Ricerca della pubblicazione

Endoscopic negative-pressure therapy (ENPT) is becoming a valuable tool in surgical complication management of transmural intestinal defects and wounds in the upper and lower gastrointestinal tract. Innovative materials for drains have been developed, endoscopic techniques adapted, and new indications for ENPT have been found. Based on our broad clinical experience, numerous tips and tricks are described, which contribute to the safety of dealing with the new therapy. The aim of this work is to present these methods. The focus is on describing the treatment in the esophagus.

Background and study aims

Endoscopic negative pressure therapy (ENPT) is used to close transmural defects in the rectum and esophagus. Very few reports have described

ENPT to manage duodenal defects. This study was designed to demonstrate ENPT in a population of 11 patients with transmural duodenal leakages.

Patients and methods

The method of ENPT was adapted for duodenal use. Open-pore polyurethane-foam or a thin, open-pore double-layered film was wrapped around the distal end of a gastroduodenal tube. First, this open-pore element was placed on the inner wound in the duodenum with endoscopy. Second, continuous negative pressure of –125mmHg was applied with an electronic pump. Drains were changed after 2 to 7 days.

Results

Eleven patients were treated with duodenal leaks. Eight defects occurred after operative closure of perforated duodenal ulcers, papillectomy or stricturoplasty, one anastomotic leakage after Billroth – 1 distal gastric resection, one iatrogenic perforation in endoscopic retrograde cholangiopancreatography, and one by a surgical drain. Median duration of therapy was 11 days (range 7 – 24 days). Complete healing of defects was achieved in all patients.

Conclusion

ENPT is an innovative endoscopic alternative for treatment of transmural duodenal defects.

Aim:

NPWT has been advocated for virtually all kinds of acute and chronic wounds. Treatment is based on local negative pressure applied to the wound surface. NPWT is mainly carried out using open-cell polyurethane foams. It could be shown that cells show a significant tendency to grow into these foams which can be inhibited by application of drainage foil** without interfering with induction of cell migration. It is of interest to investigate if this combination is robust and workable with different vacuum pumps***.

Method:

Drainage foil** was placed on fibroblast 3D-cultures in combination with largepored PU foam*. Assemblies were positioned in Petri dishes and sealed with air-tight film after medium supply and vacuum pumps*** were connected. Experiments were carried out at -80mmHg and -120 mmHg for 48h. Cell viability and ingrowths of cells into samples was

determined.

Results / Discussion:

Combination of drainage foil** and PU foam* samples during NPWT with different vacuum pumps*** led to the same cellular responses in vitro. With the PU foam* alone, cells did not stop at the pellicle edge but continued to migrate into the

dressing. In contrast, placement of drainage foil** between collagen pellicle and PU foam* inhibited ingrowths of cells into the foam.

Conclusion:

It was shown that combination of drainage foil** with PU foam* for NPWT is workable with pumps from different manufacturers***. Ingrowths of cells into large-pored foams can be inhibited in vitro by application of drainage foil**. In vivo this may prevent disruption of newly formed tissue during dressing changes.

Introduction:

Anastomotic leak is the most severe postoperative complication after total gastrectomy. Endoscopic negative pressure therapy (ENPT) in the upper gastrointestinum has been developed to treat transmural defects. For ENPT openpore polyurethane-foam drainages (OPD) and open-pore film drainages (OFD) can be used to apply intracorporal negative pressure. ENPT was used to treat an anastomotic leak after total gastrectomy in a 71 year old patient who underwent palliative total gastrectomy.

Material and method:

Intracavitary variant of ENPT started 25 days after initial gastrectomy with placement of an OPD through the anastomotic defect into the extraluminale cavity. Negative pressure of -125 mmHg was applied with an electronic vacuum device. Simultaneously the cavity was drained, and defect closed. Drain was changed regularly after 3-4 days. After shrunken to a small channel the last period of treatment was done with a small-bore open-pore OFD. For construction a very thin double layered open-pore film (Suprasorb CNP, Drainage Film; Lohmann & Rauscher International GmbH & Co. KG, Rengsdorf, Germany) was used.

Results:

Total time to treat the anastomotic leakage with ENPT (OPD and OFD) was 14 days. The anastomotic leak was closed completely only with ENPT. After starting the ENPT a laparotomy was performed because of peritonitis and an intraabdominal negative pressure therapy was applied after lavage of the abdominal cavity for 3 days. We also used the double layered open-pore film (Suprasorb CNP, Drainage Film; Lohmann & Rauscher International GmbH & Co. KG, Rengsdorf, Germany).

Conclusion:

ENPT is an innovative endoscopic method in the treatment of anastomotic leaks of the upper gastrointestium. Open-pore polyurethane- foam and small-bore open-pore film drainages can be used for the new endoscopic closure method for gastrointestinal defects. Compared to OPD one advantage of the novel OFD is its small diameter.

Keywords:

Endoscopic vacuum therapy; Esophagus; Anastomotic insuffizcieny; Peritionitis

Introduction:

Endoscopic Negative Pressure Therapy (ENPT) presents a novel treatment option for leaks in the upper gastrointestinum. We report a first use of intraluminal ENPT for intraoperative anastomotic prophylaxis in a case of high cervical tubular esophageal resection.

Material and Method of Intraluminal ENPT:

For intraluminal ENPT open-pore drainage is constructed by suturing open-pore polyurethane foam at the tip of a drainage tube. Then the drainage is placed in the esophageal lumen by endoscopic means. Negative pressure is applied with an electronic vacuum device. Esophageal lumen is occluded and drained by suction simultaneously.

Case Report:

A 46 year old woman underwent tubular resection of the upper esophagus because of a retroesophageal schwannoma. Cervical end-to-end esophago-esophagostomy anastomosis was hand sewn just below the upper esophageal sphincter. Then open-pore polyurethane foam drainage was placed intraluminal covering the whole anastomotic region and vacuum was applied.

Results:

Prophylactic ENPT ended after three days. Perfusion was excellent, no edema, ulceration or local inflammation were seen. Because of temporary left sided vocal cord paralyses artificial ventilation went on for one week postoperative. Endoscopy confirmed normal healing without stenosis in long term follow up.

Conclusion:

This first report is a single observation of the use of ENPT for intraoperative anastomotic prophylaxis. We suppose, prophylactic intraluminal ENPT might reduce the incidence of anastomotic leaks. Further studies are needed.

INTRODUCTION

Operative and interventional treatment of Boerhaave's syndrome include closure of the esophageal defect and drainage of the septic focus. Initial reports on the use of endoscopic vacuum therapy (EVT) of Boerhaave's syndrome are now available. This article describes the experiences gained from the clinical application in two patients using this new surgical endoscopic procedure. The current literature regarding treatment of Boerhaave's syndrome is presented.

MATERIAL AND METHODS

Open-pore drainage is endoscopically placed either through the transmural defect in the extraluminal wound cavity (intracavitary EVT) or overlapping the defect into the esophageal lumen (intraluminal EVT). The application of a negative pressure results in active drainage directed to the lumen and simultaneously in defect closure. Through these therapeutic measures the perforation defect and the septic focus can be healed. Open-pore drains are manufactured from drainage tubes and open-pore foam or an open-pore film.

RESULTS

In both patients the distal esophageal perforation defects were completely healed using EVT. In 1 patient the treatment with EVT alone lasted 8 days. For the second patient EVT was combined with an open thoracotomy for decortication of pleural empyema. The treatment with EVT lasted 23 days and 1 cycle of EVT was carried out with an new open-pore film drainage (OFD). Surgical treatment to close the defect or an esophageal resection was not necessary for both patients. In the currently available studies and single case reports of ETV for Boerhaave's syndrome, 11 patients (84 %) of a total of 13 patients have been successfully treated.

CONCLUSION

First clinical experiences have demonstrated that with EVT draining of the septic focus and closure of the Boerhaave defect at the gastroesophageal junction can be achieved. The EVT is an organ-preserving endoscopic surgical treatment, which can be an alternative and complementary to traditional surgery.

BACKGROUND

The simultaneous use of abdominal and endoscopic vacuum therapy in a case of an abdominal abscess caused by gastric perforation is demonstrated and innovative operative endoscopic management is described.

CASE REPORT

A computed tomography scan performed on a 67-year-old female patient showed a large abscess of the upper abdominal cavity where laparoscopic fundoplication had been performed 6 months previously. Endoscopy showed a transmural perforation of the dorsal wall of the stomach. The gastric perforation was closed and drained using intracavitary endoscopic vacuum therapy. Open pore polyurethane foam drainage was inserted through the defect into the extraluminal cavity for 3 days. A second period of therapy followed using intraluminal therapy with total drainage of the stomach, simultaneous enteral nutrition via a jejunal tube and a vacuum pressure of - 125 mmHg was applied with an electronic vacuum device. The abdominal abscess was drained via laparotomy and intra-abdominal vacuum therapy was performed with an open pore double-layered film using a vacuum pressure of - 75 mmHg. The perforation defect was not treated by operative means. Abdominal vacuum therapy ended 3 days postoperatively and the abdominal wall was closed by suture. Endoscopic vacuum therapy of the gastric perforation was terminated after 7 days and primary wound healing could then be achieved.

CONCLUSION

Use of endoscopic and abdominal vacuum therapy as well as new open pore material is an innovative option for operative management.

BACKGROUND AND STUDY AIMS

Endoscopic Vacuum Therapy (EVT) has been reported as a novel treatment option for esophageal leakage. We present our results in the treatment of iatrogenic perforation with EVT in a case series of 10 patients.

PATIENTS AND METHODS

An open pore polyurethane drainage was placed either intracavitary through the perforation defect or intraluminal covering the defect zone. Application of vacuum suction with an electronic device (continuous negative pressure, -125 mmHg) resulted in defect closure and internal drainage.

RESULTS

Esophageal perforations were located from the cricopharyngeus (4/10) to the esophagogastric junction (2/10). EVT was feasible in all patients. Eight patients were treated with intraluminal EVT, one with intracavitary EVT, and one with both types of treatments. All perforations (100 %) were healed in within a median of (3 - 7) days. No stenosis occurred, no complications were observed, and no additional operative treatment was necessary.

CONCLUSIONS

Our study suggests that intraluminal EVT will play an important role in endoscopic management of esophageal perforation.

Background: Negative pressure wound therapy (NPWT) has advanced the management of the open abdomen and other wounds. However, using the correct wound filler is essential as the material needs to convey a heterogeneous pressure distribution and create the pressure gradients required to drain interstitial fluid and remove wound exudate. This study compared the differences in fluid distribution during NPWT using a large-pore PU-foam dressing (Suprasorb1 CNP foam), drainage film (Suprasorb1 CNP drainage film) and a specialized NPT dressing system (KCI ABTheraTM NPT system) in vitro.

Methods: A tissue model was prepared from gelatine, powdered milk, and tissue marking dye. Each filler/dressing was placed on a tissue model which was connected to a fluid reservoir, linked to a TRACTM Pad and sealed. The TRACTM Pad was connected to a vacuum pump set to 120 mmHg for 8 h. An infrared camera was used to record fluid transport in the dressings.

Results: All fillers/dressings exhibited a fast fluid distribution and transport during the first hour (gradients 0.97–1.31) and steady state was reached after approximately 160 min. The NPT dressing system demonstrated a distribution limited to 70%, while the PU-foam and the drainage film presented a uniform and complete dispersal of fluid.

Conclusion: The results demonstrate that using an appropriate filler/dressing can facilitate effective wound fluid transport and drainage of interstitial fluid by producing heterogeneous pressures at the wound bed.