Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience.

BACKGROUND: Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery. OBJECTIVE: The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed. SETTING: This study was performed at a tertiary clinic and certified center of reference for bariatric surgery. METHODS: In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay. RESULTS: A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015). CONCLUSIONS: EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.

Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study.

BACKGROUND: Endoscopic vacuum therapy (EVT) is an effective treatment option for leakage of the upper gastrointestinal (UGI) tract. The aim of this study was to evaluate the clinical impact of quality improvements in EVT management on patients' outcome. METHODS: All patients treated by EVT at our center during 2012-2021 were divided into two consecutive and equal-sized cohorts (period 1 vs. period 2). Over time several quality improvement strategies were implemented including the earlier diagnosis and EVT treatment and technical optimization of endoscopy. The primary endpoint was defined as the composite score MTL30 (mortality, transfer, length-of-stay > 30 days). Secondary endpoints included EVT efficacy, complications, in-hospital mortality, length-of-stay (LOS) and nutrition status at discharge. RESULTS: A total of 156 patients were analyzed. During the latter period the primary endpoint MTL30 decreased from 60.8 to 39.0% (P = .006). EVT efficacy increased from 80 to 91% (P = .049). Further, the need for additional procedures for leakage management decreased from 49.9 to 29.9% (P = .013) and reoperations became less frequent (38.0% vs.15.6%; P = .001). The duration of leakage therapy and LOS were shortened from 25 to 14 days (P = .003) and 38 days to 25 days (P = .006), respectively. Morbidity (as determined by the comprehensive complication index) decreased from 54.6 to 46.5 (P = .034). More patients could be discharged on oral nutrition (70.9% vs. 84.4%, P = .043). CONCLUSIONS: Our experience confirms the efficacy of EVT for the successful management of UGI leakage. Our quality improvement analysis demonstrates significant changes in EVT management resulting in accelerated recovery, fewer complications and improved functional outcome.

Endoscopic Management of Large Leakages After Upper Gastrointestinal Surgery.

Background: Endoscopic vacuum therapy (EVT) is an evidence-based option to treat anastomotic leakages of the upper gastrointestinal (GI) tract, but the technical challenges and clinical outcomes of patients with large defects remain poorly described. Methods: All patients with leakages of the upper GI tract that were treated with endoscopic negative pressure therapy at our institution from 2012-2021 were analyzed. Patients with large defects (>30 mm) as an indicator of complex treatment were compared to patients with smaller defects (control group). Results: Ninety-two patients with postoperative anastomotic or staplerline leakages were identified, of whom 20 (21.7%) had large defects. Compared to the control group, these patients required prolonged therapy (42 vs. 14 days, p < 0.001) and hospital stay (63 vs. 26 days, p < 0.001) and developed significantly more septic complications (40 vs. 17.6%, p = 0.027.) which often necessitated additional endoscopic and/or surgical/interventional treatments (45 vs. 17.4%, p = 0.007.) Nevertheless, a resolution of leakages was achieved in 80% of patients with large defects, which was similar compared to the control group (p = 0.42). Multiple leakages, especially on the opposite side, along with other local unfavorable conditions, such as foreign material mass, limited access to the defect or extensive necrosis occurred significantly more often in cases with large defects (p < 0.001). Conclusions: Overall, our study confirms that EVT for leakages even from large defects of the upper GI tract is feasible in most cases but comes with significant technical challenges.

Successful management of therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up: A case report.

BACKGROUND: Gastric pull-up after esophagectomy is still a demanding surgical procedure and associated with considerable morbidity such as anastomotic leaks, fistulas or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperations may be necessary. Here, we report managing therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up. CASE SUMMARY: A 70-year-old male with dysphagia and regurgitation after esophagectomy with gastric pull-up reconstruction was transferred to our tertiary hospital. Since endoscopic approaches including balloon dilatation and stenting failed, retrosternal colonic pull-up with Roux-en-Y reconstruction was performed with no subsequent adverse events. CONCLUSION: Secondary colonic pull-up is a demanding but successful surgical procedure in patients suffering from therapy-refractory complaints after esophagectomy with gastric pull-up reconstruction.

Managing esophagocutaneous fistula after secondary gastric pull-up: A case report.

BACKGROUND: Gastric pull-up (GPU) procedures may be complicated by leaks, fistulas, or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperation may be necessary. Here, we report a combined endoscopic and surgical approach to manage a failed secondary GPU procedure. CASE SUMMARY: A 70-year-old male with treatment-refractory cervical esophagocutaneous fistula with stenotic remnant esophagus after secondary GPU was transferred to our tertiary hospital. Local and systemic infection originating from the infected fistula was resolved by endoscopy. Hence, elective esophageal reconstruction with free-jejunal interposition was performed with no subsequent adverse events. CONCLUSION: A multidisciplinary approach involving interventional endoscopists and surgeons successfully managed severe complications arising from a cervical esophagocutaneous fistula after GPU. Endoscopic treatment may have lowered the perioperative risk to promote primary wound healing after free-jejunal graft interposition.

Endoscopic full thickness resection vs. transanal endoscopic microsurgery for local treatment of rectal neuroendocrine tumors - a retrospective analysis.

PURPOSE: Local treatment of small well-differentiated rectal neuroendocrine tumors (NETs) is recommended by current guidelines. However, although several endoscopic methods have been established, the highest R0 rate is achieved by transanal endoscopic microsurgery (TEM). Since a recently published study about endoscopic full thickness resection (eFTR) showed a R0 resection rate of 100%, the aim of this study was to evaluate both methods (eFTR vs. TEM). METHODS: We retrospectively analyzed all patients with rectal NET treated either by TEM (1999-2018) or eFTR (2016-2019) in two tertiary centers (University Hospital Wuerzburg and Ulm). We analyzed clinical, procedural, and histopathological outcomes in both groups. RESULTS: Twenty-eight patients with rectal NET received local treatment (TEM: 13; eFTR: 15). Most tumors were at stage T1a and grade G1 or G2 (in the TEM group two G3 NETs were staged T2 after neoadjuvant chemotherapy). In both groups, similar outcomes for en bloc resection rate, R0 resection rate, tumor size, or specimen size were found. No procedural adverse events were noted. Mean procedure time in the TEM group was 48.9 min and 19.2 min in the eFTR group. CONCLUSION: eFTR is a convincing method for local treatment of small rectal NETs combining high safety and efficacy with short interventional time.

Assessment of a case-based training system (d3web.Train) in rheumatology.

To improve the learning experiences for third year medical students, a case-based training program based on real patient records has been introduced as a supplement to lectures. It was built with the novel training environment d3web.Train. Optimization of the learning environment d3web.Train for both teachers and learners has been considered as equally important and offers several trade-offs. The training program has been evaluated during three subsequent rheumatology courses, the first one voluntary and the latter two mandatory. For each course, we tracked how often and intensive each student used the system. In addition, the students answered questionnaires about their expectations and experiences. In the first voluntary course, 39/92 students finished at least one case and solved 187 cases in total (average: 4.8 cases from 12 cases available). In the second and third mandatory courses, all students (60 resp. 56) finished at least the required 20 cases with an average usage of 22.5 resp. 29.3 out of 31 available cases. Most of the cases were processed twice by the students in preparation for the final examinations. A positive correlation between processed cases per student and the exam score could be shown (30, 73 and 95% in the first, second and third courses, respectively). The findings clearly exceeded the expectations of the students concerning its usefulness as a supplement to lectures and as good preparation for their job as physician, as well as the learning period to use the program. For working through one case, students needed about 9 min on average. The case-based training system d3web.Train offers a new tool for medical education in rheumatology. The main advantage of the system is the relatively low effort needed to create a case-based program starting from the available dismissal records.

Evaluation of a novel case-based training program (d3web.Train) in hematology.

The new media such as the internet and digital imaging offer new opportunities in medical education. In addition to conventional lectures, we developed a case-based simulation training program of 17 hematology cases using the novel training system d3web.Train. We evaluated the assessment of this internet course by medical students, as well as their results in the hematology exam. From a group of 150 students, 47 worked through at least one case and solved 435 cases in total; in average, these students solved 9.5 cases. Eighteen different students filled in a questionnaire about the training system and 68 questionnaires about individual cases. The main results were the students found the cases very helpful (1.5+/-0.6 on a scale from 1=very helpful to 5=not at all), the training system very good (1.4+/-0.5 on a scale from 1 to 6), and want to work with it further (1.2+/-0.4 on a scale from 1 to 5). During the final examination, those 16 students who answered that they had solved more than 5 from the 17 cases scored significantly better (two-sided t test, p<0.01) in the hematological part of the exam than those 34 students solving 0 to 5 cases. To our knowledge, this is the first student evaluation of a case-based training program in general hematology. The d3web.Train system offers a new and great tool for creating a training program in a reasonable amount of time, because it is able to process available patient records.