Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis

Summary of the current guidelines for managing iatrogenic colorectal perforations and the evolving role of endoluminal vacuum therapy

Colonoscopy represents a safe procedure that is widely used in medical practice either to diagnose or treat various gastrointestinal diseases. During the last few years, the incidence rate of perforations in colonoscopic procedures has increased, especially in therapeutic colonoscopies. The recent advancements in endoscopic techniques and gastrointestinal tumoral resection procedures such as endoscopic mucosal resection, endoscopic full-thickness resection, and endoscopic submucosal dissection (ESD) could be a risk factor for this increased risk. The incidence rate of mortality of serious colonoscopic perforations is 7.1%. The management plan for these perforations starts with conservative treatment in mild cases, endoscopic closure, and surgical management in severe cases. Recently, endoluminal vacuum therapy was found to be effective in the management of colorectal perforations and this has been reported in multiple case reports. This editorial provides an overview of the current guidelines for the management of iatrogenic colorectal perforations. These insights are from the perspectives of endoscopists and gastroenterologists. We also present a management algorithm based on the guidelines of the European Society of Gastrointestinal Endoscopy, the American Gastroenterological Association, and the World Society of Emergency Surgery. We also discussed in brief the use of endoluminal vacuum therapy in colorectal perforations.

Creation of a Custom Endoluminal Vacuum-Assisted Device for Salvage of Ileal Pouch-Anal Anastomotic Leak

Endoluminal vacuum-assisted devices have become increasingly popular solutions for low-colorectal injuries and anastomotic defects in recent years. We present a case of a 23-year-old male who underwent salvage of an ileal pouch-anal anastomosis (IPAA) anastomotic leak with a customized endoluminal vacuum sponge and cavity marsupialization. This case highlights the easy-to-follow steps to create a customized endoluminal vacuum (endo-vac) sponge with readily available materials for the treatment of low colorectal anastomotic leaks. Included are step-by-step photos and instructions for successful endoluminal vacuum device construction.

Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review

Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites.

Endoscopic vacuum-assisted closure therapy for leakage of the lower gastrointestinal tract: multicenter experiences

Background and study aims  Only a few studies are available regarding endoscopic vacuum-assisted closure (E-VAC) therapy for the post-surgery leakage of the lower gastrointestinal tract. Patients and methods  In this multicenter German study, we retrospectively analyzed patients treated with E-VAC therapy due to post-surgery leakage of the lower gastrointestinal tract from 2000-2020 at Hannover Medical School, University Medical Center Schleswig-Holstein, Campus Luebeck, and Robert Koch Hospital Gehrden. Results  Overall, 147 patients were included in this study. Most patients had undergone tumor resections of the lower gastrointestinal tract (n = 88; 59.9 %). Median time to diagnosis of leakage was 10 days (interquartile range [IQR] 6-19). Median duration of E-VAC therapy was 14 days (IQR 8-27). Increase of C-reactive protein (CRP) levels significantly correlated with first diagnosis of leakage ( P  < 0.001). E-VAC therapy led to closure or complete epithelialization of leakage in the majority of patients (n = 122; 83.0 %) and stoma reversal was achieved in 60.0 %. Stoma reversal was significantly more often achieved in patients with CRP levels ≤ 100 mg/L at first diagnosis compared to patients with CRP levels > 100 mg/L (78.4 % vs. 52.7 %; P  = 0.012). Odds ratio for failure of stoma reversal was 3.36 in cases with CRP values > 100 mg/L ( P  = 0.017). In total, leakage- and/ or E-VAC therapy-associated complications occurred in 26 patients (17.7 %). Minor complications included recurrent E-VAC dislocations and subsequent stenosis. Overall, 14 leakage- or E-VAC-associated deaths were observed most often due to sepsis. Conclusions  E-VAC therapy due to post-surgery leakage of the lower gastrointestinal tract is safe and effective. High levels of CRP are a negative predictor of E-VAC therapy success.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient's presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.