Clinical Case Summary

Background: Endoscopic vacuum therapy (EVT) using sponges is recognized as an efficient approach for managing anastomotic leaks in the distal colon. However, the majority of patients needs additional proximal diversion and in case of anastomotic leakages it may not be possible to place the sponge into the cavity. The VacStent® merges the advantages of EVT and a fully covered self-expanding metal stent, accelerating wound healing and maintaining the natural anatomical pathway for unobstructed stool passage. The effectiveness of the VacStent® has been proven in treating upper gastrointestinal anastomotic leaks and esophageal perforations. It is conceivable that these advantages could extend to the colorectum.
Case description: Here we present the case of a 60-year-old patient with an anastomotic leakage following an anterior rectosigmoid resection with side-to-end descendorectostomy due to perforated sigmoid diverticulitis. The "VacStent GI Colon®", an 80 mm fully-covered, self-expanding NiTi stent with its middle 60 mm covered by a cylindrical polyurethane sponge and an inner diameter of 25 mm, was placed over the anastomosis and the defect. The VacStent® then was connected to a vacuum pump, providing continuous negative pressure at -125 mmHg. The VacStent® had to be changed twice: the first time 5 days after initial insertion, and then again 7 days later. EVT could successfully be discontinued after a total of 20 days, with no signs of anastomotic leakage observed neither endoscopically nor on CT abdomen with rectal contrast.
Conclusion: EVT in the distal colon using the VacStent® appears to be a successful and promising alternative to endoluminal sponge therapy, demonstrating rapid wound healing without the need for stool diversion.

References

Endoscopy pictures from our department that will be seen on the poster:
1 anastomotic leakage before vacuum therapy
2 anastomosis after the first stent-removal
3 VacStent in correct position in situ
4 ct-scan with the VacStent in situ
5 anastomosis after finished vacuum therapy

Introduction

Anastomotic leakage is a serious complication following colorectal surgery and is associated with early and long-term morbidity and mortality. Various endoscopic and surgical approaches have been established for management. A new therapeutic option involves the placement of a fully covered VACStent for the lower GI tract (36x80 mm, MICRO-Tech, Düsseldorf, Germany) which offers advantages such as completely covering the defect, continuous drainage, and facilitating stool passage simultaneously. Here we report our initial experiences with the VACStent in the lower GI tract for treatment of anastomotic leakage.

Aims & Methods

The fully covered VACStent (36x80 mm) was placed endoscopically under direct visualization. A continuous negative pressure between -75 and -125 mmHg was applied. The VACStent was flushed daily with 20 ml of saline to prevent adhesions of the open-pored sponge of the stent. Six hours before the stent extraction/exchange, the negative pressure was discontinued. The integrity of the leak closure was confirmed visually and via fluoroscopy.

Results

Between February and December 2024, we treated six patients with anastomotic leakage (rectal leakage n=4, sigmoid leakage n=2) using the VACStent. The leak was detected on the 6^th ± 3 postoperative day. The leak was successfully sealed with the VACStent and one to fife exchanges were performed. However, anastomotic leakages larger than 10 mm (n=2) required pretreatment with an EndoSponge (B.Braun, Melsungen, Germany) for a duration of 5 to 10 days. The leak closure with the VACStent occurred after 20 ± 6 days, with inflammatory parameters decreasing by around 85 ± 12%. Four patients received a protective stoma. The distance of the leak from the anal canal averaged 8 ± 7 cm. Patients with leaks involving the anal canal required pain relief. One patient experienced point-shaped erosion bleeding in the anal canal, which was effectively treated with APC. In two patients, the VACStent therapy could be completed in an outpatient setting.

Conclusion

The lower GI VACStent represents a novel promising and effective endoscopic treatment option for colonic anastomotic defects.

Introduction

Anastomotic leakage is a serious complication following colorectal surgery and is associated with early and long-term morbidity and mortality. Various endoscopic and surgical approaches have been established for management. A new therapeutic option involves the placement of a fully covered VACStent for the lower GI tract (36x80 mm, MICRO-Tech, Düsseldorf, Germany), which offers advantages such as completely covering the defect, continous drainage, and facilitating stool passage simultaneously. Here we report our initial experiences with the VACStent in the lower GI tract for treatment of anastomotic leakage.

Aims & Methods

The fully covered VACStent (36x80 mm) was placed endoscopically under direct visualization. A continuous negative pressure between -75 and -125 mmHg was applied. The VACStent was flushed daily with 20 ml of saline to prevent adhesions of the open-pored sponge of the stent. Six hours before the stent extraction/exchange, the negative pressure was discontinued. The integrity of the leak closure was confirmed visually and via fluoroscopy.

Results

Between February and April 2024, we treated four patients with anastomotic leakage (rectal leakage n=2, sigmoid leakage n=2) using the VACStent. The leakage was detected on the 7^th ± 4 postoperative day. The leak was successfully sealed with the VACStent, and one to two exchanges were performed. The leak closure occurred after 17 ± 3 days. Inflammatory parameters such as CRP decreased by around 85 ± 13%. Three patients had a stoma before the VACStent was placed. The distance of the leak from the anal canal averaged 10 ± 9 cm. Patients with leaks involving the anal canal required additional pain reliever. One patient experienced point-shaped erosion bleeding in the anal canal, which was effectively treated with APC.

Conclusion

The lower GI VACStent represents a novel promising and effective endoscopic treatment option for colonic anastomotic defects.

Clinical Case Summary

A 66-year-old presented with a one-day history of abdominal pain and fevers. Computer tomography imaging (CT) revealed a foreign body in a sigmoid colon diverticulum with perforation and collection. A sigmoidoscopy failed to identify the foreign body. Ultrasound-guided foreign body extraction was unsuccessful. Surgical treatment was deemed high risk due to comorbidities and he was treated conservatively. Twelve days following a second sigmoidoscopy was performed due to persisting collection. A fish bone was found puncturing a sigmoid diverticulum. A through-the-scope (TTS) clip and methylene blue dye were applied. Removal was achieved with a snare. An over-the-scope clip (OTSC) successfully sealed the perforation.
Endoscopy is proving to be an increasingly viable minimally-invasive option for the treatment of foreign body colonic perforations when used early and in the absence of peritonitis or clinical instability¹. Unique to this case is that endoscopic closure was performed one week following perforation with associated collection, factors considered to influence procedure success due to inflammatory change^1,2. A standard TTS clip was unlikely to achieve closure strength. We used the OTSC system, designed to achieve full-thickness closure³. The technical complexity of using the OTSC system was visualisation which requires colonoscope withdrawal and mounting of a cap reducing endoscopic visibility. TTS clip and dye application prior to OTSC application proved beneficial in achieving definitive endoscopic perforation management. This is a technical aspect that to our knowledge has not been documented elsewhere in the literature.
Lessons:
1. Endoscopy can be effective in delayed colonic perforation management avoiding the need for surgery.
2. A three-step technique is proposed: 1) application of a locator (TTS clip and dye) 2) foreign body removal 3) OTSC application of the perforation site.
Fig1 CT image of fish bone and collection
Fig2 Endoscopic image OTSC

References

1) Morais R, Marques M, Macedo G. Endoscopic treatment of a foreign body–associated colonic perforation. Int. J. Colorectal Dis. 2020; 35: 165-167.
2) Rogalski P, Daniluk J, Baniukiewicz A et al. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol. 2015; 21: 10542-10552.
3) Kobara H, Mori H, Nishiyama N et al. Over‐the‐scope clip system: A review of 1517 cases over 9 years. JGH. 2019; 34:22-30.

Introduction

Chronic appendicitis is a condition with chronic abdominal pain or mild attacks of appendicitis, seriously affecting the patient's quality of life. Endoscopic retrograde appendicitis therapy (ERAT) has emerged as a promising, non-invasive treatment for acute uncomplicated appendicitis.

Aims & Methods

We aim to assess the safety and efficacy of ERAT for chronic fecalith appendicitis.
We retrospectively reviewed the medical records of consecutive patients who underwent ERAT for chronic fecalith appendicitis at Zhongshan Hospital, Fudan University, Shanghai, China between December 2017 and June 2023. Clinicopathological characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed.

Results

A total of 60 patients were included. ERAT intubation was successfully performed in all patients (100%). The median procedure time was 15 minutes (IQR, 12-25 minutes). The postoperative abdominal pain scores were significantly reduced (P<0.0001). Short-term adverse events included 5 cases of abdominal pain (8.3%) and 2 cases of fever (3.3%). Long-term adverse events included recurrent abdominal pain in 3 cases (5.0%) and recurrent appendicitis in 2 cases (3.3%). The median time to recurrence was 5 months (IQR, 2-12 months). Logistic regression analysis revealed appendiceal stenosis (OR=25.000, 95% CI, 1.114-561.281, P=0.043) and distorted appendix lumen (OR=12.500, 95% CI, 1.373-113.806, P=0.025) as significant risk factors for long-term adverse events.

Conclusion

ERAT may be a safe, effective and minimally invasive alternative approach for chronic fecalith appendicitis. Appendix lumen stenosis and distortion are risk factors of recurrence. Further large-scale prospective studies are necessary to assess the efficacy and safety of ERAT compared with antibiotic therapy and surgery.