Endoluminal Negative Pressure Wound Therapy (E-NPWT) for anastomotic leakage after rectal resection
Local management of anastomotic leakage after rectal cancer resection has traditionally consisted of rinsing and drainage. Transanal endoluminal application of NPWT (E-NPWT or endo-VAC or endo-sponge) is an interesting novel concept that has been explored in a few studies and case series over the last decade. We report herein our institutional experience over a three year period during which E-NPWT was the local treatment of choice for all cases with anastomotic leakage after rectal resection.
Patients and Methods
This study retrospectively evaluated the clinical charts of 147 consecutive patients who underwent anterior rectal resection from 2011-2013. A postoperative anastomotic leak occurred in eight (5%) patients from two straight anastomoses, one side-to-end construction, and five colonic pouches. All patients had undergone curative anterior resection with diverting ostomy. Transanal debridement and application of a trimmed foam were performed by rigid or fexibel endoscopy and started without delay after confirmation of diagnosis in seven patients 8-15 days postoperatively. In one patient E-NPWT began after failed fibrin-glue treatment 6 weeks later. The foams were connected to a standard vacuum pump with the pressure set at -70mmHg in a continuous mode. E-NPWT was maintained for a median period of 10 (5-25) days. The treatment intervals were typically 2-3 days.
Complete healing was achieved in three cases during E-NPWT. In the remaining five patients, the defect reduced in size to allow further spontaneous healing. This occurred twice. One persistent sinus was successfully sealed with fibrin glue. One persisting recto-vaginal fistula required surgical closure. One large defect secondary to ischemic pouch necrosis required secondary pouch explantation and permanent colostomy. The overall ileostomy reversal rate was 75%.
E-NPWT is feasible and without severe side effects. Early initiation prevents septic progression and results in a high closure rate in patients with pelvic leakage. Although complete healing is not achieved in recto-vaginal fistulas or ischemic necrosis of the neorectum, E-NPWT may play a potential role in bridging and damage control.
Einenkel J, Holler B, Hoffmeister A. Sonographic diagnosis and Endo-SPONGE assisted vacuum therapy of anastomotic leakage following posterior pelvic exenteration for ovarian cancer without using a protective stoma. J Gynecol Oncol. 2011 Jun 30;22(2):131-4. doi: 10.3802/jgo.2011.22.2.131. PubMed PMID: 21860740; PubMed Central PMCID: PMC3152754.
Van Koperen PJ, Van Berge Henegouwen MI, Slors JF, Bemelman WA. Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases. Colorectal Dis. 2008 Nov;10(9):943-4. doi:10.1111/j.1463-1318.2008.01485.x. Epub 2008 Feb 11. PubMed PMID: 18266880.
Weidenhagen R, Gruetzner K, Weilbach C, Spelsberg F, Schildberg F. Endoscopic vacuum assisted closure of anastomotic leakage after anterior resection of the rectum - a new method. Surg Endosc 2003; 17: S92
Nagell CF, Holte K. Treatment of anastomotic leakage after rectal resection with transrectal vacuum-assisted drainage (VAC). A method for rapid control of pelvic sepsis and healing. Int J Colorectal Dis. 2006 Oct;21(7):657-60. Epub 2006 Jan 31. PubMed PMID: 16447032.
Glitsch A, von Bernstorff W, Seltrecht U, Partecke I, Paul H, Heidecke CD. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses. Endoscopy. 2008 Mar;40(3):192-9. doi: 10.1055/s-2007-995384. Epub 2008 Jan 14. PubMed PMID:18189215.
Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc. 2008 Aug;22(8):1818-25. Epub 2007 Dec 20. PubMed PMID: 18095024.
Mees ST, Palmes D, Mennigen R, Senninger N, Haier J, Bruewer M. Endo-vacuum assisted closure treatment for rectal anastomotic insufficiency. Dis Colon Rectum. 2008 Apr;51(4):404-10. doi: 10.1007/s10350-007-9141-z. Epub 2008 Jan 15. PubMed PMID: 18197452.
Riss S, Stift A, Meier M, Haiden E, Grünberger T, Bergmann M. Endo-sponge assisted treatment of anastomotic leakage following colorectal surgery. Colorectal Dis. 2010 Jul;12(7 Online):e104-8. doi: 10.1111/j.1463-1318.2009.01885.x. Epub 2009 Apr 13. PubMed PMID: 19508536.
von Bernstorff W, Glitsch A, Schreiber A, Partecke LI, Heidecke CD. ETVARD (endoscopic transanal vacuum-assisted rectal drainage) leads to complete but delayed closure of extraperitoneal rectal anastomotic leakage cavities following neoadjuvant radiochemotherapy. Int J Colorectal Dis. 2009 Jul;24(7):819-25. doi: 10.1007/s00384-009-0673-7. Epub 2009 Feb 25. PubMed PMID: 19241081.
Riss S, Stift A, Kienbacher C, Dauser B, Haunold I, Kriwanek S, Radlsboek W,Bergmann M. Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery. World J Gastroenterol. 2010 Sep 28;16(36):4570-4. PubMed PMID: 20857528; PubMed Central PMCID: PMC2945489.
van Koperen PJ, van Berge Henegouwen MI, Rosman C, Bakker CM, Heres P, Slors JF, Bemelman WA. The Dutch multicenter experience of the endo-sponge treatment for anastomotic leakage after colorectal surgery. Surg Endosc. 2009 Jun;23(6):1379-83. doi: 10.1007/s00464-008-0186-4. Epub 2008 Nov 27. PubMed PMID:19037698; PubMed Central PMCID: PMC2686802.
Birke-Sorensen H, Malmsjo M, Rome P, Hudson D, Krug E, Berg L, Bruhin A, Caravaggi C, Chariker M, Depoorter M, Dowsett C, Dunn R, Duteille F, Ferreira F, Francos Martínez JM, Grudzien G, Ichioka S, Ingemansson R, Jeffery S, Lee C, Vig S, Runkel N; International Expert Panel on Negative Pressure Wound Therapy [NPWT-EP], Martin R, Smith J. Evidence-based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer)--steps towards an international consensus. J Plast Reconstr Aesthet Surg. 2011 Sep;64 Suppl:S1-16. doi: 10.1016/j.bjps.2011.06.001. Epub 2011 Aug 24. Review. PubMed PMID: 21868296.
Krug, E., et al. "Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus." Injury 42 (2011): S1-S12.
Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N.Evidence Based Recommendations for the use of Negative Pressure Wound Therapy in Open Abdomen: Steps towards an International Consensus. Int Surgery. Accepted for publication
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