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Tu1052 NEVER LOSE SUCTION: MODIFIED ENDOSCOPIC VACUUM THERAPY AS PRIMARY TREATMENT FOR ACUTE ESOPHAGOGASTRIC ANASTOMOSIS FISTULAS.

2018; Elsevier BV; Volume: 87; Issue: 6 Linguagem: Inglês

10.1016/j.gie.2018.04.2112

1097-6779

Flaubert M. Sena, Dilhana Badurdeen, Rodrigo Conrado de Lorena Medeiros, Gabriel Tavares Xavier Simplicio, Mouen A. Khashab, Anthony N. Kalloo, Luiz Gustavo de Quadros, Manoel Galvão Neto, Vivek Kumbhari, Josemberg Marins Campos,

Tracheal and airway disorders

Esophagogastric anastomosis fistulas are one of the most formidable surgical complications encountered after esophagectomy and esophagogastrectomy.The standard of care is endoscopic stent placement with approximately 80% success rate. Stent migration, stenosis and difficulty removing the stent have led to innovative new approaches to manage this dreaded complication. Endoclips, fibrin glue and histoacryl glue have been tried with limited success. Endoscopically placed vacuum sponge(EVAC) therapy entails placement of a sponge within the fistula cavity, connected to a drainage tube with a negative-pressure pump. In his retrospective analysis Menningen et al. compared EVAC therapy to stent placement and found a superior healing rate with EVAC(93.3% versus 63.3%; P=0.038). It is an ingenious system except that it requires multiple procedures under general anesthesia with orotracheal intubation for frequent sponge changes that are challenging to both introduce and remove. The healed fistulous tract is often disrupted during extraction of the sponge due to adhesions and patients require an alternative means of nutrition for the duration of therapy. To describe the success of a modified EVAC technique as primary therapy for healing of acute esophagogastric anastomosis fistulas. We describe a modified EVAC technique using 4x4 gauze wrapped in perforated plastic that is introduced with a 12 or 14 french nasogastric tube (Figure 1). The device can be placed under moderate sedation endoscopy without intubation, requires less frequent changes and is better tolerated by the patient. A total of 8 patients with esophagogastric fistulas were treated with the modified EVAC system as primary therapy between July 2013 and July 2015 (Table 1). The mean age of patients was 55.1 years. The average time between fistula detection and intervention was 5-8 days. All patients had drains in place. Alternative interventions such as stent placement, endoclips, fibrin or histoacryl glue had not been attempted prior to placement of the modified EVAC system which was done under moderate sedation endoscopy. The NG tube was connected to continuous suction via drainage tubes and changed every seventh day. Suction was interrupted to allow patients to consume a full liquid diet. No major or minor complications were encountered. All patients had successful healing of their esophagogastric fistulas in an average of 21.5 days, with 1.9 procedures per patient for device change. No complications were encountered. Modified EVAC therapy is a feasible, less complicated and easy alternative to conventional EVAC therapy or stent placement for primary treatment of acute esophagogastric anastomosis fistulas. It results in successful fistula healing in a short duration of time with no complications.Figure 1- Modified EVAC technique using 4x4 gauze wrapped in perforated plastic that is introduced with a 12 or 14 french nasogastric tube.View Large Image Figure ViewerDownload Hi-res image Download (PPT)