Ryan M Juza, MD, Karima Fitzgerald, Niraj Gusani, MD, Ann M Rogers, MD, Eric M Pauli, MD. Penn State Hershey Medical Center
Introduction: Leak is an uncommon but serious complication of gastrointestinal surgery. When identified post-operatively, percutaneous drains are used to manage abscesses and prevent further peritoneal contamination. If drain position is suboptimal, however, the consequences of persistent leak may necessitate a formal surgical intervention in a hostile abdomen. In select situations, we have utilized natural orifice transluminal endoscopic surgery (NOTES) methods to enter the abdominal cavity and place/reposition drains under direct endoscopic visualization a part of our comprehensive endoscopic management algorithm for leaks.
Methods and Procedures: A prospectively collected database was queried for patients who had undergone transluminal endoscopic drain repositioning (TEDR) as part of multimodal endolumenal therapy for leak (including interventions like defect closure, enteral feeding access, or endolumenal stent placement). Inadequate drainage was identified pre-procedurally by undrained fluid collections in conjunction with clinical signs of sepsis. Translumenal access was obtained via the leak site and carbon dioxide insufflation was used in all cases. The peritoneal cavity was surveilled and cleared of gross debris by irrigation and suction. Intraabdominal drains were located endoscopically and fluoroscopically, grasped with an endoscopic snare or grasper and repositioned adjacent to the leak site to ensure better drainage.
Results: Four patients (3 female), average age 50 (range 52-60), average body mass index 34 (range 29-39) were managed with TEDR as a component of endoscopic treatment of full-thickness gastrointestinal leak. Two patients developed leak following revisional bariatric surgery. One patient had an acutely dislodged gastrostomy tube with intraperitoneal leak after multiple laparotomies recently closed with a granulating vicryl mesh. One patient developed a leak at an esophagojejunostomy following total gastrectomy. Three patients had adequate drainage after the initial TEDR, while one patient required TEDR on two occasions. All patients had improved drainage demonstrated by resolution of clinical signs of sepsis and resolution of fluid collections. Drains were removed as clinically indicated.
Conclusion: Intraabdominal drains are an essential element in the management of full-thickness gastrointestinal leaks, but are not always able to be adequately positioned percutaneously. Transluminal endoscopic drain repositioning via a gastrointestinal defect is a viable option to avoid surgical intervention in an otherwise hostile field and is a novel practical NOTES application.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87886
Program Number: P386
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster