eP106 - Case Report: Endoluminal Vacuum-Assisted Therapy as a Bridge to Definitive Surgery

Purpose/Background: Anastomotic leaks are a universally feared and devastating complication after low rectal anastomoses. Endoluminal vacuum-assisted therapy (EVAT) has been shown to help resolve acute leaks in select patients. However, this technique is less successful in resolving chronic anastomotic leaks. Despite being insufficient to fully resolve a chronic leak, this case demonstrates a role for EVAT as a bridge to definitive surgery in a patient suffering from recurrent sepsis due to chronic anastomotic leak with associated presacral and gluteal abscesses.Methods/Interventions: A 65-year-old woman was diagnosed with rectal cancer (MRI T3N2) 8 cm from the anal verge and treated with neoadjuvant chemoradiation followed by robotic low anterior resection, coloanal anastomosis and diverting ileostomy in May 2017. Ten months after ileostomy reversal, she developed a presacral abscess seen on computed tomography scan and was confirmed to have breakdown of her anastomosis on endoscopic exam under anesthesia. Despite marsupialization, fecal diversion, and interventional radiology drainage, the abscesses persisted, and she developed multiple sinus tracts. Between 2021 and 2022 she had several admissions for sepsis, which delayed her completion abdominoperineal resection (APR). Additionally, her quality of life was poor due to chronic pain and frequent hospitalizations. In December 2022, the decision was made to trial EVAT as all other attempts to control the abscesses and sepsis had failed. She underwent a total of 21 weekly sponge exchanges over a 5-month period. A black sponge, cut to appropriate size, was secured onto a 14 French straight urinary catheter with three 0-Silk sutures. This was subsequently connected to vacuum tubing and canister, with the pressure set to 125 mmHg. On initial placement of the endosponge, the vacuum tubing was placed such that it transversed the abscess cavities and exited the body via the transgluteal tract previously occupied by the IR drain. After three weeks of EVAT, the vacuum tubing was repositioned to exit transanally to allow the transgluteal tract to heal.Results/Outcomes: Prior to EVAT trial, endoscopic examination demonstrated an infected abscess cavity with pus and necrotic debris. Upon subsequent examinations, EVAT successfully debrided necrotic tissue, collapsed the gluteal abscess, and facilitated development of healthy granulation tissue (Figure 1). The presacral abscess cavity did not completely resolve, as was expected due to its large size, but she had no episodes of sepsis during this period. She was able to undergo robotic-assisted APR with vertical rectus abdominis musculocutaneous (VRAM) flap in June 2023 and was started on empiric treatment for suspected osteomyelitis. At 4-weeks following APR, the patient had significant improvement of pain and external sinus tracts were no longer draining. At her 6-week follow up she completed empiric osteomyelitis treatment. Surgical drains were removed at 8-week follow up and flap was completely healed by 9-week follow up.Conclusion/

Discussion: EVAT therapy successfully controlled this patient’s recurrent sepsis after other interventions had failed, and this allowed preoperative optimization prior to completion APR. In this case study, EVAT demonstrated potential utility in patients with chronic leaks/abscesses acting as a bridge to definitive surgery while preventing recurrent sepsis.Figure 1: Impact of EVAT on abscess cavities due to chronic anastomotic leakA. Large persistent presacral abscess (Red arrow), CTAP September 2022
B. Healing abscess cavity, EVAT in place, CTAP April 2023
C. Endoscopic exam showing infected abscess cavity with pus, seton in place, December 2022
D. Endoscopic exam after EVAT, April 20