Endoscopic management of postsurgical leaks

Abstract

Postsurgical leaks are a major complication with significant mobidity and mortality. Conventional conservative and surgical approaches are highly morbid with limited success. Over the last decade several endoscopic techniques have proved effective with a favorable safety profile. Nevertheless, most data still come from retrospective series, and many studies included heterogenous patient groups pooling complex surgical leaks with minor endoscopic perforations. This review focuses on the endoscopic management of the more difficult postsurgical leaks. Stents and over-the-scope clips are currently the key endoscopic techniques for leak closure, but emerging techniques such as vacuum sponge therapy and endoscopic internal drainage have proved to be at least as effective. The current trend is to use these different techniques interchangeably or simultaneously rather than assuming a single standardized approach.

Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review

“…They are delivered via a dual-barrel syringe and combined at the site of the anastomotic defect through a specially designed long double-lumen catheter inserted through the biopsy channel of the endoscope [33]; upon contact of the two components, thrombin converts fibronectin into fibrin, forming a stable clot within 10-60 s in a manner similar to that of the coagulation cascade. This fibrin clot initially acts like an acellular clot, the aprotinin component increasing its resistance to degradation in a fibrinolytic environment, while, within the next two weeks of application, it is fully reabsorbed progressively by macrophages and fibroblasts [33,34]. It is advised that fibrin glue be applied after a thorough debridement of the area and coating with normal saline [33,35], while others consider the fibrin clot to be most effective when applied to dry areas [3].…”

“…For the same reason, both the biopsy channel and the distal part of the endoscope must be lubricated with silicon oil to prevent the permanent attachment of glue [33]. When cyanoacrylate comes in contact with the tissue, it initially generates a localized foreign body reaction, leading to an inflammatory response which promotes angiogenesis and, finally, tissue healing while the glue itself sloughs off spontaneously within the next five to ten days [33,34].…”

“…Endoscopic clips, originally used in the context of an emergency hemostasis or for mucosal marking, were first used in 1990 in an effort to close gastric and colonic perforations, mainly iatrogenic ones [38]. However, their small size opening makes them incapable of successfully treating large mucosal defects since they grasp only the mucosal layer margins and exhibit weak closing force and limited mucosal tissue apposition [34,39]. Today, the newly available endoclips, also called through-the-scope clips (TTS), are fully rotatable and have a wingspan of 11 mm; thus, a success rate of 60 to 80% is reported [3,40], mainly in cases of upper GI tract perforations and esophageal defects, while in cases of inflammation and fibrosis of tissue around the perforation, their placement is a struggle due to their limited closure potential [28].…”

“…For OTSC positioning, when the endoscope, having loaded the cup with the clip, is against and in touch with the defect, the surrounding tissue can be sufficiently aspirated within the cap and, by turning the hand wheel, the clip is deployed. If the entire defect can't be suctioned within the cup, the tissue anchor or the twin grasper is also used [34,41].…”

“…Metal stents are made of either Elgiloy, an alloy of cobalt, nickel, and chromium, or of Nitinol, an alloy of nickel and titanium [3]. Those stents, used for sealing defects, are either fully or partially covered by a polyurethane, polyethylene, or silicone rubber membrane, either along their full length or leaving uncovered the distal and proximal ends [3,34,49]. It is well understood that the use of a totally non-covered stent, although having the advantage of not migrating, is not finally a wise decision, since it is unable to seal the leakage and, additionally, the tissue overgrowth through the stent metal grid results in it rapidly becoming impacted in the mucosa and thus totally impossible to remove.…”