Gastroenterology Report, 8(6), 2020, 481–483 doi: 10.1093/gastro/goaa036 Advance Access Publication Date: 20 July 2020 Brief Report BRIEF REPORT Use of endoscopic vacuum (E-Vac) therapy for the treatment of a cervical oesophagoileostomy leakage after a right-colon interposition for oesophageal replacement Sonia Fernández-Ananı́n1,*, Eulalia Ballester,1 Carlos Guarner Argente,1,2 Carmen Balague1 and Eduard M. Targarona1 1 Department of General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2 Gastroenterology and Hepatology Department, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona *Corresponding author. Department of General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, 87 Barcelona, Barcelona 08025, Spain. Tel: þ34630116640; Email: sfernandeza@santpau.cat Introduction treatment with chemotherapy and posterior laparoscopic gas- trectomy and D2 lymphadenectomy. Post-operative evolution Anastomotic leakage is considered the Achilles heel after oeso- was successful. An upper endoscopy examination 5 months later phagogastric resection and its therapeutic management remains revealed a neoplastic anastomotic recurrence. An extension a challenge. Different endoscopic options, such a clips, stents, in- study showed no metastatic lesions. A resection of the oesopha- ternal drainage, fibrin glue instillation, or suturing devices, have gojejunal anastomosis with a new oesophagojejunal anastomo- been suggested as minimally endoscopic therapies to treat these sis was performed without further complications. complications. Recently, the use of endoscopic vacuum (E-Vac) In September 2018, a follow-up PET-CT detected a new therapy has proven to be useful for the healing of these adverse anastomotic recurrence. The case was discussed by the events and some studies have even reported its superiority to Esophagogastric Tumours Committee, who decided to per- other endoscopic devices [1]. The E-Vac promotes the growth of form chemoradiotherapy prior to the following surgery. A to- granulation tissue and increases microcirculation while provid- tal oesophagectomy with right-colon interposition with a ing debridement of the cavity leak in each sponge replacement cervical end-to-end hand-sewn oesophago-ileal anastomosis by continuous negative pressure. We describe an exceptional was performed 4 months later. On the fifth post-operative clinical scenario in which the use of the E-Vac allows the success- day, a cervical fistula appeared (Figure 1A) and a thoracic CT ful closure of a cervical oesophagoileostomy leakage and the res- scan identified a 7-cm mediastinal abscess (Figure 1B). The olution of a mediastinal abscess after an ileum and right-colon clinical stability of the patient allowed conservative treat- interposition for oesophageal replacement. ment with intravenous antibiotics and nutritional support by a jejunostomy tube. Despite these measures, the anastomotic leak persisted for Case presentation the next 2 months with a daily output of >500 mL. As the leak- A 62-year-old man diagnosed in 2017 with a cT2N0M0 adenocar- age persisted with a large cavity and high-output, in April 2019, cinoma of the oesophagogastric junction underwent neoadjuvant E-Vac therapy with the Endo-SPONGE system (B. Braun Submitted: 7 December 2019; Revised: 29 January 2020; Accepted: 12 June 2020 C The Author(s) 2020. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University V This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 481 482 | S. Fernández-Ananı́n et al. Figure 1. A cervical anastomostic leakage cured with endoscopic vacuum device. (A) Cervical oesophagoileostomy fistula after total oesophagectomy with right-colon interposition. (B) Thoracic CT scan showing mediastinal collection with extra-luminal contrast leakage. (C) Endoscopic vacuum (E-Vac) device placement. (D) Post E- Vac therapy swallow test showing correct downstream flow through the cervical anastomosis, without leakage or other complications. Melsungen AG, Melsungen, Germany) was proposed. The treatment for these complications. However, open drainage of the sponge was placed in the cavity with a regular gastroscope un- wound, intravenous antibiotic therapy, and nil per oral is some- der general endotracheal anaesthesia (Figure 1C). It was con- times ineffective and substantially prolongs hospital stay. nected to a continuous negative pressure of 80–100 mmHg. The case reported shows an exceptional clinical situation. Initially, the endosponge was replaced every 3 days, then every While experience with E-Vac therapy in upper-gastrointestinal 10 days and every 15 days, until the complete sealing of the fis- disorders is increasing, the majority of the published studies tula. The total number of different E-Vac therapy exchanges re- focus on the use of this device for the treatment of iatrogenic or quired was seven. spontaneous oesophageal perforations. Nevertheless, the E-Vac On the 18th day after the E-Vac therapy was applied, an has also demonstrated efficacy in anastomotic leaks after upper endoscopy showed the apparition of granulation tissue surgery, especially in intrathoracic anastomosis leaks after and an 80% decrease in cavity size. Two weeks later, a barium Ivor-Lewis oesophagectomy [3–9]. swallow demonstrated correct downstream flow without ste- Evidence published on the management of cervical fistulas nosis or evidence of leaks (Figure 1D). Oral liquid diet was after oesophageal surgery is scarce. Recently, Min et al. [10] started with good toleration and no further complications reported the first seven cases of cervical anastomosis leaks occurred. successfully managed with E-Vac therapy. However, none of them occurred after a cervical oesophagoileostomy for oesopha- geal reconstruction using the terminal ilium and right colon. Discussion Limitations that have been attributed to this endoscopic Colon interposition as an oesophageal reconstruction after treatment are the need for hospitalization to perform the oesophageal resection is a complex surgical technique that is procedure, the repeated endoscopic examinations, and the cost associated with major complications. In high-volume centres, of the material required. On the other hand, the achievement the rate of cervical anastomotic leakage, reported as a conse- of several endoscopies during the process allowed us to assess quence of colon interposition, achieves 46%, with an operative the evolution of the defect, to irrigate, and to debride the cavity mortality that reaches 17% [2, 3]. until its complete closure. Traditionally, if conduit necrosis is ruled out and the patient is In our case, the use of E-Vac therapy shortened the hospital clinically stable, conservative medical management is the usual stay compared to conservative treatment, allowing the Endoscopic vacuum therapy | 483 successfully closure of the cervical fistula at Day 21 after the be- endoscopic vacuum-assisted closure, a retrospective analy- ginning of the E-Vac therapy, with optimal functional results. sis. Endoscopy 2013;45:433–8. The duration of treatment until the closure of the fistula in our 2. Hamai Y, Hihara J, Emi M et al. Esophageal reconstruction us- case was similar to that published in other series. ing the terminal ileum and right colon in esophageal cancer Although the nature of the series published to date is surgery. Surg Today 2012;42:342–50. retrospective and heterogeneous due to different types of anas- 3. Davis PA, Law S, Wong J. Colonic interposition after esopha- tomosis and localization, E-Vac therapy is positioning itself as a gectomy for cancer. Arch Surg 2003;138:303–8. good therapeutic option for the management of anastomotic 4. Mencio M, Ontiveros E, Burdick J et al. Use of a novel tech- leakages in upper-gastrointestinal surgery. Further randomized nique to manage gastrointestinal leaks with endoluminal studies are needed to include this device in the multidiscipli- negative pressure: a single institution experience. Surg Endosc nary algorithm and standardize treatment guidelines of these 2018;32:3349–56. major complications. 5. Goenka M, Goenka U. Endotherapy of leaks and fistula. World J Gastrointest Endosc AU 6. Still S, Mencio M, Ontiveros E et al. Primary and rescue endo- Authors’ contributions luminal vaccum therapy in the management of esophageal All authors have participated in the preparation and revision of perorations and leaks. Ann Thorac Cardiovasc Surg 2018;24: this paper. 173–9. 7. Laukoetter MG, Mennigen R, Neumann PA et al. Successful closure of defects in the upper gastrointestinal tract by endo- Funding scopic vacuum therapy (EVT): a prospective cohort study. None. Surg Endosc 2017;31:2687–96. 8. Smallwood NR, Fleshman JW, Leeds SG et al. The use of endo- luminal vacuum (E-Vac) therapy in the management of upper Conflicts of interest gastrointestinal leaks and perforations. Surg Endosc 2016;30: None declared. 2473–80. 9. Bludau M, Hölscher AH, Herbold T et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted clo- References sure system (E-VAC). Surg Endosc 2014;28:896–901. 1. Brangewitz M, Voigtlander T, Helfritz FA et al. Endoscopic clo- 10. Min YW, Kim T, Lee H et al. Endoscopic vacuum therapy for sure of esophageal intrathoracic leaks: stent versus postoperative esophageal leak. BMC Surg 2019;19:37.