Endovacuum therapy. Two methods of successful endosponge placement for treatment of anastomotic leak in the upper gastrointestinal tract. This is a 74 year old man presenting for evaluation of anastomotic leak. Past medical history of distal esophageal adenocarcinoma treated with robot-assisted esophagectomy with gastric conduit. Post-operative course was complicated by anastomotic leak in right-sided pneumothorax requiring right thoracostomy tube placement. Esophogram with contrast reveals leak at surgical dehiscence. Endoscopy shows gastric conduit revealing anastomotic clips and dehiscence of the surgical staple line. The multidisciplinary team and patient's preference was for non-surgical management of the anastomotic leak. The patient consented to presenting his procedure. Shown are the instruments needed for both methods. The most important are the endosponge, a 16 or 18 french nasogastric tube, rat tooth forceps, and a suture. First we cut a hole in the sponge using scissors or a hemostat, cutting all the way through the sponge in order to create a passage for the nasogastric tube. Then we insert the nasogastric tube through the center of the sponge. All of the holes of the nasogastric tube should be within the sponge. Next we secure the nasogastric tube to the sponge by suturing one suture alternating from one side of the sponge to the other, descending from the most proximal end to the most distal end of the nasogastric tube as shown. We then decrease the volume of the sponge using scissors, cutting it into a cylindrical shape in order to fit the cavity we are trying to reduce. In the first method we create two to three loops of the suture at the tip of the dressing which will be used to guide the sponge down to the cavity. We then insert a guide wire through a needle into the nasogastric tube. Next we grasp the loops on the distal end of the sponge with a rat tooth forceps and insert the endoscope orally. As we advance the endoscope to the cavity the sponge is guided and pulled down behind our scope. Once in the cavity we ensure that the wire is in place so that it can act as a guide to prevent us from inadvertently pushing the endosponge into the esophagus. Next we release the loop, retract the endoscope to before the sponge, grasp the tube using the rat tooth forceps and then push the sponge further into the cavity. The wire in the center of the tube serves as a guide when grasping the tube with the rat tooth forceps. This process then continues as we repeatedly insert the endosponge further into the cavity, release the rat tooth forceps, pull the endoscope back, grasp a more proximal part of the orogastric tube and push farther in. When finished we can see the esophagus and the mediastinal esophageal cavity with the endosponge in place. We will now present the second method of placing the endosponge. The primary difference of this method is the use of an overtube. When using the overtube it is important to cut the tip to widen the tube's opening so that the endosponge can later be inserted through the overtube. After the overtube is placed on the endoscope, the endoscope is inserted orally and advanced to the mediastinal cavity. Once the endoscope reaches inside the cavity, we remove our endoscope leaving the overtube in place. Next we lubricate the endosponge and insert it into the overtube that now leads directly to the cavity. We guide it down the overtube until reaching the cavity. If the orogastric tube connected to the endosponge coils within the overtube, we can feed a rat tooth forceps down and grasp the endosponge in order to stiffen and uncoil the orogastric tube. If the tip of the overtube is still too tight and the endosponge gets stuck, we can use our scope to push the endosponge through the overtube. Once the endosponge is in place, we can then remove the endosponge. Next, we pull the overtube out. In both methods, we then perform a nasal exchange of the gastric tube by inserting a trumpet into the nares, grasping the trumpet in the pharynx with forceps, inserting the tube into the trumpet, and then pulling the trumpet out of the nares, bringing the nasogastric tube into the pharynx. Next, we pull the trumpet out of the nares, bringing the nasogastric tube with it. We then connect the nasogastric tube to the wound vac and seal the connection. The wound vac is turned on continuous therapy at 125 millimeters Hg. On follow-up exam, we can see the beginning of the structural changes within the cavity from the vacuum therapy with granulation tissue forming. The endosponge is replaced every three to four days. The last endosponge is removed and we can see here the successfully closed cavity. The patient was discharged after 10 endovacuum sessions. On follow-up, patient denied any symptoms of dysphagia and is eating without any difficulty. There is no evidence of recurrence of the lesion on two subsequent endoscopic exams. Patient did not require any further surgery. Endovacuum therapy can successfully treat anastomotic lesions of the gastrointestinal tract using the two different methods of endosponge placement shown. Endovacuum therapy can be used to treat endoscopic lesions of the gastrointestinal tract using the two different methods of endosponge placement shown.

endovacuum therapy

endosponge placement

anastomotic leaks

upper gastrointestinal tract

vacuum therapy