Introduction

Anastomotic leaks and fistulae following upper gastrointestinal (GI) surgery remain a serious clinical challenge, carrying high morbidity and mortality. Endoscopic vacuum therapy (EVT) has emerged as a promising minimally invasive treatment option for managing these complications. This study aimed to assess the efficacy and safety of EVT for postoperative anastomotic leaks in a high-volume tertiary referral center.

Aims & Methods

We conducted a retrospective analysis of all patients treated with EVT for anastomotic leakage following upper GI surgery between January 2022 and January 2025. The primary outcome was EVT success, defined as complete leak closure confirmed through both endoscopic and radiologic assessment. Secondary outcomes included procedure-related adverse events and all-cause mortality.

Results

Twenty-four patients were included (79.2% male; mean age: 64 ± 12 years). Of these, 16 patients underwent oesophagectomy and 8 total gastrectomy; only two surgeries were performed for benign conditions. EVT achieved leak closure in 20 patients (87%). One patient died due to hemorrhagic shock from a hepatic artery pseudoaneurysm, unrelated to EVT.
Among successful cases, the mean duration of EVT was 30 ± 19 days, with a median of four sponge exchanges (IQR = 5). Median hospital stay was 52 days (IQR = 41). EVT failure occurred in three patients, all of whom had cancer-related surgeries and defect sizes exceeding 30 mm. In these cases, adjunctive endoscopic treatment with self-expanding metallic stents led to successful leak closure.
A larger defect size was associated with a lower likelihood of closure (p = 0.067), suggesting a trend toward reduced efficacy in extensive leaks. Importantly, no EVT-related complications were observed throughout the study period.

Conclusion

EVT demonstrated a high success rate (87%) and an excellent safety profile for managing postoperative anastomotic leaks following upper GI surgery. Larger leak sizes showed a trend toward lower closure rates, highlighting the importance of early diagnosis and timely initiation of EVT when defects are smaller. Given its effectiveness and minimal risk, EVT should be considered a first-line endoscopic treatment for anastomotic leaks. Further studies are warranted to refine treatment protocols and establish standardized indications based on leak characteristics.

References

1. de Moura DTH, et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World JGastrointestEndosc. 2019 May 16;
2. Mastoridis S, et al. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. Minim Invasive TherAllied Technol. 2022 Mar;
3. Livingstone I, et al. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc. 2021 Nov;
4. Panneerselvam K,et al. Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects. Clin Endosc. 2023 Nov.

Introduction

Alternate day oral iron therapy is better than daily oral iron therapy in Iron deficiency anemia (IDA) as it increases the fractional absorption of iron. In Ulcerative colitis (UC) with IDA increased fractional absorption of iron with alternate day iron may not only be better in improvement of anemia but also results in reduced unabsorbed iron delivery to distal bowel and may hence reduce adverse effects.

Aims & Methods

In a randomized, open label trial, from February 2023 to December 2024 patients of UC in remission (Mayo ≤2 OR partial Mayo ≤1 with fecal calprotectin <150mcg/gm for last 3 months) with IDA (ferritin <30mcg/l, transferrin saturation <20%, Hb 8-12 gm/dl) were randomized to every other day 132mg (EOD group) or daily 66mg (OD group) elemental oral iron given as ferrous fumarate for 8 weeks. Primary outcome was the difference in mean change in Hemoglobin (Hb) at 8 weeks. Secondary outcomes were the difference in mean change in RBC indices, iron indices and adverse events at 8 weeks.

Results

54 patients were randomized between both groups. One patient in EOD and 2 in OD group withdrew before treatment initiation. Eleven patients had disease flare on oral iron therapy (5 in EOD and 6 in OD group) p= 0.62 and two patients in EOD group had intolerance requiring oral iron stoppage. Thirty-eight patients completed treatment. The mean change in Hb at 8 weeks in EOD and OD groups was 2.08±1.0gm/dl and 2.09±1.11gm/dl respectively in per protocol analysis (p=0.797). The mean change in serum ferritin, serum iron, transferrin saturation and total iron binding capacity in both the groups is not significant. Disease flare within 6 months prior to oral iron therapy correlated with increased incidence of flare on oral iron therapy. (P=0.04)

Conclusion

Alternate day oral iron is not better than daily oral iron in improving Hb levels, iron indices and with similar incidence of adverse events in patients of UC in remission. A recent flare has increased chances of disease flare with oral iron therapy

Introduction

It is a common practice to have nasogastric or nasojejunal tubes(NG or NJ) decompression after gastrectomy. It is believed that it can help to rest the bowel, prevent abdominal distension, decrease nausea and vomiting, and possibly protect the anastomosis. However, evidence from many "Enhanced Recovery After Surgery" programs shows NG and NJ tubes are associated with discomfort, decreased coughing effect and impaired mobilization. Patients without these tubes may have less throat discomfort and less pulmonary complications.

Aims & Methods

The aim of our study is to investigate the need of the use of NG and NJ tubes after gastrectomy for cancer in a randomized controlled trial setting. If the non-necessity can be proved, the practice can be applied to "Enhanced Recovery After Surgery" programs. The patients may have less discomfort and earlier discharge without compromise in complication and mortality.
This is an open labelled randomized controlled trial conducted in Department of Surgery, Tuen Mun Hospital, Hong Kong. It is approved by the ethics and research committee. Inclusion criteria include patients undergoing elective operations for gastric cancer, patents with age>18, and patients mentally fit. Exclusion criteria include gastric outlet obstruction, intestinal obstruction, unresectability, ASA>2. Randomization is made at pre-anaesthetic clinic by generation of random number. In Group A, NG or NJ tubes are inserted in operation room and removed at the end of operation. In Group B, NG or NJ tubes are inserted in operation room and kept at the end of operation. Primary end points include pulmonary and overall complications rate, degree of throat discomfort(0 to 4), length of hospital stay. Secondary endpoints include anastomotic leakage rate, reoperation and mortality. Sample size is calculated assuming a difference of 5% in pulmonary complication rate, alpha=0.5, beta=0.8, thus requiring 70 patients in each arm. Analysis is based on intention-to-treat basis. Chi-square or Fisher exact tests are used to compare categorical variables. Student t-test or Mann-Whitney test are used to compare continuous variables. P values are 2-sided and values less than 0.05 will be considered significant.

Results

From 2013 to 2021, 160 patients were recruited. 80 patients were randomized to group A and 80 to group B. The overall crossover rate was 13.1%. In group A, the mean age was 64.1. In group B, the mean age was 64. Concerning throat discomfort score on postoperative day 1, the mean score for group A and group B were 0.45 and 1.01 respectively(p<0.005). The mean score on day 3 were 0.31 and 0.40. The mean score on day 7 were 0.03 and 0.23(P>0.05).The pulmonary complication rate for group A and Group B was 17.5% and 21.3%(no significant difference). The non-pulmonary complication rate for group A and B was 20% and 21.3%(no significant difference). The mean time for patients to pass flatus for group A and B was 3.5 and 3.9(no significant difference). The mean length of stay for group A and B was 15.11 and 15.7(no significant difference). There was no hospital mortality.

Conclusion

This randomized controlled trial showed similar postoperative recovery for patients with and without NG or NJ tubes after gastrectomy for cancer. The was a trend for less throat discomfort, postoperative complications, time to pass flatus and shorter length of stay for the group without tubes. However, it only reached statistical significance in early postoperative throat discomfort score.
Performing gastrectomy for cancer without NG and NJ tubes is safe. It also causes less throat discomfort for the patients. It should be part of the "Enhanced Recovery After Surgery" program.

References

1. The future of fast-track surgery--British Journal of Surgery 2012;99: 1025-1026
2. Efficacy and necessity of nasojejunal tubes after gastrectomy--Intenrational Journal of Surgery 2011;9: 233-236
3. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial--Arch Surg 2004;139(12): 1309-13
4. Enhanced Recovery after Surgery for gastric cancer patients improves clinical outcomes at a US Cancer Centre--J Gastric Cancer 2018;18(3): 230-241
5. Omitting nasogastric tube placement after gastrectomy does not enhance postoperative recovery:a propensity score matched analysis--Langenbeck's Archives of Surgery 2022;407:113-122
6.The application of enhanced recovery after surgery in total gastrectomy: a propensity score-matched analysis--World Journal of Surgical Oncology 2023;21:148

Disclosure

Nothing to declare.