ABSTRACT
Esophageal leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with esophageal leaks from a range of different causes that were treated with EVT in a tertiaryUKhospital over a 10-year period. Methods: Between April 2011 and March 2021, 45 patients with a median age of 67 years (31-92) who had an esophageal leak were treated with EVT. All patients were treated with an ad-hoc endoluminal vacuum device (EVD) constructed using V.A.C GRANUFOAMTM (KCI) and a standard nasogastric (Ryles) tube. The median Apache II score for patients at the time of leak diagnosis was 20 (6-36). The cause of the leak was anastomotic in 16 patients (36%), iatrogenic in 14 patients (31%), spontaneous in 14 patients (31%), and traumatic in 1 patient (2%). Information related to treatment and outcome was recorded prospectively. Results: Successful resolution of the leak was achieved in 39 (87%) patients. The median number of EVD changes required to heal the leak was 6 (1- 17). There were no complications related to insertion of the EVD. The median length of hospital stay was 49 days (1-108). Six (13%) patients died during treatment. Six (13%) patients had complications during treatment requiring further intervention;2 (4%) had a significant bleed requiring angiography and aortic stent placement, 1 (2%) had a stroke, 1 (2%) had a pulmonary embolism, 1 (2%) had a myocardial infarction, and 1 (2%) contracted COVID-19. Conclusion: EVT is a safe and effective treatment that can be used successfully to treat esophageal leaks froma disparate range of leak causes in selected critically unwell patients. Further studies are required to develop a standardized procedure and management pathway which will enable broader adoption of EVT in this group of patients.
ABSTRACT
Introduction: Upper gastrointestinal (UGI) leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Traditional treatment strategies such as surgery are associated with high mortality rates. Endoluminal vacuum therapy (EVT) is an emerging treatment option which may reduce morbidity and mortality compared to traditional treatments in this group of patients. We report the outcomes for patients with UGI leaks treated with EVT in a tertiary UK hospital over a 10-year period. Aims & Methods: Between April 2011 and April 2021, 66 patients with UGI leaks from different causes were treated with EVT using an ad-hoc endoluminal vacuum device (EVD). The EVD was constructed using a piece of open cell foam sutured around the distal end of a nasogastric tube, and placed endoscopically either through the perforation and into the extra-luminal leak cavity or intraluminally depending on the morphology of the leak cavity. Continuous negative pressure (125 mmHg) was applied. Endoscopic re-evaluation of the leak cavity with a change of the EVD was performed every 48-120h depending on the patients clinical condition. Patients were fed enterally, and treated with broad-spectrum antibiotics and anti-fungal medication until healing was complete. Information related to treatment and outcome was recorded prospectively. Results: Patients had a median age of 67 years (range 25-92), and mean Apache II score of 21 (range 6-36) at the time of leak diagnosis. Fifty-one (77%) leaks were oesophageal, 12 (18%) gastric, 2 (3%) duodenal, and 1 (2%) pharyngeal. The cause of the leak was anastomotic in 24 patients (36%), iatrogenic in 21 patients (32%), spontaneous in 20 patients (30%), and traumatic in 1 patient (2%). The median number of EVD changes required to heal the leak was 6 (range 1-27), and the median length of hospital stay was 44 days (range 1-196). Successful resolution of the leak occurred in 58 (88%) patients. Eight (12%) patients died during treatment. There were no complications related to insertion of the EVD. Nine (14%) patients had complications during treatment which required further intervention including bleeding in 4 patients (6%), a cerebrovascular accident in 1 patient (2%), a pulmonary embolism in 1 patient (2%), a myocardial infarction in 1 patient (2%), and COVID-19 infection in 2 patients (3%). Following resolution of the leak, one patient (2%) developed a stricture which required endoscopic dilation. Conclusion: EVT is a safe and effective treatment for UGI leaks, and can be used successfully to treat a disparate range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to improve the ease with which EVT can be delivered, and enable broader adoption of EVT for this group of patients.
ABSTRACT
Introduction: Management of upper gastrointestinal (UGI) leaks is challenging, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with UGI leaks treated with EVT in a tertiary UK hospital over a 10-year period. Methods: Between April 2011 and February 2021, 63 patients with UGI leaks from different causes were treated with EVT using an ad-hoc endoluminal vacuum device (EVD). Information related to treatment and outcome was recorded prospectively. Results: Patients had a median age of 67 years (25-92), and mean Apache II score of 20.7 (6-36) at the time of leak diagnosis. The cause of the leak was anastomotic (n=23;37%), iatrogenic (n=20;32%), spontaneous (n=19;30%), and traumatic (n=1;2%). Forty-seven (75%) leaks were oesophageal, 12 (19%) gastric, 2 (3%) duodenal, and 1 (2%) pharyngeal. The median number of EVD changes required to heal the leak was 9 (1-27), and median length of hospital stay was 31 days (1-196). Successful resolution of the leak occurred in 55 (87%) patients. Eight (13%) patients died during treatment. There were no complications related to insertion of the EVD. Eight (13%) patients had complications during treatment which required further intervention including bleeding (n=4;6%), stroke (n=1;2%), pulmonary embolus (n=1;2%), myocardial infarction (n=1;2%) and COVID-19 (n=1;2%). Conclusion: EVT is safe, and can be used to successfully treat UGI leaks from a disparate range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to enable broader adoption of EVT in this group of patients.