Endoluminal Negative Pressure Wound Therapy (E-NPWT) for anastomotic leakage after rectal resection
Abstract
Background
Local management of anastomotic leakage after rectal cancer resection has traditionally consisted of rinsing and drainage. Transanal endoluminal application of NPWT (E-NPWT or endo-VAC or endo-sponge) is an interesting novel concept that has been explored in a few studies and case series over the last decade. We report herein our institutional experience over a three year period during which E-NPWT was the local treatment of choice for all cases with anastomotic leakage after rectal resection.
Patients and Methods
This study retrospectively evaluated the clinical charts of 147 consecutive patients who underwent anterior rectal resection from 2011-2013. A postoperative anastomotic leak occurred in eight (5%) patients from two straight anastomoses, one side-to-end construction, and five colonic pouches. All patients had undergone curative anterior resection with diverting ostomy. Transanal debridement and application of a trimmed foam were performed by rigid or fexibel endoscopy and started without delay after confirmation of diagnosis in seven patients 8-15 days postoperatively. In one patient E-NPWT began after failed fibrin-glue treatment 6 weeks later. The foams were connected to a standard vacuum pump with the pressure set at -70mmHg in a continuous mode. E-NPWT was maintained for a median period of 10 (5-25) days. The treatment intervals were typically 2-3 days.
Results
Complete healing was achieved in three cases during E-NPWT. In the remaining five patients, the defect reduced in size to allow further spontaneous healing. This occurred twice. One persistent sinus was successfully sealed with fibrin glue. One persisting recto-vaginal fistula required surgical closure. One large defect secondary to ischemic pouch necrosis required secondary pouch explantation and permanent colostomy. The overall ileostomy reversal rate was 75%.
Conclusion
E-NPWT is feasible and without severe side effects. Early initiation prevents septic progression and results in a high closure rate in patients with pelvic leakage. Although complete healing is not achieved in recto-vaginal fistulas or ischemic necrosis of the neorectum, E-NPWT may play a potential role in bridging and damage control.
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Copyright (c) 2014 Norbert Severin Friedrich Runkel, Mechthilde Birk
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