Time to endoscopic vacuum therapy—lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center

Abstract

Objective of the study In esophageal surgery, anastomotic leak (AL) remains one of the most severe and critical adverse events after oncological esophagectomy. Endoscopic vacuum therapy (EVT) can be used to treat AL; however, in the current literature, treatment outcomes and reports on how to use this novel technique are scarce. The aim of this study was to evaluate the outcomes of patients with an AL after IL RAMIE and to determine whether using EVT as an treatment option is safe and feasible. Material and methods This study includes all patients who developed an Esophagectomy Complications Consensus Group (ECCG) type II AL after IL RAMIE at our center between April 2017 and December 2021. The analysis focuses on time to EVT, duration of EVT, and follow up treatments for these patients. Results A total of 157 patients underwent an IL RAMIE at our hospital. 21 patients of these (13.4%) developed an ECCG type II AL. One patient died of unrelated Covid-19 pneumonia and was excluded from the study cohort. The mean duration of EVT was 12 days (range 4–28 days), with a mean of two sponge changes (range 0–5 changes). AL was diagnosed at a mean of 8 days post-surgery (range 2–16 days). Closure of the AL with EVT was successful in 15 out of 20 patients (75%). Placement of a SEMS (Self-expandlable metallic stent) after EVT was performed in four patients due to persisting AL. Overall success rate of anastomotic sealing independently of the treatment modality was achieved in 19 out of 20 Patients (95%). No severe EVT-related adverse events occurred. Conclusion This study shows that EVT can be a safe and effective endoscopic treatment option for ECCG type II AL.

Endoscopic vacuum therapy significantly improves clinical outcomes of anastomotic leakages after 2-stage, 3-stage, and transhiatal esophagectomies

“…Furthermore, Mandarino et al demonstrated a 100% technical success rate of eVAC and a dehiscence closure rate of 75% after failed redo surgery or previous endoscopic treatment in twelve patients with post-esophagectomy anastomotic leakages, which highlights the role of eVAC as a potential salvage therapy [ 14 ]. In a recently published study by Chon et al, the safety and feasibility of eVAC in robotic-assisted minimally invasive esophagectomies (RAMIE) was assessed [ 15 ]. Twenty-one out of 157 patients developed an anastomotic leakage after Ivor-Lewis RAMIE in the postoperative course.…”

Impact of the Surgical Approach for Neoadjuvantly Treated Gastro-Esophageal Junction type II Tumors- a Multi-National, High-Volume Center Retrospective Cohort Analysis

“…17,18,31,32 Furthermore, the invention of endoscopic vacuum sponge therapy for anastomotic leakage has optimized complication management. 33 With the current aim of centralizing esophageal surgery in Europe, the number of resections performed in high-volume centers will increase and are expected to reduce perioperative mortality. 34 In The Netherlands, centralization led to fewer hospitals performing esophagectomies, while the mean number per hospital increased.…”

“…In this context, hybrid, fully minimally invasive, and robotic Ivor-Lewis TTE, with less perioperative trauma and pulmonary complications, may be relevant 17,18,31,32 . Furthermore, the invention of endoscopic vacuum sponge therapy for anastomotic leakage has optimized complication management 33 . With the current aim of centralizing esophageal surgery in Europe, the number of resections performed in high-volume centers will increase and are expected to reduce perioperative mortality 34 .…”

Reducing the Risks of Esophagectomies: A Retrospective Comparison of Hybrid versus Full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) Approaches

“…Anastomotic insufficiencies remain the most common postoperative complications [ 12 ], and while our results are no exception to this, the full-RAMIE group had relatively fewer incidences than the hybrid group. Although the benefit of a generalized, prophylactic EndoVAC therapy has not yet been established, its use has been standard procedure at our clinic as a way to proactively prevent and detect anastomotic insufficiencies [ 35 ]. This could also have had an impact on the overall severity and explain our significantly lower rate when compared to other studies.…”