[E-VAC therapy as treatment of complications in gastrointestinal surgery in a gastroenterology reference center in Colombia: Case series]. / Terapia E-VAC como tratamiento de complicaciones en cirugía gastrointestinal en centro de referencia de gastroenterología en Colombia: Serie de casos.

Gastrointestinal postoperative anastomotic leaks and fistulas occur frequently and many are managed surgically; however, endoscopic interventions have shown to improve healing outcomes and length of hospital stay. The experience of vacuum-assisted closure therapy (E-VAC) is described, in complications such as fistulas and postoperative anastomotic leaks, in a gastrointestinal reference center in Colombia. A case series study was carried out in patients with anastomotic leaks and fistulas at different levels of the digestive tract, treated by E-VAC, by the Gastroenterology Service in Colombia, during a period from February 2019 to November 2021. Sociodemographic, clinical and surgical variables were described. 6 cases are described, 4 from lower digestive tract and 2 from upper digestive tract. 83% were men; the mean age was 51.8 years (+/-17.5). The indication for E-VAC was colorectal anastomotic fistula in 66%; the most frequent anatomical location was near the anal region (66%), less frequently at the level of the cardia (16%) and esophagus (16%). The size of the defect was described between 20 and 80% in patients undergoing E-VAC therapy, with an average hospitalization length of stay of 22.5 days, with an average number of exchanges of seven per patient. Anastomotic leaks and fistulas are potentially fatal complications in gastrointestinal surgery. E-VAC therapy has shown to be effective and safe, promoting defect closure and drainage of collections present, also decreasing the length of hospital stay.

Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert-A systematic review and meta-analysis.

BACKGROUND: The role of proximal diversion in patients undergoing sigmoid resection and primary anastomosis for diverticulitis with generalized peritonitis is unclear. The aim of this study was to compare the clinical outcomes of sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with a proximal diversion in perforated diverticulitis with diffuse peritonitis. METHOD: A systematic literature search on sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with proximal diversion for diverticulitis with diffuse peritonitis was conducted in the Medline and EMBASE databases. Randomized clinical trials and observational studies reporting the primary outcome of interest (30-day mortality) were included. Secondary outcomes were major morbidity, anastomotic leak, reoperation, stoma nonreversal rates, and length of hospital stay. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS: A total of 17 studies involving 544 patients (sigmoid resection and primary anastomosis: 287 versus sigmoid resection and primary anastomosis with proximal diversion: 257) were included. Thirty-day mortality (odds ratio 1.12, 95% confidence interval 0.53-2.40, P = .76), major morbidity (odds ratio 1.40, 95% confidence interval 0.80-2.44, P = .24), anastomotic leak (odds ratio 0.34, 95% confidence interval 0.099-1.20, P = .10), reoperation (odds ratio 0.49, 95% confidence interval 0.17-1.46, P = .20), and length of stay (sigmoid resection and primary anastomosis: 12.1 vs resection and primary anastomosis with diverting ileostomy: 15 days, P = .44) were similar between groups. The risk of definitive stoma was significantly lower after sigmoid resection and primary anastomosis (odds ratio 0.05, 95% confidence interval 0.006-0.35, P = .003). CONCLUSION: Sigmoid resection and primary anastomosis with or without proximal diversion have similar postoperative outcomes in selected patients with diverticulitis and diffuse peritonitis. However, further randomized controlled trials are needed to confirm these results.

Tube-in-tube endoscopic vacuum therapy for treatment of colorectal anastomotic leaks: A low-cost, patient-friendly, feasible and efficient technical modification of sponge-based endoscopic vacuum therapy.

BACKGROUND AND AIMS: Colorectal endoscopic vacuum therapy (CR EVT) is usually performed using sponges passed through the anus. It may be associated with patient discomfort and displacement of the aspiration tube. METHODS: With the tube-in-tube endoscopic vacuum therapy modification (CR TT-EVT), it is possible to position the aspiration tube in the pelvic cavity through the abdominal wall. In addition, it allows frequent cleaning of the fistula, eliminates the need for programmed device changes, and enables a standardized approach to such a wide variety of fistulas, leaks, and perforations. RESULTS: Here is a technical note on how to perform CR TT-EVT, while we are at the early phase of our case series we have reached 100% of technical success.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations.

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Homemade endoscopic vacuum therapy device for the management of transmural gastrointestinal defects.

OBJECTIVES: Endoscopic vacuum therapy (EVT) possesses a unique mechanism of action providing a less invasive alternative for the management of transmural gastrointestinal defects (TGID). This study evaluates the efficacy and safety of a novel homemade EVT (H-EVT) for the treatment of TGID. METHODS: Retrospective multicenter study including patients who underwent H-EVT for TGID between January 2019 and January 2022. Main outcomes included technical and clinical success as well as safety outcomes. Subgroup analyses were included by defect location and classification. Logistic regression analyses were performed to determine predictors for successful closure. RESULTS: A total of 144 patients were included. Technical success was achieved in all patients, with clinical success achieved in 88.89% after a mean of 3.49 H-EVT exchanges over an average of 23.51 days. After excluding 10 cases wherein it was not possible to achieve negative pressure, successful closure occurred in 95.52% of patients. Time to clinical success was less for defects caused by endoscopic (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.33-1.20) compared to surgical procedures and for patients with simultaneous intracavitary and intraluminal H-EVT placement (HR 0.70; 95% CI 0.55-0.91). Location and classification of defect did not impact clinical success rate. Simultaneous placement of both an intraluminal and intracavitary H-EVT (odds ratio 3.08; 95% CI 1.19-7.95) was a significant predictor of clinical success. Three device-related adverse events (2.08%) occurred. CONCLUSIONS: The use of the H-EVT is feasible, safe, and effective for the management of TGID.

Endoscopic Vacuum Therapy (EVT) for the Treatment of Post-Bariatric Surgery Leaks and Fistulas: a Systematic Review and Meta-analysis.

Bariatric surgery remains the most effective treatment for morbid obesity and its comorbidities. However, post-surgical leaks and fistulas can occur in about 1-5% of patients, with challenging treatment approaches. Endoscopic vacuum therapy (EVT) has emerged as a promising tool due to its satisfactory results and accessibility. In this first systematic review and meta-analysis on the subject, EVT revealed rates of 87.2% clinical success, 6% moderate adverse events, and 12.5% system dislodgements, requiring 6.47 EVT system exchanges every 4.39 days, with a dwell time of 25.67 days and a total length of hospitalization of 44.43 days. Although our results show that EVT is a safe and effective therapy for post-surgical leaks and fistulas, they should be interpreted with caution due to the paucity of available data.

Tratamiento endoscópico de una fístula aguda tras gastrectomía vertical laparoscópica / Endoscopic treatment of an acute fistula after laparoscopic sleeve gastrectomy / Tratamento endoscópico de uma fístula aguda após gastrectomia vertical laparoscópica

La fístula gástrica aguda es una de las principales complicaciones vinculadas a la gastrectomía vertical laparoscópica (GVL). Existen múltiples opciones terapéuticas para su resolución, siendo el tratamiento endoscópico mediante colocación de clips o stents uno de los más importantes. La aplicabilidad de cada método va a depender del tipo de fístula y del estado del paciente. Presentamos el caso de una mujer de 35 años, que desarrolla una fístula aguda posterior a una GVL. Se realiza tratamiento endoscópico con colocaciónn del sistema "over-the-scope clip" (Ovesco®) a nivel del orificio fistuloso, con posterior colocaciónn de stent metálico auto expandible.

Acute gastric fistula is one of the main complications associated with laparoscopic vertical gastrectomy (LVG). There are multiple therapeutic options for its resolution, being endoscopic treatment by placing clips or stents one of the most important. The applicability of each method will depend on the type of fistula and the patient's condition. We present the case of a 35-year-old woman who developed an acute fistula after LGV. Endoscopic treatment is performed with placement of the over-the-scope clip system (Ovesco®) at the level of the fistulous orifice, with subsequent placement of a self-expanding metal stent.

A fístula gástrica aguda é uma das principais complicações associadas à gastrectomia vertical laparoscópica (GVL). Existem múltiplas opções terapêuticas para a sua resolução, sendo o tratamento endoscópico com colocação de clipes ou stents uma das mais importantes. A aplicabilidade de cada método dependerá do tipo de fístula e do estado do paciente. Apresentamos o caso de uma mulher de 35 anos que apresentou uma fístula aguda após GVL. O tratamento endoscópico foi realizado com a colocação do sistema de clipe over-the-scope (Ovesco®) no nível do orifício fistuloso, com posterior colocação de stent metálico autoexpansível.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis.

BACKGROUND: Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS: A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS: A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION: HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations.

BACKGROUND : Although endoscopic vacuum therapy (EVT) has been successfully used to treat postoperative upper gastrointestinal (UGI) wall defects, its use demands special materials and several endoscopic treatment sessions. Herein, we propose a technical modification of EVT using a double tube (tube-in-tube drain) without polyurethane sponges for the drainage element. The tube-in-tube drainage device enables irrigation and application of suction. A flowchart for standardizing the management of postoperative UGI wall defects with this device is presented. METHODS : An EVT modification was made to achieve frequent fistula cleansing, with 3 % hydrogen peroxide rinsing, and the application of negative pressure. A tube-in-tube drain without polyurethane sponges can be inserted like a nasogastric tube or passed through a previously positioned surgical drain. This was a retrospective two-center observational study, with data collected from 30 consecutive patients. Technical success, clinical success, adverse events, time under therapy, interval time from procedure to fistula diagnosis and treatment start, size of transmural defect, volume of cavity, number of endoscopic treatment sessions, and mortality were reviewed. RESULTS : 30 patients with UGI wall defects were treated. The technical and clinical success rates were 100 % and 86.7 %, respectively. Three patients (10 %) had adverse events and three patients (10 %) died. The median time under therapy was of 19 days (range 1-70) and the median number of endoscopic sessions was 3 (range 1-9). CONCLUSIONS : This standardized approach and EVT modification using a tube-in-tube drain, with frequent fistula cleansing, were successful and safe in a wide variety of UGI wall defects.

Endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy: a systematic review and meta-analysis.

The curative treatment for esophageal and gastric cancer is primarily surgical resection. One of the main complications related to esophagogastric surgery is the anastomotic leak. This complication is associated with a prolonged length of stay, reduced quality of life, high treatment costs, and an increased mortality rate. The placement of endoluminal stents is the most frequent endoscopic therapy in these cases. However, since its introduction, endoscopic vacuum therapy has been shown to be a promising alternative in the management of this complication. This study primarily aims to evaluate the efficacy and safety of endoscopic vacuum therapy for the treatment of anastomotic leak in esophagectomy and total gastrectomy. A systematic review and meta-analysis was performed. Studies that evaluated the use of endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy were included. Twenty-three articles were included. A total of 559 patients were evaluated. Endoscopic vacuum therapy showed a fistulous orifice closure rate of 81.6% (rate: 0.816; 95% CI: 0.777-0.864) and, when compared to the stent, there is a 16% difference in favor of endoscopic vacuum therapy (risk difference [RD]: 0.16; 95% CI: 0.05-0.27). The risk for mortality in the endoscopic vacuum therapy was 10% lower than in endoluminal stent therapy (RD: -0.10; 95% CI: -0.18 to -0.02). Endoscopic vacuum therapy might have a higher rate of fistulous orifice closure and a lower rate of mortality, compared to intraluminal stenting.

Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options.

PURPOSE: To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients. METHODS: This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs. RESULTS: The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m2. In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00. CONCLUSION: The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.

Filtración de anastomosis colorrectal tratada con E-VAC con espuma de polivinilo podría reducir el tiempo de tratamiento / Colorectal anastomotic leak treated with E-VAC with polyvinyl sponge could reduce treatment time

RESUMEN Las filtraciones de anastomosis colorrectales tienen una incidencia de 5 a 15% y su manejo depende de las manifestaciones clínicas, la distancia desde el margen anal y su ubicación intra o extra peritoneal. En algunos casos seleccionados el manejo endoscópico ha demostrado ser un tratamiento efectivo. En el presente reporte de caso se utilizó el sistema de drenaje rectal transanal asistido por vacío descrito por Weidenhagen et al., para el tratamiento de una fuga anastomótica pero se utilizó una espuma de polivinilo en vez la espuma tradicionalmente usada de poliuretano con el fin de disminuir el número de cambios de la espuma y el tiempo de tratamiento.

ABSTRACT Colorectal anastomosis leaks have an incidence of 5 to 15% and their management depends on the clinical manifestations, the distance to the anal verge and the intra or extra peritoneal location. In some selected cases, endoscopic management has proven to be an effective treatment. In this case report, the vacuum-assisted transanal rectal drainage system described by Weidenhagen et al. was used for the treatment of an anastomotic leak. We used a polyvinyl sponge instead of the polyurethane sponge traditionally used with the intention to reduce sponge changes and treatment time.

Percutaneous Image-Guided Surgery in Complications After Bariatric Surgery.

Background: Although bariatric surgery is a standardized procedure, it is not without complications. Image-guided surgery allows minimally invasive resolution of complications, making it ideal for bariatric patients. The objective of this work was to analyze the image-guided surgery approach to postoperative complications of bariatric surgery. Materials and Methods: Retrospective comparative study in patients with complications after bariatric surgery. Patients were included consecutively according to selection criteria. All the patients were treated by the same surgical team. Results: n = 58 patients were recruited. The average age was 47.3 (range 16-62) years; the distribution by sex was male 52% and female 48%. Average body mass index was 42% (±1.26). The associated comorbidities were diabetes mellitus 41% (±0.49), dyslipidemia 41% (±0.49), and high blood pressure 39% (±0.48). Of the total, 39 (67.2%) underwent laparoscopic sleeve gastrectomy (LSG) and 19 (32.8%) under Roux-en-Y Gastric Bypass (RYGB) (P ≥ .05). Complications reported were leaks/fistulas (with/without abdominal collections) in 94.8% (±0.22), gallstones 3.5% (±0.18), and hemorrhage 1.7% (±0.13). There was no statistically significant difference between the type of bariatric surgery (LSG versus RYGB) and the complications found (P ≥ .005). There were no intestinal obstructions, strictures or acute gastric dilations, or deaths. The treatment of complications was approached percutaneously (56.9%), endoscopically (29.4%), reoperation laparoscopically (12%), and clinical control (1.7%). Conclusion: The image-guided surgery approach to postoperative complications of bariatric surgery is feasible and safe. Good results are obtained with a decrease in the surgical comorbidities associated with the procedure.

Early Management of Esophageal Leak in Esophageal Atresia: Changing Paradigms.

Introduction: A leak at the esophageal anastomosis can occur in 10%-20% of cases of esophageal atresia (EA). Thoracoscopic repair is trans-pleural, with the potential development of an empyema. Standard treatment of an anastomotic leak in a stable patient is often nonoperative, which can lead to prolonged parenteral nutrition and hospitalization. Our objective is to show that early thoracoscopic redo anastomosis management is safe and feasible. Materials and Methods: Retrospective study of a case series of four infants, diagnosed with EA and treated with early thoracoscopic esophageal leak repair between 2013 and 2018. Variables analyzed included age, weight, type of EA, day of leak, surgical approach, time to start feeding, surgical complications, and follow-up. Results: Three patients were type III, and one was type I originally repaired with a thoracoscopic approach. Leaking of the anastomosis was found the second postoperative day in one patient, third day in two patients, and the fifth day in the last one. All were confirmed with an esophagogram. All patients were operated in the first 24 hours after diagnosis by the thoracoscopic approach. The site of leak was found and re-sutured. Patients started feeding between the third and fourth day through a transanastomotic tube, starting oral feeding at the seventh day after an esophagogram did not show a leak. No complications were found. Mean time to complete oral feeding was 10 days. Two patients needed esophageal dilations. Mean time of follow-up has been 33 months. Conclusion: Early thoracoscopic repair of an anastomotic leak can be considered an alternative to the standard nonsurgical management. The early re-suture of the area of leak is a change in paradigm, but it offers the benefits of preservation of the native esophagus, early resumption of enteral feedings, and a shorter length of parental nutrition and hospitalization. Level of Evidence: IV.

Postoperative outcomes in patients undergoing colorectal surgery with anastomotic leak before and after hospital discharge.

Anastomotic leak (AL) is the most feared complication after colorectal surgery and time to diagnosis is variable. The aim of this study was to analyze the outcomes of patient who had an AL during or after hospital discharge. A retrospective analysis of a prospectively collected database of all patients undergoing laparoscopic colorectal resections without proximal diversion during the period 2008-2018 was conducted. The sample was divided into two groups: patients who had AL during hospitalization (G1) and those who had AL after hospital discharge (G2). Demographics, operative variables and postoperative outcomes were compared between groups. A total of 853 patients were included; AL was diagnosed in 60 (7%) patients and was more frequent during initial hospitalization than after hospital discharge (G1: 49 (82%) vs. G2: 11 (18%), p < 0.001). Demographics were similar between groups. Most patients were treated with laparoscopic lavage and diverting ileostomy in both groups (G1: 92% vs. G2: 82%, p = 0.30). Severity of peritonitis at reoperation and length of hospital stay after AL were similar between groups (G1: 11 vs. G2: 9 days, p = 0.54). Overall postoperative morbidity (G1: 57% vs. G2: 36%, p = 0.31), mortality (G1: 10% vs. G2: 27%, p = 0.15) and intestinal reconstruction rate (G1: 92% vs. G2: 100%, p = 1) were similar between groups. Outpatient onset of anastomotic leak did not increase the severity of peritonitis, had no impact on the type of treatment performed, and showed similar postoperative morbidity and mortality as compared to those having AL during hospitalization.

Anastomotic complications after esophagectomy: Influence of omentoplasty in propensity-weighted cohorts.

OBJECTIVE: A recent meta-analysis of 3 randomized controlled trials reported reduced incidence and severity of postesophagectomy anastomotic dehiscence with anastomotic omentoplasty. Unfortunately, these trials excluded neoadjuvant patients who received chemoradiation. We aimed to determine whether anastomotic omentoplasty was associated with differential postesophagectomy anastomotic complications after neoadjuvant chemoradiotherapy. METHODS: Data for patients who underwent minimally invasive esophagectomy following neoadjuvant chemoradiotherapy were abstracted (n = 245; 2001-2016; omentoplasty = 147 [60%]). Propensity for omentoplasty was estimated on 21 pretreatment variables, using augmented inverse probability of treatment weights, and used to determine the adjusted proportion of adverse anastomotic outcomes, major morbidity, and 30-day/in-hospital mortality. RESULTS: Overall, anastomotic leak rate was 15%; leak-associated mortality was 13% (n = 5 out of 37). Leak rates (omentoplasty n = 24 [16%] vs no omentoplasty n = 13 [13%]; P = .512) and incidence of any major complications (48% vs 48%; P = .958) were similar. Leaks requiring surgical intervention occurred in 12 patients (5% vs 5%; P = .904). Propensity weighting achieved excellent balance across all 21 pretreatment variables (before weighting, standardized differences ranged from -0.23 to 0.35; postweighting standardized differences ranged from -0.09 to 0.07). In propensity-weighted data, omentoplasty was not associated with differential adjusted risk of anastomotic leak (13.2% vs 14.3%; P = .83), major morbidity (27.9% vs 32.6%; P = .44), or mortality (6.7% vs 4.8%; P = .61). CONCLUSIONS: Within the limits of our sample size and statistical approach, our study failed to find evidence that anastomotic omentoplasty during esophagectomy after neoadjuvant chemoradiation reduced anastomotic leak rate or need for leak-related reoperation.