[New strategies and materials in endoscopic vacuum therapy in the lower gastrointestinal tract]

Placing vacuum sponges in esophageal anastomotic leaks - how we do it

PURPOSE

Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult.

METHODS

We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits.

RESULTS

Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation.

CONCLUSION

We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.

Minimally invasive intrathoracic negative-pressure therapy and flexible thoracoscopy (FlexVATS) for patients with pleural empyema

To determine whether a new surgical method using a flexible endoscope (FlexVATS) to perform sparing debridement and apply negative-pressure therapy without extensive decortication may be an alternative treatment option for empyema. Surgical treatment of pleural empyema is associated with considerable postoperative complications and mortality rates, and alternative treatment options are being explored to improve patient outcomes. This was a prospective case series. Seventeen consecutive patients treated with FlexVATS between February 2021 and August 2022 were included in the study. Only patients for whom FlexVATS was the first therapeutic intervention for pleural empyema were included. Treatment success, defined as infection resolution, was the primary endpoint of the study. The secondary endpoints were length of hospital stay, 90-day mortality, and empyema cavity volume reduction. Patients who had previously been treated for pleural empyema by either drainage or surgery were excluded. The trial was performed as a single-centre study at a tertiary medical centre in Germany. In total, 17 patients with pleural empyema were included in the study. The median (IQR) duration of vacuum treatment was 15 days (8-35 days). Twelve of the 17 (71%) patients were successfully treated, and a significant reduction in the empyema cavity volume was observed. 41% of the dressing changes were performed outside the operating room. Compared with a historic cohort of conventionally treated patients (decortication via VATS or thoracotomy), the 90-day mortality rates tended to be lower without reaching statistical significance. Three patients (18%) died in hospital during treatment. No negative pressure-therapy-related complications were observed. FlexVATS therapy is a promising alternative therapy for both healthy and debilitated patients with pleural empyema. Larger randomised trials are required to validate this treatment option.

Challenges in the interdisciplinary treatment of leakages after left-sided colorectal surgery: endoscopic negative pressure therapy, open-pore film drainage therapy and beyond

PURPOSE

The treatment of anastomotic leakage after left colorectal surgery remains challenging. Since its introduction, endoscopic negative pressure therapy (ENPT) has proven to be advantageous, reducing the necessity of surgical revision. The aim of our study is to present our experience with endoscopic treatment of colorectal leakages and to identify potential factors influencing treatment outcome.

METHODS

Patients who underwent endoscopic treatment of colorectal leakage were retrospectively analyzed. Primary endpoint was the healing rate and success of endoscopic therapy.

RESULTS

We identified 59 patients treated with ENPT between January 2009 and December 2019. The overall closure rate was 83%, whereas only 60% of the patients were successfully treated with ENPT and 23% needed further surgery. The time between diagnosis of leakage and uptake of endoscopic treatment did not influence the closure rate, but patients with chronic fistula (> 4 weeks) showed a significantly higher reoperation rate than those with an acute fistula (94% vs 6%, p = 0.01).

CONCLUSION

ENPT is a successful treatment option for colorectal leakages, which appears to be more favorable when started early. Further studies are still needed to better describe its healing potential, but it deserves an integral role in the interdisciplinary treatment of anastomotic leakages.

Differences in fluid removal of different open-pore elements for endoscopic negative pressure therapy in the upper gastrointestinal tract

Endoscopic negative pressure therapy is an effective treatment strategy for various defects of the gastrointestinal tract. The functional principle is based on an open-pore element, which is placed around a perforated drainage tube and connected to a vacuum source. The resulting open-pore suction device can undergo endoluminal or intracavitary placement. Different open-pore suction devices are used for endoscopic negative pressure therapy of upper gastrointestinal tract defects. Comparative analyses for features and properties of these devices are still lacking. Eight different (six hand-made devices and two commercial devices) open-pore suction devices for endoscopic negative pressure therapy of the upper gastrointestinal tract were used, amount fluid removed was evaluated. The evaluation parameters included the time to reach the target pressure, the time required to remove 100 ml of water, and the material resistance of the device. All open-pore suction devices are able to aspirate the target volume of fluids. The time to reach the target volume varied considerably. Target negative pressure was not achieved with all open-pore suction devices during the aspiration of fluids; however, there was no negative effect on suction efficiency. Of the measurement data, material resistance could be calculated for six open-pore elements. We present a simple experimental, nonphysiologically setup for open-pore suction devices used for endoscopic negative pressure therapy. The expected quantity of fluids secreted into the treated organs should affect open-pore suction device for endoscopic negative pressure therapy.

Learning of flexible endoscopy, particularly endoscopic vacuum therapy (EVT)

BACKGROUND

Anastomotic insufficiency and perforations in the gastrointestinal tract are severe complications associated with a high complication rate and mortality. Conventional treatment options (particularly re-operations) are often unsatisfactory. Endoscopic vacuum therapy (EVT) is increasingly being used as a promising alternative.

PROBLEM

The use of EVT requires a high level of competence in interventional flexible endoscopy, which is primarily not available to every surgeon. Special training programs are required here.

METHODS

Based on this need the long-proven Tuebingen training system for flexible endoscopy was modified to meet the special requirements of surgeons and is currently being extended by a special training module for EVT.

RESULTS

In addition to the theoretical principles, the training is focused on learning the manual skills for flexible endoscopy. A 2-stage process was developed for this purpose: 1) to become familiar with handling of the flexible endoscope and to learn spatial orientation by means of a didactically optimized abstract phantom ("Tuebingen Orientophant") and 2) learning and training of EVT using a newly developed patient-analogous training model with various insufficiencies and abscess cavities in the upper and lower gastrointestinal tract ("Tuebinger Spongiophant"). The procedure can be trained hands-on step by step exactly as with the patient, whereby the sponge can be applied using different methods, such as overtube and dragging procedures. The consequences of mistakes and complication management can also ideally be trained hands-on using the phantom.

DISCUSSION

Evaluations of the first course series show that surgeons achieve endoscopic competence very quickly and learn to master the new procedure. The structure of such a course must, however, be designed according to long-term experience in an optimal didactic manner. Decision-makers in healthcare policy should give much more support to such courses in order to improve patient care and to increase patient safety.

Intrauterine negative-pressure therapy (IU-NPT) to treat peritonitis after caesarean section

Objectives

We describe the first application of intrauterine negative-pressure therapy (IU-NPT) for an early rupture of a uterine suture after a third caesarean section with consecutive peritonitis and sepsis. Because all four quadrants were affected by peritonitis, a laparotomy was performed on the 15th day after caesarean section. Abdominal negative-pressure wound therapy (A-NPWT) of the open abdomen was initiated. During the planned relaparotomy, a suture defect of the anterior uterine wall was identified and sutured. In the second relaparotomy, the suture appeared once more insufficient.

Case presentation

For subsequent IU-NPT, we used an open-pore film drainage (OFD) consisting of a drainage tube wrapped in the double-layered film. The OFD was inserted into the uterine cavity via the uterine defect and IU-NPT was established together with A-NPT. With the next relaparotomy, local inflammation and peritonitis had been resolved completely. IU-NPT was continued transvaginally, the uterine defect was sutured, and the abdomen was closed. Vaginal IU-NPT was also discontinued after another eight days.

Conclusions

By using IU-NPT, local infection control of the septic focus was achieved. The infectious uterine secretions were completely evacuated and no longer discharged into the abdominal cavity. As a result of the applied suction, the uterine cavity collapsed around the inlaid OFD. The total duration of IU-NPT was 11 days. The uterine defect was completely closed, and a hysterectomy was avoided. The patient was discharged four days after the end of IU-NPT. IU-NPT follows the same principles as those described for endoscopic negative-pressure wound therapy of the gastrointestinal tract.

A hairy cavity: endoscopic therapy of a presacral recurrence of a complex pilonidal sinus

BACKGROUND

Recently, minimally invasive techniques to avoid radical excisions of the pilonidal sinus with long-lasting secondary wound healing were developed. We describe a rare case of an intrapelvic, pararectal recurrence of a pilonidal sinus, who was innovatively treated with flexible endoscopy.

CASE PRESENTATION

A 43-year-old Caucasian man presented with an intrapelvic, pararectal recurrence of a primarily wide-stretched pilonidal sinus, originally located in the sacrococcygeal region and spreading laterally to the gluteal region and intrapelvic to the presacral area. No connection to the bowel was evident. Up until presentation in the endoscopic department, a total of five attempts of surgical resection were performed, always confirming the diagnosis of a pilonidal sinus. Endoscopic therapy consisted of a combination of debridement, laser ablation and endoscopic vacuum therapy. After completion of APC and VAC therapy, the patient irrigated the abscess cavity for a further 2 weeks with a rinsing syringe. The resulting deep scar at the gluteal fistula was resected after secondary wound healing was completed. Two years after the end of the therapy, no recurrence was evident.

CONCLUSION

Flexible endoscopy is, with its multiple therapeutic applications, an effective tool even in very complex inflammatory fistula and abscesses. Correctly indicated, it is with its minimally invasive character an excellent alternative to open surgical approaches.

[Learning of flexible endoscopy, particularly endoscopic vacuum therapy (EVT)]

BACKGROUND

Anastomotic insufficiency and perforations in the gastrointestinal tract are severe complications associated with a high complication rate and mortality. Conventional treatment options (particularly re-operations) are often unsatisfactory. Endoscopic vacuum therapy (EVT) is increasingly being used as a promising alternative.

PROBLEM

The use of EVT requires a high level of competence in interventional flexible endoscopy, which is primarily not available to every surgeon. Special training programs are required here.

METHODS

Based on this need the long-proven Tübingen training system for flexible endoscopy was modified to meet the special requirements of surgeons and is currently being extended by a special training module for EVT.

RESULTS

In addition to the theoretical principles, the training is focused on learning the manual skills for flexible endoscopy. A 2-stage process was developed for this purpose: 1) to become familiar with handling of the flexible endoscope and to learn spatial orientation by means of a didactically optimized abstract phantom (Tübingen Orientophant) and 2) learning and training of EVT using a newly developed patient-analogous training model with various insufficiencies and abscess cavities in the upper and lower gastrointestinal tract. The procedure can be trained hands-on step by step exactly as with the patient, whereby the sponge can be applied using different methods, such as overtube and dragging procedures. The consequences of mistakes and complication management can also ideally be trained hands-on using the phantom.

DISCUSSION

Evaluations of the first course series show that surgeons achieve endoscopic competence very quickly and learn to master the new procedure. The structure of such a course must, however, be designed according to long-term experience in an optimal didactic manner. Decision-makers in healthcare policy should give much more support to such courses in order to improve patient care and to increase patient safety.