Endoscopic transanal vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from...

A major leak from a rectal anastomosis is an important surgical complication. Endoscopic transanal vacuum-assisted rectal drainage (ETVARD) is a new method for treating nonseptic major anastomotic leaks after extraperitoneal rectal anastomoses.

Between January 2002 and March 2007 a total of 17 patients (mean age 61.2 years) who developed anastomotic leakage after resection of the rectum or rectosigmoid colon were prospectively evaluated. Their treatment began with endoscopic debridement of the leak/cavity; nylon sponges were then endoscopically fitted into the cavity. Continuous suction was applied via suction tubes inserted into the sponges. Repeat endoscopies and sponge exchanges, including further debridement were essential.

In 16/17 patients ETVARD was successful, relieving patients quickly from infectious symptoms and other complaints; one patient eventually required a Hartmann's procedure. Cavity sizes varied from 2 cm x 2 cm to 10 cm x 13 cm. The mean duration of drainage was 21.4 days, with a mean of 5.4 sponge exchanges and 10.7 endoscopies, and a mean total time to closure of the cavity of 53.1 days. The total time to closure of the cavity was directly dependent on the size of the cavity ( P< 0.015). Fifteen patients received additional intramural fibrin glue injections. In eight patients ETVARD was continued on an outpatient basis. There was no advantage demonstrated for patients with diverting loop ileostomies. Patients with anastomoses that were 6 cm or less from the anocutaneous line had considerably longer healing times. The healing time depended significantly on age ( P< 0.036). Follow-up endoscopies have shown only minor anastomotic changes in two patients.

ETVARD is a well-tolerated and effective therapeutic option for the treatment of major leaks after extraperitoneal rectal anastomoses. In most cases ETVARD obviates the need for additional surgery, in particular diverting loop ileostomy.