James S. Burdick

Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy

BACKGROUND Sleeve gastrectomy has become a popular weight loss procedure, but it is associated with staple line leak resulting in high morbidity and mortality. Current management options range from endoscopic techniques (predominantly stent placement) to surgical intervention. OBJECTIVE The purpose of this study was to recognize endoluminal vacuum (E-Vac) therapy as a viable option for use in anastomotic leaks of sleeve gastrectomies. SETTING This study took place at Baylor University Medical Center at Dallas, Texas. METHODS Retrospective and prospectively gathered registries for use of E-Vac therapy were queried to identify 35 patients. Using upper gastrointestinal series (UGI) and esophagogastroduodenoscopy, 9 of these patients were identified with a staple line leak from laparoscopic sleeve gastrectomy (LSG). E-Vac therapy was used to resolve the leak. RESULTS Nine patients were treated with E-Vac therapy. Eight of 9 patients were admitted from outside hospitals with a mean of 61 days (5-233) after LSG. During treatment, an average of 10.3 procedures per patient was done to place and exchange the Endo-SPONGE. All 9 patients had resolution of leaks confirmed by upper gastrointestinal series, after undergoing E-Vac therapy for an average of 50 days. Six of 9 patients had laparoscopic procedures before their admission. During admission, 5 of the 9 patients had self-expanding metal stents placed with failure of leak resolution. Discharge disposition included 2 patients sent to rehabilitation facilities, 1 death not attributable to E-Vac, and 6 patients went home. CONCLUSION E-Vac therapy is a viable option for patients with staple line leak after LSG.

Use of a novel technique to manage gastrointestinal leaks with endoluminal negative pressure: a single institution experience

BackgroundPerforations and anastomotic leaks of the gastrointestinal tract are severe complications, which carry high morbidity and mortality and management of these is a multi-disciplinary challenge. The use of endoluminal vacuum (EVAC) therapy has recently proven to be a useful technique to manage these complications. We report our institution’s experience with this novel technique in the chest, abdomen, and pelvis.MethodsThis is a retrospective review of an IRB approved registry of all EVAC therapy patients from July 2013 to December 2016. A total of 55 patients were examined and 49 patients were eligible for inclusion: 15 esophageal, 21 gastric, 3 small bowel, and 10 colorectal defects. The primary endpoint was closure rate of the GI tract defect with EVAC therapy.ResultsFifteen (100%) esophageal defects closed with EVAC therapy. Mean duration of therapy was 27 days consisting of an average of 6 endosponge changes every 4.8 days. Eighteen (86%) gastric defects closed with EVAC therapy. Mean duration of therapy was 38 days with a mean of 9 endosponge changes every 5.3 days. Three (100%) small bowel defects closed with EVAC therapy. Mean duration of therapy was 13.7 days with a mean of 2.7 endosponge changes every 4.4 days. Six (60%) colorectal defects closed with EVAC therapy. Mean duration of therapy was 23.2 days, consisting of a mean of 6 endosponge changes every 4.0 days. There were two deaths, which were not directly related to EVAC therapy and occurred outside the measured 30-day mortality.ConclusionOur experience demonstrates that EVAC therapy is feasible and effective for the management of gastrointestinal perforations/leaks throughout the GI tract and can be considered as a safe alternative to surgical intervention in select cases.

Endolumenal Vacuum Therapy and Fistulojejunostomy in the Management of Sleeve Gastrectomy Staple Line Leaks

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgery performed for morbid obesity. Leaks of the vertical staple line can occur in up to 7% of cases and are difficult to manage. Endolumenal vacuum (EVAC) therapy and fistulojejunostomy (FJ) have separate documented uses to heal these complicated leaks. We aim to show the benefit of using EVAC with FJ in the treatment of LSG staple line leaks. The patient presented with an LSG chronic leak. EVAC therapy was initiated but failed to close the fistula after 101 days. EVAC therapy was abandoned, and FJ was performed to resolve the leak. Postoperatively, no leak was encountered requiring any additional procedures. Based on our findings, we conclude that EVAC therapy facilitates in resolving leaks that restore gastrointestinal continuity and maintain source control. It promotes healing and causes reperfusion of ischemic tissue and fistula cavity debridement.

Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks

Background: To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. Methods: We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. Results: In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5–6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. Conclusion: Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

Comparison of Outcomes of Laparoscopic Heller Myotomy Versus Per-Oral Endoscopic Myotomy for Management of Achalasia

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called per-oral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patients postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia.