Endoscopic Vacuum Therapy (EVT) in the Gastrointestinal Tract: a Paradigm Shift in the Surgical Treatment and Prevention of Anastomotic Insufficiencies and Perforations

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Background

The clinical development and introduction of negative wound pressure therapy (NPWT) has greatly changed the treatment of complex and extensive wounds on the body surface in the past decades. The beneficial effects of suction on wound healing with continuous elimination of inflammatory secretion, induction of angiogenesis, and wound granulation were understood, and then implemented clinically using various methods. In particular, open-pore sponges and controlled suction have shown very positive clinical effects.

The decisive innovative step was then to transfer this concept to endoscopically accessible regions of the GI tract inside the body. The primary idea was to place the sponge directly into the wound cavity to accelerate healing. However, it was observed that it is also possible to place the sponge endoluminally on the mucosa to achieve direct wound closure by the applied suction. This was a surprising observation, because there was a justified fear that the suction might cause a lesion in the intestinal wall, as application of the sponge directly to the serosa of intestinal loops during open abdominal treatment had resulted in fistulas and perforations. Meanwhile, it is clear that the application on the mucosa does not have this problem, but on the contrary leads to good support of wound healing. However, endoluminal sponge therapy is associated with occlusion of the respective intestinal segment, which leads to corresponding problems and limitations. The main clinical advantage of EVT is that it allows immediate treatment of anastomotic insufficiency or perforation as a source of sepsis, thus usually making open surgical intervention unnecessary. This has been reflected in a dramatic improvement in clinical outcomes with significantly lower morbidity and mortality.

To discuss EVT as a new standard in the treatment of anastomotic insufficiencies and perforations, it is necessary to consider the upper and lower gastrointestinal tract separately, as different requirements exist. In the upper GI tract, endocavitary application is fraught with the erosion of mediastinal structures, which themselves can cause lethal bleeding. The advantage is the effective cleaning and drainage, while the disadvantage is the sometimes problematic sponge application. Endoluminal sponge application with wound closure usually achieves very good healing, but with the disadvantage of obstruction of the intestinal passage.

In the lower GI tract, endocavitary application is successful especially in the lower rectum. However, the remaining residual wound cavity and also later anastomotic stenosis after healing being the overt problems. Endoluminal application is only conceivable with a simultaneously applied anus praeter and has been limitedly worked on so far. Alternative approaches try to improve anastomosis healing by an internal bypass fixed proximal with an endoluminal suction stent in the colon and lead out transanal. A new approach is to use the endoluminal EVT effect with the VACStent, as this procedure leaves the passage open.

However, especially acute lesions and perforations caused iatrogenic or by endoscopic procedures are excellently treatable with very favorable results, so that great expectations are also attached to the prophylactic intraoperative use. This EVT-based approach has the goal not to treat failed suture lines but to improve wound healing prophylactically by implementing the new concept of intraoperative preemptive EVT treatment. Indications for these EVT concepts are mainly the insufficiencies after oncological esophagectomy, bariatric surgery and sigmoid/rectal resections.

With regard to these different topics, the state of the discussion and actual literature regarding EVT approaches should be presented. In the upper GI tract, the topics are EVT in the treatment of anastomotic insufficiency after esophagectomy, in bariatric surgery after sleeve gastrectomy and gastric bypass, and in spontaneous (Boerhaave syndrome) or iatrogenic perforations. Intraoperative application for the prevention of anastomotic insufficiency represents a further topic.

In the lower GI tract, intracavitary EVT treatment after rectal resection has been most important to date, with AP creation usually associated with it. Intraluminal use has been obligatorily associated with AP and is poorly reported. Here, it is new approaches with the VACStent, which allows the use of the EVT principle even without the settlement of an anus praeter.


All types of articles concerning the research topic are welcome:
Clinical Trial, Hypothesis & Theory, Methods, Original Research, Policy and Practice Reviews, Review, Systematic Review, Study Protocol, Technology and Code, Mini Review, Perspective, Opinion.


Topic Editor Prof. Markus Heiss has a patent - VACStent. The other Topic Editors declare no competing interests with regard to the Research Topic subject.

Keywords: Endoscopic Vacuum Therapy, Anastomotic Leakage Upper GI-tract, Preemptive Vacuum Therapy, Esophageal Perforations, Colorectal Anastomotic Leakages

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