Watson Andrew, Zuchelli Tobias
Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA.
VideoGIE. 2019 Jan 1;4(1):40-44. doi: 10.1016/j.vgie.2018.09.018. eCollection 2019 Jan.
GI perforations, leaks, and fistulas are types of full-thickness mural defects that frequently occur as adverse events from GI surgeries such as esophagectomy for malignancy and bariatric surgery. Historically, treatment has entailed a combination of reoperation, percutaneous drainage, and bowel rest. Recently, there has been a changing paradigm in the management of these defects. Endoscopic interventions, including endoclipping and placement of self-expanding metal stents (SEMSs), have been increasingly used with good success. Despite this, some defects remain refractory to these techniques. Endoscopic vacuum-assisted closure (EVAC) is a new, promising endoscopic approach to repairing these defects. EVAC works through applying continuous, controlled negative pressure at the defect with the use of an endoscopically placed polyurethane sponge connected to an electronic vacuum device. EVAC has been shown to be feasible, safe, and effective.
We present a video series of 3 cases demonstrating the successful application of EVAC for the treatment of anastomotic leakage after esophagectomy and of fistula formation after bariatric surgery.
Two patients experienced anastomotic leakage after esophagectomy for esophageal adenocarcinoma, and 1 patient experienced a chronic gastric fistula after Roux-en-Y gastric bypass. The gastric bypass patient's fistula failed to resolve with over-the-scope-clip placement, and all 3 patients' defects did not heal despite SEMS placement; therefore, EVAC was performed. The bariatric surgery patient required 9 sponge exchanges over 35 days, and the 2 esophagectomy patients each required 3 sponge exchanges over 13 days. All 3 patients had resolution of their defects with EVAC. No adverse events occurred, and all patients have had no recurrence for several months.
These cases help to highlight the feasibility, safety, and efficacy of EVAC for the closure of full-thickness GI defects. On the basis of our experience, the use of EVAC should be considered for these complex and refractory cases.
胃肠道穿孔、渗漏及瘘管是全层壁层缺损的类型，常作为恶性肿瘤食管切除术和减肥手术等胃肠道手术的不良事件出现。从历史上看，治疗方法包括再次手术、经皮引流和肠道休息的联合应用。近来，这些缺损的管理模式发生了变化。包括内镜夹闭和自膨式金属支架（SEMS）置入在内的内镜干预措施已越来越多地被使用且取得了良好的效果。尽管如此，一些缺损对这些技术仍难以治愈。内镜下真空辅助闭合术（EVAC）是一种新型、有前景的修复这些缺损的内镜方法。EVAC通过使用连接到电子真空装置的内镜下放置的聚氨酯海绵在缺损处施加持续、可控的负压来发挥作用。EVAC已被证明是可行、安全且有效的。
我们展示了一个视频系列，包含3例病例，展示了EVAC在治疗食管切除术后吻合口漏和减肥手术后瘘管形成方面的成功应用。
2例患者在食管腺癌食管切除术后发生吻合口漏，1例患者在Roux-en-Y胃旁路术后发生慢性胃瘘。胃旁路手术患者的瘘管经内镜套扎夹放置未能愈合，所有3例患者的缺损在置入SEMS后仍未愈合；因此，进行了EVAC治疗。减肥手术患者在35天内需要更换9次海绵，2例食管切除术患者在13天内各需要更换3次海绵。所有3例患者的缺损通过EVAC均得到了愈合。未发生不良事件，所有患者在数月内均无复发。
这些病例有助于突出EVAC闭合全层胃肠道缺损的可行性、安全性和有效性。基于我们的经验，对于这些复杂且难治的病例，应考虑使用EVAC。
