Tech Coloproctol (2010) 14:279–281 DOI 10.1007/s10151-010-0569-0
MULTIMEDIA ARTICLE
Endoluminal vacuum therapy for anastomotic leaks after rectal surgery A. Arezzo • A. Miegge • A. Garbarini M. Morino
•
Received: 2 December 2009 / Accepted: 17 February 2010 / Published online: 30 March 2010 ! Springer-Verlag 2010
Abstract Anastomotic leakage after rectal surgery is a very serious complication and is the main cause of postoperative morbidity and mortality. We describe three cases of rectal leakage which we treated with endoscopic vacuum-assisted closure. We used the Endo-SPONGE (B. Braun Aesculap AG, Germany), which consists of an open-cell, cylindrical polyurethane sponge connected to a drainage tube which is linked to a vacuum system to exert constant suction. The possible role of this new tool in the management of anastomotic leaks is also discussed.
AG, Germany). The device consists of an open-cell, cylindrical polyurethane sponge, cut to fit the estimated size of the abscess cavity to be treated (Fig. 1). The drain tube is connected to a Redyrob Trans Plus" bottle (B. Braun Aesculap AG, Germany) which exerts a constant suction at 120 psi. We present three exemplary cases in which we used endoluminal vacuum therapy with Endo-SPONGE.
Keywords Endosponge ! Surgical wound dehiscence ! Negative pressure wound therapy ! Vacuum-assisted closure
Case 1 (video 1)
Introduction Anastomotic leaks are a major complication after rectal surgery and the main cause of morbidity and mortality in the postoperative period. We recently gained some experience with the indications and contraindications for the use of the novel device Endo-SPONGE (B. Braun Aesculap Electronic supplementary material The online version of this article (doi:10.1007/s10151-010-0569-0) contains supplementary material, which is available to authorized users. A. Arezzo ! A. Miegge ! A. Garbarini ! M. Morino Digestive, Colorectal and Minimal Invasive Surgery, University of Turin, Turin, Italy A. Arezzo (&) Digestive, Colorectal and Minimal Invasive Surgery, University of Torino, Corso Dogliotti, 14, 10126 Torino, Italy e-mail:
[email protected];
[email protected]
Case reports
A 62-year-old woman with a history of obstructed defecation, but no other surgery, was transferred to our hospital on the 7th postoperative day after an internal Delorme procedure for the treatment of rectocele. The patient complained of local discomfort and fever up to 38.5#C. Endoscopy revealed an anterior anastomotic disruption and a draining fistula tract on each side. The right opening was wide enough to allow the introduction of the scope into an abscess cavity measuring 10 9 3 cm which was thoroughly washed. Contrast injection through the irrigation channel demonstrated a communication between the abscess and the vagina. A fistula was confirmed at colposcopy, as a pinpoint orifice in the posterior fornix. The Endo-SPONGE was inserted in the abscess cavity and replaced every 48 h without clinical improvement. After 6 days, a diverting loop colostomy on the descending colon was performed. The Endo-SPONGE was then replaced every 72–96 h as an inpatient, until complete obliteration of the cavity. At 21 days from the colostomy, the anastomotic site was completely covered by mucosa and the patient discharged. Two months later, the patient had a
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epithelialized and the patient was asymptomatic, the loop ileostomy was closed 30 months after the original operation. The patient is still asymptomatic 4 months after ileostomy closure. Case 3 (video 3)
Fig. 1 Endo-SPONGE, sponge
an open-cell,
cylindrical polyurethane
reversal of the loop colostomy and has been asymptomatic for 6 months. Case 2 (video 2) A 73-year-old man was referred 24 months after total mesorectal excision and diverting loop ileostomy for Stage III rectal adenocarcinoma following neoadjuvant chemoradiotherapy done elsewhere. A routine contrast enema performed in the immediate postoperative period showed a small radiologic leak which spontaneously closed after 2 weeks. Three months after surgery, CT scan, PET-CT and MRI were considered diagnostic for an asymptomatic presacral local recurrence. Because of the proximity to the small bowel, radiotherapy was contraindicated and the patient was started on chemotherapy. At that time, colonoscopy showed an anastomotic leak which never resolved. Colonoscopy done in our department showed a 3-mm anastomotic fistula. After balloon dilatation, a large presacral abscess cavity was entered, thoroughly washed, and an Endo-SPONGE was inserted. After 48 h, the sponge was changed and fresh granulation tissue was noticed. In the following 2 months, the sponge was changed two times a week as outpatient while granulation tissue progressively filled the cavity to a size of 12 9 10 mm. In the following 4 months, no further improvement was noticed and attempts to close the fistula orifice with fibrin glue injection, and with fibrin glue injection associated with OTSC nitinol clip (Ovesco Endoscopy AG, Tuebingen, Germany), were unsuccessful. Since the fistula orifice was
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A 69-year-old man presenting to our department with rectal bleeding due to Stage I rectal adenocarcinoma underwent total mesorectal excision and diverting loop ileostomy. He was asymptomatic when discharged but returned 4 weeks later with fever to 38#C and a normal abdominal examination. An abdominopelvic CT scan with iv contrast only showed a wide discontinuity of the rectal wall at the anastomotic site and an associated pelvic abscess. No free air or collection of fluid was visible in the abdomen. Endoscopy confirmed an almost circumferential leak and a large abscess cavity filled with necrotic material. After extensive debridement performed by a Roth Net retriever (US Endoscopy, Mentor, OH, USA) and lavage of the cavity, contrast injection through the irrigation channel confirmed a large posterior cavity with a 6-cm-long branch extending cranially but excluded any communication to the peritoneal cavity. An Endo-SPONGE was placed at the cranial extremity of the abscess cavity. After 48 h, the patient had persistent high temperature despite antibiotic therapy, and the Endo-SPONGE device was replaced as planned. After another 48 h without clinical improvement, a CT scan with iv contrast only showed the sponge in place and a large amount of free air, for which an emergency proctectomy, ileostomy closure and end colostomy were performed. Postoperative course was complicated by pneumonia. He was discharged 21 days after proctectomy and has been asymptomatic 6 months.
Discussion Vacuum therapy has been used for many years for septic wound treatment, with excellent results. It promotes healing of chronic wounds by enhancing the formation of granulation tissue, increasing vascularity and decreasing bacterial colonization [1, 2]. Transanal vacuum therapy has also been used to treat perirectal abscess following surgery for prolapsed hemorrhoids [3]. Recently, a device named Endo-SPONGE was introduced for the endoscopic treatment of anastomotic dehiscence after colorectal surgery. The device is approved in the European Community for this indication. Preliminary results are promising for the treatment of para-anastomotic abscesses following anastomotic leakage after total mesorectal excision [4–7]. The sponge should be changed every 48–72 h according to instructions for use. Despite this, it is our policy to change
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it three times a week for the first week and then twice a week. A careful selection of cases is necessary. In acute cases with non-irradiated tissue, as in Case 1, the EndoSPONGE treatment may take an average of 45 days and it is reported to be highly successful and well tolerated [5–7]. It is not always necessary to create a diverting stoma but we always perform a copious irrigation with saline and iodopovidone solution before entering the abscess cavity to decrease contamination and practice a thorough washout of the cavity prior to positioning the device. A diverting stoma may facilitate healing as in Case 1. After radiotherapy, an anastomotic dehiscence may present late and with chronic features. However, a case report described successful treatment of a chronic nonhealing wound after radiotherapy [8] but complete closure may not always be achieved as in our Case 2. Treatment with Endo-SPONGE under fecal diversion may be of help to keep the wound clean and maximize the chance of healing. In the presence of an acute severe dehiscence and a complex fistula tract as in Case 3, manipulation of the abscess and placement of the Endo-SPONGE delayed surgical treatment and may have been harmful. In cases like this, an accurate radiologic evaluation of the anatomy of the leak may be able to predict the adverse outcome. A selected number of patients with a rectal anastomotic leak may benefit from endoscopic treatment. Beside clip placement and stenting the Endo-SPONGE now offers the possibility of endo-luminal vacuum drainage. Careful evaluation of the anatomy of the leak, local conditions and systemic disease is necessary to select patients who may
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benefit from endoscopic vacuum therapy. More experience is needed to draw firm conclusions on the correct indications of this new device.
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