Perioperative management - Eso-SPONGE® – Endoluminal vacuum treatment in staple line failure and perforations of the upper GI tract

• Endoscopic vacuum therapy with the Eso-SPONGE® system is suitable for the treatment of esophageal defects of all sizes, levels and in infectious conditions. It can be used at/as:

• • Esophageal staple line failure
  • Esophageal perforations (iatrogenic, foreign body, Boerhaave syndrome)
  • “Bridge-to-Surgery”: Vacuum therapy as a therapeutic option for sepsis control until definitive surgical defect repair

Paraesophageal wound cavities must be accessible by endoscopy!

Other diseases successfully treated with this technique to date:

• • Necrotizing pancreatitis (transgastric necrosectomy)
  • Staple line failure in pancreaticojejunostomy

Prophylactic placement of endoluminal sponges to protect fragile esophageal anastomoses is conceivable.

• Transmural esophageal defect with extensive necrosis, gangrene, and ischemia: Vacuum therapy as bridging option, at best
• Transmural defect with tracheobronchial fistula: technically impossible to establish a vacuum

Flexible endoscopy

• • Repeat daily when facing diagnostic uncertainties
  • Defect level = distance from dental arch
  • Size of defect estimated relative to inserted endoscope
  • Assessment of blood supply to the anastomosis/interposition graft and the local inflammation
  • Exploration of small defects with a small-bore nasal gastroscope: extraluminal wound cavity?

Contrast-enhanced computed tomography

• • Baseline and in the course of treatment to monitor the sponge position and drainage of the septic focus
  • Visualization of undrained pleural and mediastinal air and fluid retention as well as concomitant pulmonary complications

Airway protection requires endoscopic sponge placement under general anesthesia.

The Eso-SPONGE® set comprises:

• • Overtube (*)
  • Pusher
  • Eso-SPONGE® sponge component
  • Irrigation set
  • Y-connector
  • Slide clamp

(*) Two sizes are available:
Size 1: inside 13 mm, outside 17 mm
Size 2: inside 15 mm, outside 19 mm

The following are also needed

• • Endoscope or gastroscope (flexible endoscope, CO2 as examination gas)
  • Sterile, glycerol-based hydrogel
  • Gastric tube Ch 16
  • Adjustable medical pump for vacuum therapy (-125 mmHg vacuum needed)

Nutrition
The type of nutrition during the ongoing treatment depends on the type of therapy:

• • Intraluminal sponge drainage ⇒ gastric tube, PEG
  • Intracavitary sponge drainage ⇒ oral nutrition, bypassing the indwelling drain

A diet of water and tee, then soft diet, is recommended after vacuum therapy has been terminated. In the presence of superficial mural evaginations, coarse dietary fibers such as grains should be avoided initially because of the risk of fistula formation.

Endoscopic wound inspection and sponge replacement
Endoscopic wound inspection is performed after 48 to 72 hours. To that effect, turn off the vacuum and remove the in-dwelling sponge drain. Replace the sponge drain if continued treatment has to be continued.

In small defects treatment can be terminated once defect closure is visible. In large wound cavities, vacuum treatment is continued until the wound bed has cleared, the cavity has significantly reduced in size, and the entire wound bed is granulated.

Close endoscopic monitoring of wound healing is recommended even after vacuum treatment has been terminated, so that sponge drainage may be reinstated if necessary.