When it comes to postoperative complications, among a medical team's greatest concerns are that a wound will open along the patient's sutures (dehiscence) or that fistulas will form. Until recently, endoscopic vacuum therapy (EVT) was the most common technique for cleansing these defects when they occurred in the gastrointestinal wall. Developed in Germany by a group of endoscopists, EVT involves endoscopically positioning polyurethane sponges near the defects and applying suction via drainage tubes fixed to the sponges. Several endoscopic treatment sessions are needed to change the sponges.
About a year ago, this technique was modified by a group of specialists affiliated with the endoscopy department at the Beneficência Portuguesa (BP) Hospital of São Paulo, Brazil. "Starting with a suggestion made by Dr Marcelo Simas de Lima, endoscopic vacuum therapy went through a number of modifications, such as doing away with sponges. That was made possible by using a double tube for the drainage element (tube-in-tube drain). This allows the vacuum to be left in for a longer period of time, without needing to change the sponges, and this has been a huge advantage," Fauze Maluf‑Filho, MD, PhD, told Medscape Medical News. Maluf‑Filho coordinates one of the endoscopy department teams and worked with Marcelo Simas de Lima, MD, digestive surgeon at BP Hospital, on implementing the new technique.
"Looking over our files, I'd say that today we have about a hundred cases," said Maluf‑Filho. "We've had excellent results, especially in severe cases where it was necessary to operate again."
In conventional EVT, the specialist uses an endoscope to insert a drain into the gastrointestinal tract to remove anything that, because of dehiscence, has collected at the site or in the abdominal cavity.
"The drain is connected to a vacuum pump that delivers continuous high-pressure suction. This helps promote healing and fight infection. The fluid that comes out of the wound fills the sponge, which then needs to be changed from time to time," explained Maluf‑Filho. "It's actually a lot like a diagnostic endoscopy. You determine where the wound hasn't healed and, with the aid of a guidewire and radioscopy, you position the tube to apply continuous suction there, where things haven't healed correctly."
In April, the team's article "Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations" was published in Endoscopy. It describes a retrospective, two-center, observational study that collected data from 30 consecutive patients. "The results were very promising," said Maluf‑Filho. "The procedure was a success in 80% to 85% of cases, and the median time under therapy was not long at all: 19 days. And for conventional endoscopic vacuum therapy? Around 40% to 50% and 6 to 8 weeks, respectively. In addition, vacuum therapy procedures have been very effective in avoiding having to operate on patients again."
Anastomotic complication rates vary greatly. "Rates can easily be up to 15% in patients with severe acute illnesses. But among those who aren't in such a serious situation, we see problems around 1% to 2% of the time," said Maluf‑Filho. He added that a reasonable estimate would be that anastomotic dehiscence occurs as a complication in approximately 5% of surgeries. Even more significant is the volume of these interventions, as it includes those performed to treat cancer as well as bariatric surgeries, which are increasing in number. "The vacuum technique has been used in operations on patients with obesity, and the results have been very good," he stated.
At BP Hospital, where the procedure in question was studied and tested, interest in modified endoscopic vacuum therapy is growing every day. "What I can say is that our proposed modification has already become a new standard that many groups around the world are using. Surgeons are seeing how useful and effective it is. They're our biggest proponents," said Maluf‑Filho. "When they realize that an anastomosis isn't healing well, they call us right up to perform the vacuum therapy on the patient."
This article was translated from the Medscape Portuguese edition.
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Cite this: Adaptation Refines Endoscopic Vacuum Therapy Post GI Surgery - Medscape - Jul 14, 2022.