First domestic apparatus for vacuum therapy

The first domestic device for vacuum therapy, Impulse KM-1, has been developed. The device is intended for the treatment of wounds, using a method of VAC therapy. Copyright protected by 2 patents. The device includes: an electronic unit with an internal power source, an external battery charge source, a reservoir for collecting of wound discharge, a disposable sterile dressing kit. The kit consists of a sponge, a film covering, a tube with a fixing head, a connector tube. The device is designed for a multiple use, provides continuous, variable and intermittent operation. Clinical trials of the device have been successfully carried out. As part of clinical trials, 17 patients who were treated at the hospital surgery clinic of the Vitebsk State Order of Peoples’ Friendship Medical University with surgical infections of the skin and soft tissues received vacuum therapy of wounds using the Impulse KM-1 apparatus. A significant reduction in the time of wound treatment was noted. The device has established itself as a reliable, easy to use device. The cost of the Impulse KM-1 apparatus is approximately 2500 $ and the cost of a disposable dressing kit is 40 $.

O-EGS08 Endoluminal Vacuum Therapy (EVT) for leaks in the upper gastrointestinal (UGI) tract; 10-years’ experience in a specialist Oesphagogastric centre

Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for UGI leaks. When compared to traditional treatments strategies EVT is reported to reduce morbidity and mortality, especially in patients with delayed presentation and established sepsis. We report the outcomes for patients with UGI leaks and perforations treated with EVT using an ad-hoc endoluminal vacuum device (EVD) in a tertiary UK hospital over a 10-year period. Methods Sixty-seven patients with UGI leaks from disparate causes were treated with EVT between April 2011 and July 2021. The ad-hoc EVD was constructed using a piece of open cell foam sutured around the distal end of a nasogastric tube, and placed endoscopically either through the perforation and into the extra-luminal leak cavity OR intraluminally depending on the morphology of the leak cavity. Continuous negative pressure (125mmHg) was applied. Endoscopic re-evaluation of the leak cavity with change of EVD was performed every 48-120 hours depending on the patients clinical condition. Information related to treatment and outcome was recorded prospectively. Results Patients had a median age of 66 years (range 23-92), and median Apache II score of 21 (range 4-36) at presentation. Fifty-two leaks were oesophageal (78%), 12 gastric (18%), 2 duodenal (3%), and 1 pharangeal (1%). The leak cause was anastomotic in 26 (39%), iatrogenic in 20 (30%), spontaneous in 19 (28%), and traumatic in 2 (3%). The median number of EVD changes required to heal the leak was 6 (range 1-27), and median length of hospital stay was 42 days (range 1-182). Successful resolution of the leak was achieved in 59 patients (88%). Eight (12%) patients died during treatment. There were no complications related to insertion of the EVD. Conclusions EVT is an effective treatment for UGI leaks which can be delivered safely in a tertiary oesophagogastric centre, and used to treat a wide range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to improve the ease with which EVT can be delivered. This will enable broader adoption of EVT for this group of patients.

P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair

Background Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management. Methods A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube. Results The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation. Conclusions Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract. Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.

P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy

Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer. Methods Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively. Results Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation. Conclusions In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

Background Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation. Case presentation We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis. Conclusion Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery

Introduction Gastric leaks constitute some of the most severe complications after obesity surgery. Resulting peritonitis can lead to inflammatory changes of the stomach wall and might necessitate drainage. The inflammatory changes make gastric leak treatment difficult. A common endoscopic approach of using stents causes the problem of inadequate leak sealing and the need for an external drainage. Based on promising results using endoscopic vacuum therapy (EVT) for esophageal leaks, we implemented this concept for gastric leak treatment after bariatric surgery (Ahrens et al., Endoscopy 42(9):693–698, 2010; Schniewind et al., Surg Endosc 27(10):3883–3890, 2013). Methods We retrospectively analyzed data of 31 gastric leaks after bariatric surgery. For leak therapy management, we used revisional laparoscopy with suturing and drainage. EVT was added for persistent leaks in sixteen cases and was used in four cases as standalone therapy. Results Twenty-one gastric leaks occurred in 521 sleeve gastrectomies (leakage rate 4.0%), 9 in 441 Roux-en-Y gastric bypasses (leakage rate 2.3%), and 1 in 12 mini-bypasses. Eleven of these gastric leaks were detected within 2 days after bariatric surgery and successfully treated by revision surgery. Sixteen gastric leaks, re-operated later than 2 days, remained after revision surgery, and EVT was added. Without revision surgery, we performed EVT as standalone therapy in 4 patients with late gastric leaks. The EVT healing rate was 90% (18 of 20). In 2 patients with a late gastric leak in sleeve gastrectomy, neither revisional surgery, EVT, nor stent therapy was successful. EVT patients showed no complications related to EVT during follow-up. Conclusion EVT is highly beneficial in cases of gastric leaks in obesity surgery where local peritonitis is present. Revisional surgery was unsuccessful later than 2 days after primary surgery (16 of 16 cases). EVT shows a similar healing rate to stent therapy (80–100%) but a shorter duration of treatment. The advantages of EVT are endoscopic access, internal drainage, rapid granulation, and direct therapy control. In compartmentalized gastric leaks, EVT was successful as a standalone therapy without external drainage.

Management of post-operative pancreatic fistulas following Longmire–Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy

Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.