Successful treatment of cervical esophageal leakage by endoscopic-vacuum assisted closure therapy

Abstract

Aim: To evaluate the efficacy and safety of endoscopic-vacuum assisted closure (E-VAC) therapy in the treatment of cervical esophageal leakage.

Methods: Between May and November 2012, three male patients who developed post-operative cervical esophageal leakage were treated with E-VAC therapy. One patient had undergone surgical excision of a pharyngo-cervical liposarcoma with partial esophageal resection, and the other two patients had received surgical treatment for symptomatic Zenker's diverticulum. Following endoscopic verification of the leakage, a trimmed polyurethane sponge was fixed to the distal end of a nasogastric silicone tube and endoscopically positioned into the wound cavity, and with decreasing cavity size the sponge was positioned intraluminally to cover the leak. Continuous suction was applied, and the vacuum drainage system was changed twice a week.

Results: The initial E-VAC placement was technically successful for all three patients, and complete closure of the esophageal leak was achieved without any procedure-related complications. In all three patients, the insufficiencies were located either above or slightly below the upper esophageal sphincter. The median duration of the E-VAC drainage was 29 d (range: 19-49 d), with a median of seven sponge exchanges (range: 5-12 sponge exchanges). In addition, the E-VAC therapy reduced inflammatory markers to within normal range for all three patients. Two of the patients were immediately fitted with a percutaneous enteral gastric feeding tube with jejunal extension, and the third patient received parenteral feeding. All three patients showed normal swallow function and no evidence of stricture after completion of the E-VAC therapy.

Conclusion: E-VAC therapy for cervical esophageal leakage was well tolerated by patients. This safe and effective procedure may significantly reduce morbidity and mortality following cervical esophageal leakage.

Keywords: Anastomotic leakage; Cervical esophageal leakage; Endoscopic-vacuum assisted closure therapy; Negative pressure wound therapy; Vacuum therapy.

Figures

Figure 1

Radiographic findings of the second patient with Zenker’s diverticulum. A: Barium swallow showing the Zenker’s diverticulum (arrow) out-pouching from the posterior wall of the esophagus. Computed tomography scan showing the cervical esophageal leakage with periesophageal mediastinal abscess and extraluminal air (arrow); B: Contrasted esophagus (asterisk) with extravasation; C: Gastrografin swallow after endoscopic-vacuum assisted closure treatment showing a small residual saccular protrusion (arrow), but no leakage and no stenosis, clip in situ.

Figure 2

Endoscopic images of cervical esophageal leakage after surgical diverticulectomy and cricopharyngeal myotomy and subsequent treatment with endoscopic-vacuum assisted closure. A: The defect was large enough to be intubated with a standard endoscope (arrow); B: Sponge positioned in the extraluminal wound cavity and connected to a drainage tube; C: Clean wound ground and formation of fresh granulation tissue with good vascularisation at 3 d after the endoscopic-vacuum assisted closure (E-VAC) therapy; D: Appearance of esophageal defect (arrow) at 11 d after the E-VAC therapy; E: Complete healing of the leakage at 47 d after completion of the E-VAC treatment.