Discussion
sponge ruptures, loosened, anastomotic leakage, rupture
COLLAPSE, CAVITY, LEAKAGE
In this study, the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center is described. EVT appeared efficient and safe in this implementation phase, with a success rate of 74 % and an AE rate of 5 %.
Although these results correspond with previous studies, with success rates of 60 % to 100 % and AE rates of 0 % to 6 %, some studies found higher success rates
In this cohort, a relatively high number of sponge ruptures occurred. To prevent this, we have developed a technique to safely remove the sponge without rupture. Before sponge removal, a distal attachment cap is placed on the endoscope and, subsequently, the endoscope is maneuvered between the sponge and the mucosa to carefully separate the sponge from the (esophageal) wall. After all sides of the sponge have been loosened, the sponge is easily removed, without needing to firmly pull it, and rupture is prevented.
Comparison of the EVT success and failure groups might indicate factors that contribute to therapy failure, which could help determine the best indications for EVT. In this cohort, no significant differences were found between these groups; however, because of the small sample sizes in the subgroups, it is possible that factors that actually do contribute to therapy failure were not statistically significant. For example, more esophagojejunal anastomoses, shorter time to diagnosis, higher C-reactive protein (CRP) at diagnosis, and more “intermediate” and “large” defects are striking in the failure group and could possibly be predictors for therapy failure. Book et al.
This study describes the outcomes of consecutive patients treated during the implementation phase of EVT into the routine treatment of anastomotic leakage at a tertiary referral center. The protocol was optimized during this implementation phase and some important lessons were learned. For example, the use of a grasping forceps to introduce the sponge under endoscopic visualization replaced the overtube as the preferred placement technique. In addition, intracavitary EVT was found to be of great importance for adequate treatment when a cavity was present. The intraluminal technique should be applied only when a cavity is small enough to collapse with the vacuum.Close and efficient collaboration between the surgical and gastroenterological departments is also essential to optimize individualized management of patients with EVT. The implementation of EVT can be associated with logistic challenges. In 45 % (95 %CI 29 %–61 %) of the patients in our cohort, the first sponge placement occurred outside of the regular endoscopy program, requiring flexibility of both the endoscopy and anesthesiology teams. Moreover, the regular sponge exchanges with the patient under deep propofol sedation or general anesthesia are difficult to schedule. Therefore, having a dedicated team of trained interventional endoscopists and designated endoscopy slots is helpful in organizing optimal care for EVT patients.This study has several strengths. Because this study describes a consecutive cohort of patients in the implementation phase of EVT, it allows us to share important lessons on EVT treatment. Furthermore, all patients were treated by a group of experienced interventional endoscopists, in close collaboration with the surgical team. Lastly, to our knowledge, this study is the first to compare the characteristics of the EVT failure and success groups in patients with anastomotic leakage only.This study also has limitations. First, as there is no control group, no conclusions can be drawn regarding the comparison of EVT with other treatment options for anastomotic leakage. Second, owing to the mostly retrospective nature of the study, selection and information bias could have occurred.
Currently, our group is working on a white book with technical and logistic tips and tricks to facilitate EVT implementation in other centers, where implementation may be hampered by logistical challenges and difficulties in obtaining adequate training. Wider application of the technique, as well as prospective registration, will enable future studies in larger cohorts of patients. Moreover, this will enable the evaluation of new devices for EVT, such as open-pore film drainage, which provides the benefits of a longer small-lumen device and less sponge ingrowth
In conclusion, EVT is a paradigm shifting treatment for anastomotic leakage after upper GI surgery, with a success rate of 74 % in this study during implementation of the technique. Currently many aspects of EVT are experience-based, rather than evidence-based. Future studies will provide more evidence on the best indications and techniques for EVT, which, along with more experience, will likely improve outcomes in the future.