Introduction
Uncontrolled sepsis following leak from major oesophago-gastric surgery is a devastating condition with increased morbidity and mortality and intensive care stay. We hypothesised that endoluminal vacuum therapy (EVT) could be used in the prophylactic setting to provide source-control, prevent mediastinitis and minimise sepsis related morbidity from leaks.
Aims & Methods
An ad-hoc EVT device was created using VAC granufoam (KCI) and a nasogastric-tube (16/18Fr), and placed intraluminally across the high risk anastomosis/area of repair. Continuous negative pressure (75–125mmHg) was applied. Assessment of the repair site/anastomosis was performed by radiology, endoscopy, clinical assessment or a combination following cessation of EVT and removal of the prophylactic EVT device.
Results
Twenty-seven patients had prophylactic EVT; M:F ratio was 3:1 and the median age was 68 years (range: 41-82 years). Twenty-six patients had cancer resections while 1 had benign surgery. The rationale for prophylactic EVT included preoperative factors (10), intra-operative factors (16) or both (1). The median duration of prophylactic EVT was 7 days (range: 4-14 days). The median length of stay was 19.7 days (range: 6-96 days), the two longest admissions were unrelated to the anastomosis (prolonged chyle leak, and long-term-sequelae of life-threatening bleed). One patient developed full-thickness microleak at endoscopic evaluation, remained clinically well with no systemic signs of sepsis, and was successfully managed with luminal EVT for a further 6 days in a ward-based environment. Though prophylactic EVT did not prevent the leak, it significantly minimised the systemic hit that traditionally results from leak and associated mediastinal sepsis.
Conclusion
Prophylactic EVT is a useful adjunct for management of patients with a high-risk for leak and can serve as a risk reducing strategy in select cases. There are no short-term complications, yet the additional morbidity, mortality, and length of stay associated with a fully-fledged leak is avoided. Our results lay the foundation for the use of prophylactic EVT in randomised controlled trials to further standardise selection criteria, assess longer term potential patient benefit and impact on survivorship.
References
1. Pournaras DJ, Hardwick RH, Safranek PM, Sujendran V, Bennett J, Macaulay GD, Hindmarsh A. Endoluminal vacuum therapy (E-Vac): a treatment option in oesophagogastric surgery. World journal of surgery. 2018 Aug;42:2507-11.
2. Afzal Z, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Bennett J, O'Neill R, Noorani A, Hindmarsh A. O-EGS08 Endoluminal Vacuum Therapy (EVT) for leaks in the upper gastrointestinal (UGI) tract; 10-years’ experience in a specialist Oesphagogastric centre. British Journal of Surgery. 2021 Dec 1;108(Supplement_9):znab429-022.
3. Müller PC, Morell B, Vetter D, Raptis DA, Kapp JR, Gubler C, Gutschow CA. Preemptive endoluminal vacuum therapy to reduce morbidity after minimally invasive Ivor Lewis esophagectomy: including a novel grading system for postoperative endoscopic assessment of GI-anastomoses. Annals of Surgery. 2021 Nov 1;274(5):751-7.
