Perioperative management - VAC Stent

The VAC-Stent therapy is a suitable treatment method for small to medium-sized defects of the upper gastrointestinal tract, whether they occur spontaneously, postoperatively at an anastomosis, or iatrogenically as a result of an endoscopic or surgical procedure.

Since the VAC-Stent can only be placed intraluminally, it is important in the case of an extraluminal cavity to check whether the cavity collapses under intraluminal suction. A contaminated cavity only heals if it is optimally drained. For a large and/or contaminated cavity, an endoscopic vacuum therapy with an intracavitary sponge should initially be considered. Once the cavity has become smaller, a switch to a VAC-Stent can be made.

The technique can be used for:

• Anastomotic insufficiency after oncological gastroesophageal surgery
   
• Esophageal fistula
   
• Spontaneous esophageal perforation in the context of Boerhaave syndrome
   
• Iatrogenic/endoscopy-related perforations of the esophagus
  • as a result of balloon dilation of strictures or in achalasia
  • during/after EMR/ESD (endoscopic mucosal resection/submucosal dissection)
  • during transesophageal echocardiography
  • during the introduction of feeding tubes and similar procedures
     
• Trauma, including foreign body ingestion, gunshot wounds, etc.
   
• Second-line therapy after previous endoscopic treatment with SEMS, EVT, or an Over-the-Scope Clip (OTSC)
   
• Preventive applications to reduce the rate of anastomotic insufficiency, especially in potentially high-risk anastomoses after a history of chemotherapy or radiochemotherapy for esophageal carcinoma
   
• Suture insufficiencies along the staple line after bariatric surgery, such as sleeve gastrectomy or Roux-en-Y gastric bypass

Note 1: The VacStent was originally developed for leaks after esophageal resection but soon found application in patients with leakages after bariatric surgery.

Note 2: In sleeve gastrectomy, leakages typically occur along the suture line. Staple line leaks are most common in the proximal third of the staple line (in about 85% of cases) and less common in the middle or distal section.

Recommendation: It is recommended to use the VAC-Stent as early as possible, ideally at the time of diagnosis, to prevent the formation of larger wound cavities and chronic fistulas.

• Clinically unstable patients requiring emergency surgery for immediate treatment of the septic focus
   
• Patients with a full stomach and/or severe persistent vomiting with clinical signs of ileus
   
• Patients requiring full anticoagulation or thrombocytopenia < 20,000/µl
   
• Defect larger than the available sponge (>5 cm due to sponge length)
   
• Patients with leaks that are not endoscopically accessible with the VAC stent, e.g., in the case of a stenosis (Ø stent body 14 mm, Ø flange 30 mm)
   
• Too small distance of the leak to the proximal esophageal sphincter
   
• Contaminated extraluminal cavity

Note: In the case of a large and/or contaminated cavity (Ø > 2 cm), the VAC stent is not suitable as sole therapy, especially if there is no further access to the esophagus. Initially, intracavitary EVT should be applied.

• Significant ischemia of the gastric conduit
   
• Cavity/fistula with direct contact to large blood vessels or the airways

Flexible Endoscopy

• Exploration of the defect/anastomosis, determination of the distance from the anterior tooth row
   
• Estimation of defect size/depth in relation to the inserted endoscope
   
• Assessment of the blood supply of the anastomosis region/conduit or interposition
   
• Assessment of the local inflammatory situation

Contrast-enhanced computed tomography with water-soluble oral contrast agent (Gastrografin)

• initially and in the course of treatment to monitor sponge positioning and source control
   
• Detection of any undrained pleural and mediastinal air and fluid collections as well as accompanying pulmonary complications

• Since anastomotic leakages or other esophageal leaks are often associated with the thoracic cavities, pleural effusions should be drained via thoracic drains in these cases
   
• Upon signs of infection, initiation of antibiotic therapy. In most cases, routine antibiotic prophylaxis with piperacillin/tazobactam is administered for 5 – 7 days
   
• As long as the VAC stent is in situ, a feeding tube can be placed through the stent if indicated