Treatment of dejunal duodenal anastomosis de recense with endoscopic vacuum therapy. Primary author, Marcos Eduardo Leira dos Santos. Co-authors, Igor Proença, Fernando Pontineto, Gabriel Souza, Antonio Madruga Neto, Facundo Galetti, Epifanio Monte Jr., Diogo de Moura, Igor Braga, Eduardo de Moura. These are our disclosures. Clinical case. We report a case of an 81 years old woman who presented considerable weight loss in the last six months associated with change in the consistency of stools. Computer tomography of the abdomen and pelvis showed thickening in the descending colon measuring 2.5 centimeters. There was also a synchronous lesion in the rectum which was located five centimeters from the inner border. Colonoscopy was performed followed by endoscopic submucosal dissection of the lesion in the rectum. In descending colon, a serrated lesion with an infiltrated aspect was addressed with an stenosing component. In rectum, we identified a vegetating lesion which was better evaluated using narrowband imaging, NBI optical chromoscopy technology. We opted for the endoscopic submucosal dissection to remove the lesion in the rectum to preserve the inner canal. The procedure was carried out without complications. This is the final aspect of the resection bed at the end of the procedure. Histological analysis identified venous adenoma with low-grade dysplasia in the rectum and colon biopsy showed invasive adenocarcinoma. After two weeks, partial left colectomy was performed with colorectal anastomosis. During the procedure, there was a duodenal inadvertent injury which was repaired with duodenoraphy. Two days after surgery, patient presented clinical worsening and bio-outlet through the abdominal drain. Exploratory laparotomy was performed. It was found the resense of duodenoraphy. Thus, enterotomy was performed with duodenodegeneral anastomosis. The patient remained in the critical condition with severe acute pancreatitis. Twelve days after surgery, there was clinical worsening and bio was found in depth of the drain. Thus, a new computer tomography of the abdomen and pelvis was performed and the CT showed a collection of the left flank and free liquid inside abdominal cavity, but no leak after oral contrast intake. The main diagnostic hypothesis was another dehiscence of the duodenodegeneral anastomosis, being opted for conservative treatment, but it was unsatisfactory after two weeks. The new tomography images on the 27th as operative day showed free fluid and pneumoperitoneum. The first endoscopy was performed 28 days after the first approach. We could confirm the dehiscence of the duodenodegeneral anastomosis with transmural defect and fluoroscopy showed contrast leakage due to transmural defect. We opted for vacuum endoscopic therapy. We used nesogastric tube with gauze at the distal tip and covered with artificially fenestrated sterile plastic. Then, we fixed it with nylon wire. The nesogastric tube tip was placed in an intracavitary position and connected to a negative pressure system. The second endoscopy was performed after seven days. Significant decrease in the size of the transmural defect was evidenced, also confirmed by fluoroscopy. We opted for interluminal EVT placement. The third endoscopy was performed two weeks after EVT. Endoscopy did not identify a transmural defect, only shallow ulcer. Fluoroscopy confirmed no contrast overflow. A new CT was performed 42 days after surgery. There were no free liquid in the cavity or pneumoperitoneum. 14 days after EVT, patient presented a better clinical condition, being discharged 22 days after the beginning of endoscopy therapy. Clinical Implications. EVT is a relatively recent and promising technique in the treatment of GI fistulas and dehiscence. It has been reported good results in case series and cohort studies. EVT should also be remembered after failure of other treatments. Conclusion. EVT takes relatively short time to close anastomosis dehiscence. In our case, EVT was the choice after failure of both surgical correction and conservative treatment.

treatment

dejunal duodenal anastomosis dehiscence

endoscopic vacuum therapy

EVT

gastrointestinal fistulas