment. If treatment is delayed for more than 24 hours after perforation onset, the mortality rate is more than 20%.
Except in selected cases allowing a strictly conservative approach with systemic antibiotics, gastric tube diversion, and parenteral nutrition, all other treatment strategies are aimed at closure of the defect and adequate drainage of the extraluminal septic focus.
Up until about the turn of the millennium, the treatment of staple line failure was confined to surgery (suture, refashioning of anastomosis, discontinuity resection as the last resort). The years since then have seen the emergence of conservative and interventional endoscopic treatment options. The most common procedures are stenting and, less frequently, stand-alone treatment with fibrin sealants or clips.
Benefits and drawbacks of stenting
The most common endoscopic procedure in treating anastomotic leakage is the placement of self-expanding stents. Both fully covered metal stents and fully covered plastic stents are employed. The mean rate of success when stenting esophageal staple line failure is about 50%.
Benefits of stenting:
- Immediate sealing of leaks
- Correspondingly rapid resumption of oral diet
- Easy to perform
Drawbacks of stenting:
- Requires both an endoscopy and fluoroscopy suite, to which a patient with mediastinitis and possibly clinically unstable multi-organ failure and sepsis must be transported ( repeatedly)
- Problematic in larger leakage/dehiscence
- Poor positional stent stability in cervical leaks, at the gastroesophageal junction and postoperatively following esophagogastrostomy or esophagocoloplasty (luminal incongruence)
- Stent-related stenosis and perforation, stent migration/dislocation/embedment, endoleakage (inadequate sealing)
- Need for concurrent drainage of septic focus by external percutaneous drainage (usually CT-guided centesis)
- Assessment of the anastomosis or leakage (usually after 2–4 weeks) requires stent removal, as the stent cover does not allow visual inspection of the leakage site; re-stenting may become necessary
Endoscopic vacuum therapy in upper GI tract perforation and staple line failure
Endoscopic vacuum therapy is an innovative therapeutic option in esophageal leakage.
Vacuum-assisted closure (VAC) is an established procedure in the treatment of extensive infected superficial defects. The vacuum ensures removal of the infected secretions and reduces edema in the wound bed. It improves perfusion of the latter, expediting the healing process. The open-cell polyurethane sponge promotes the formation of granulation tissue and accelerates wound healing.
The principle of vacuum-assisted closure can also be applied to defects accessible only on endoscopy, as is the case in staple line failure. The following link presents the Endo-SPONGE® system for VAC treatment in staple line failure of the rectum:
Similarly, the Eso-SPONGE system featured in the present article can be used for endoscopic vacuum treatment of esophageal leaks and thoracic staple line failure.
Endo-SPONGE® and Eso-SPONGE® – Defect closure and drainage
Both systems (manufactured by B. Braun Melsungen, Germany) are based on the proven surgical principles of defect closure and drainage. The defect is closed endoscopically by applying the therapeutically effective vacuum to the defect via an open-cell polyurethane sponge. In endoscopic vacuum therapy the septic focus is drained intraluminally, thus generally obviating the need for external percutaneous wound drainage as required in stenting. As with the topical application of the VAC system, intracorporeal vacuum therapy promotes stable wound healing by secondary intention which should heal once vacuum therapy has been terminated.
Intraluminal and intracavitary endoscopic vacuum therapy with Eso-SPONGE®
With endoscopic sponge placement, drainage systems can be inserted under endoscopic vision anywhere in the intestinal tract accessible by gastroscopy. Intraluminal sponge placement with defect sealing must be differentiated from intracavitary sponge placement in extraluminal wound cavities.
In the intracavitary variant, the draining sponge is inserted through the transmural defect into the extraluminal wound cavity. If the mural defect is too small to allow passage of the endoscope, dilation is required (tip of the endoscope or balloon dilation). After positioning the sponge inside the wound cavity and applying vacuum, the wound cavity collapses around the polyurethane sponge, with the edges of the mural defect now tightly enclosing the drainage tube and sealing off the wound cavity against the intestinal lumen. These cases require sponges considerably smaller than the extraluminal wound cavity.
In the intraluminal variant, the draining sponge is left within the intestinal lumen and placed at the level of the mural defect. Once the vacuum is applied, the surface epithelium adheres tightly to the sponge component of the drain. The mural defect is closed by the applied sponge and the wound secretions are drained into the lumen. Since the esophageal lumen collapses because of the suction effect, enteral nutrition is only possible through a feeding tube or PEG.
Benefits of Eso-SPONGE® treatment:
- Continuous drainage without secretion buildup
- Infection control
- Debridement and rapid cleansing the wound
- Improved granulation
- Mechanical wound cavity diminution
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