Endoscopic vacuum therapy for the treatment of colorectal leaks — a systematic review and meta-analysis

Abstract

Background During the last two decades, vacuum-assisted wound therapy has been successfully transferred to an endoscopic treatment approach of various upper and lower gastrointestinal leaks called endoscopic vacuum therapy (EVT). As mostly small case series are published in this field, the aim of our systematic review and meta-analysis was to evaluate the efficacy and safety of EVT in the treatment of colorectal leaks. Methods A systematic search of MEDLINE/PubMed and Cochrane databases was performed using search terms related to EVT and colorectal defects (anastomotic leakage, rectal stump insufficiency) according to the PRISMA guidelines. Randomized controlled trials (RCTs), observational studies, and case series published by December 2020 were eligible for inclusion. A meta-analysis was conducted on the success of EVT, stoma reversal rate after EVT as well as procedure-related complications. Statistical interferences were based on pooled estimates from random effects models using DerSimonian-Laird estimator. Results Only data from observational studies and case series were available. Twenty-four studies reporting on 690 patients with colorectal defects undergoing EVT were included. The mean rate of success was 81.4% (95% CI: 74.0%–87.1%). The proportion of diverted patients was 76.4% (95% CI: 64.9%–85.0%). The mean rate of ostomy reversal across the studies was 66.7% (95% CI: 58.0%–74.4%). Sixty-four patients were reported with EVT-associated complications, the weighted mean complication rate across the studies was 12.1% (95% CI: 9.7%–15.2%). Conclusions Current medical evidence on EVT in patients with colorectal leaks lacks high quality data from RCTs. Based on the data available, EVT can be seen as a feasible treatment option with manageable risks for selected patients with colorectal leaks.

Endoscopic Treatment Options for Gastrointestinal Leaks

“…A recent meta-analysis from our department comprises 24 studies with 690 patients treated with EVT for AL after colorectal surgery [4]. This represents the largest body of evidence for EVT so far.…”

“…Leakages of the gastrointestinal (GI) tract are associated with detrimental consequences for the respective patient [1][2][3][4][5]. Those damages may occur spontaneously, after local diagnostic and interventional measures, as well as after surgery [4][5][6].…”

“…Leakages of the gastrointestinal (GI) tract are associated with detrimental consequences for the respective patient [1][2][3][4][5]. Those damages may occur spontaneously, after local diagnostic and interventional measures, as well as after surgery [4][5][6]. Consequently, those leaks lead to bacterial migration from endoluminally toward the surrounding space, thereby causing local inflammation and infection, abscess cavities, or even systemic septic complications [2,3,[7][8][9][10].…”

“…Here, postsurgical complications, such as anastomotic leaks (AL) and Hartmann stump leaks, are regarded very carefully, as they increase the patient's outcome significantly [8,[11][12][13][14][15]. The incidence of AL ranges from 6 to 30% after colorectal surgery, and up to 18% after esophageal or gastric resection [1,4,8,11,14,16].…”

“…During the last two decades, an obvious paradigm shift in the treatment of GI leaks, especially AL, could be monitored. Whereas surgery for perforations and anastomotic leaks was considered the only treatment option available before that time, minimally invasive, and therefore, endoscopic therapies have gained growing significance in the therapeutic armamentarium [4][5][6]. Especially, redooperations for AL are associated with relevant morbidity and mortality in both the upper and lower GI tract and should hence be indicated carefully [8,11,17,18].…”