Prophylactic negative vacuum therapy of high-risk esophageal anastomoses in pediatric patients

Applications of endoscopic vacuum therapy in the upper gastrointestinal tract

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.

Advances in Complex Congenital Tracheoesophageal Anomalies

Esophageal atresia with or without tracheoesophageal fistula and tracheobronchomalacia encompass 2 of the most common complex congenital intrathoracic anomalies. Tailoring interventions to address the constellation of problems present in each patient is essential. Due to advances in neonatology, anesthesia, pulmonary, gastroenterology, nutrition and surgery care for patients with complex congenital tracheoesophageal disorders has improved dramatically. Treatment strategies tailored to the individual patient needs are best implimented under the aegis of a comprehensive longitudinal multidisciplinary care team.

Prophylactic endoluminal vacuum therapy after major gastrointestinal surgery: a systematic review

In the last decade, endoluminal vacuum therapy (eVAC) has emerged as an effective treatment for anastomotic leak (AL); however, little is known regarding its prophylactic use. In this systematic review we evaluated overall outcomes in patients undergoing major gastrointestinal surgery and treated with prophylactic eVAC. A systematic review of English articles on four electronic databases was performed according to the PRISMA statement up until January 2022. References of selected articles were manually screened to identify relevant missing papers. Primary endpoints were AL and mortality rates estimates. Secondary endpoints included analysis of eVAC-associated morbidity, treatment duration, long-term complications, and general indications for the eVAC management in the perioperative period. A total of 11 studies (5 case reports, 5 retrospective case series and a retrospective, case-control study) were included in the analysis. AL ranged from 0 to 25%. No major eVAC-associated complications were observed, except for sponge dislocation or obstruction. Overall mortality ranged between 0 and 12.5%; however, these fatalities were neither related to the use of eVAC, nor to AL-associated complications. The most frequent long-term complication was anastomotic stenosis responsive to endoscopic dilatation in most cases. The operating negative pressure ranged from -25 to -125 mmHg among different papers. In all studies but two, prophylactic eVAC was applied to anastomoses at high risk of dehiscence based on the subjective evaluation of the leading surgeon. In conclusion, prophylactic eVAC is safe and it could lead to potential benefit for prevention of AL, especially in high-risk anastomoses.

Contemporary outcomes of the Foker process and evolution of treatment algorithms for long-gap esophageal atresia

BACKGROUND

Esophageal growth using the Foker process (FP) for long-gap esophageal atresia (LGEA) has evolved over time.

METHODS

Contemporary LGEA patients treated from 2014-2020 were compared to historical controls (2005 to <2014).

RESULTS

102 contemporary LGEA patients (type A 50%, B 18%, C 32%; 36% prior anastomotic attempt; 20 with esophagostomy) underwent either primary repair (n=23), jejunal interposition (JI; n = 14), or Foker process (FP; n = 65; 49 primary [p], 16 rescue [r]). The contemporary p-FP cohort experienced significantly fewer leaks on traction (4% vs 22%), bone fractures (2% vs 22%), anastomotic leak (12% vs 37%), and Foker failure (FP→JI; 0% vs 15%), when compared to historical p-FP patients (n = 27), all p ≤ 0.01. Patients who underwent a completely (n = 11) or partially (n = 11) minimally invasive FP experienced fewer median days paralyzed (0 vs 8 vs 17) and intubated (9 vs 15 vs 25) compared to open FP patients, respectively (all p ≤ 0.03), with equivalent leak rates (18% vs 9% vs 26%, p = 0.47). At one-year post-FP, most patients (62%) are predominantly orally fed.

CONCLUSION

With continued experience and technical refinements, the Foker process has evolved with improved outcomes, less morbidity and maximal esophageal preservation.