Anatomy - Eso-SPONGE® – Endoluminal vacuum treatment in staple line failure and perforations of the upper GI tract

Gastrointestinal tract leakage develops after anastomotic surgical procedures as well as following endoscopic interventions, such as dilation or ablation of precancerous lesions and early cancer, involving endoscopic mucosal resection or submucosal dissection. The risk of postoperative leakage is on the rise because of the increased use of neoadjuvant treatment regimens in esophageal, gastric and rectal cancers.

In esophageal resection and extended transhiatal gastrectomy, reconstruction requires an esophageal anastomosis. The failure rate reported in the literature for esophageal anastomoses ranges from 0% to 30%, with mortality rates of up to 50%. The leading cause of mortality in both staple line failure and perforation is developing mediastinitis with severe clinical sepsis.

The prognosis of esophageal leakage in both staple line failure and perforation largely depends on early initiation of adequate treatment. If treatment is delayed for more than 24 hours after perforation onset, the mortality rate is more than 20%.

Except in selected cases allowing a strictly conservative approach with systemic antibiotics, gastric tube diversion, and parenteral nutrition, all other treatment strategies are aimed at closure of the defect and adequate drainage of the extraluminal septic focus.

Up until about the turn of the millennium, the treatment of staple line failure was confined to surgery (suture, refashioning of anastomosis, discontinuity resection as the last resort). The years since then have seen the emergence of conservative and interventional endoscopic treatment options. The most common procedures are stenting and, less frequently, stand-alone treatment with fibrin sealants or clips.

The most common endoscopic procedure in treating anastomotic leakage is the placement of self-expanding stents. Both fully covered metal stents and fully covered plastic stents are employed. The mean rate of success when stenting esophageal staple line failure is about 50%.

Benefits of stenting:

• Immediate sealing of leaks
• Correspondingly rapid resumption of oral diet
• Easy to perform

Drawbacks of stenting:

• Requires both an endoscopy and fluoroscopy suite, to which a patient with mediastinitis and possibly clinically unstable multi-organ failure and sepsis must be transported ( repeatedly)
• Problematic in larger leakage/dehiscence
• Poor positional stent stability in cervical leaks, at the gastroesophageal junction and postoperatively following esophagogastrostomy or esophagocoloplasty (luminal incongruence)
• Stent-related stenosis and perforation, stent migration/dislocation/embedment, endoleakage (inadequate sealing)
• Need for concurrent drainage of septic focus by external percutaneous drainage (usually CT-guided centesis)
• Assessment of the anastomosis or leakage (usually after 2–4 weeks) requires stent removal, as the stent cover does not allow visual inspection of the leakage site; re-stenting may become necessary