Endoscopic Vacuum Therapy for the Treatment of Colorectal Leaks
Since the first reports in the late 1990s, vacuum-assisted wound therapy has conquered almost all areas of surgery, as it is a versatile and easy-to-use method for treating complicated wounds [1]. In 2001, Weidenhagen et al. began using endoscopic vacuum therapy for the management of complications from colorectal anastomotic insufficiencies as a "minimally invasive method for continuous and effective drainage of perianastomotic abscesses and fistulas in the pelvic region in combination with debridement and consecutive mechanical closure of the leak" [2]. In 28 out of 29 cases of colorectal anastomotic insufficiency, these healed after endoluminal vacuum therapy (EVT) without renewed surgical intervention [2]. Subsequently, EVT was successfully used for the interventional treatment of various defects in the upper and lower gastrointestinal tract [3] and has been available as a certified medical product since 2007 (Eso-, Endo-SPONGE®).
Anastomotic leaks (AL) and other colorectal defects such as Hartmann's stump leaks are associated with high morbidity and mortality [4]. The incidence of AL in rectal cancer surgeries ranges from 6 to 30% with an average of 11%, depending on the height of the anastomosis [4]. Therefore, a significant number of patients are affected by this serious complication.
The EVT of colorectal leaks is based on the transanal placement of an open-cell microporous sponge intraluminally at the level of the AL (or other colorectal defects) or through the leak into an extraluminal perianastomotic abscess cavity using flexible endoscopes [2]. The negative pressure ("vacuum") is applied via an evacuation tube attached to the sponge [5]. The sponge is usually changed every 2-4 days until the infection has subsided and the defect is closed with granulation tissue, which can be demonstrated endoscopically [5]. This active drainage of the infection site leads to a reduction in bacterial contamination, local edema, and secretion, demonstrably improves blood circulation, and induces granulation tissue [7].
EVT has become a standard treatment for surgical leaks in many - predominantly European countries - [5-26]. A wealth of smaller observational studies and case series have been published on this topic, but no data from randomized controlled trials. A systematic review and meta-analysis on the efficacy and safety of the treatment of colorectal leaks from 2022 has filled this gap [27]. Following an appropriate database search, 24 studies with a total of 690 patients with colorectal defects (after colorectal procedures including Hartmann, diverticular perforations, trauma) who underwent EVT were included. The study concluded that EVT is a feasible treatment option with manageable risks for selected patients with colorectal leaks:
1. Duration of EVT treatment and number of sponge changes: 23.4 days and 6.8 sponge changes.
2. Success rate of EVT: 81.5%
3. Frequency of stoma creation: 76.4%
4. Mean stoma reversal rate after EVT: 66.7% (415 patients required only a temporary stoma, 139 patients did not require stoma creation)
5. EVT complications (fistulas, stenoses, presacral abscesses, bleeding): 12.1%
6. EVT-associated mortality: 0%