P1.038. Minimising the Systemic Effects of an Oesophageal Leak Following High Risk Myotomy Repair Using Prophylactic Endoluminal Vacuum Therapy (EVT) – Time for a Change?

Abstract

Abstract Topic Benign Disease: Iatrogenic Esophageal Disease, Perforation and Postsurgical Complications Case Submission An 80 year old frail lady (ASA 2, BMI 22) was referred with progressive dysphagia, regurgitation, and unintentional weight loss. Endoscopy demonstrated a dilated oesophagus and tight lower oesophageal sphincter without mucosal lesions. Computed Tomography confirmed a patulous lower oesophagus with no malignancy. Barium swallow showed a dilated, aperistaltic oesophagus with severe tertiary contractions and incomplete emptying at the gastro-oesophageal junction. High resolution manometry confirmed type II achalasia. Symptoms persisted despite balloon dilatation, and she was deemed fit for surgery. An elective laparoscopic Heller’s myotomy with Dor fundoplication was performed. Intraoperatively, a hiatus hernia was noted with gastric displacement into the left upper quadrant. Dense fibrosis between the muscular layer and mucosa was encountered, likely secondary to prior interventions. The hiatus was opened ventrally and the intra-abdominal and distal thoracic oesophagus mobilised. The cardio-oesophageal fat pad was reflected, preserving the anterior vagus nerve. A myotomy was created using harmonic energy, extending 6 cm proximally and 2.5 cm onto the cardia. At 38 cm from the incisors, a 1 cm full thickness mucosal breach occurred and was closed with five interrupted 3/0 Maxon sutures. Intraoperative endoscopy confirmed luminal patency without leak. Although primary repair is standard, the thoracic location, submucosal fibrosis and patient frailty raised concern regarding potential breakdown. Mediastinitis in this context would likely require reintervention and could be poorly tolerated. The repair was therefore reinforced with prophylactic endoluminal vacuum therapy (pEVT). An ad hoc device was fashioned using V.A.C. GranuFoam secured circumferentially to an 18F nasogastric tube and positioned endoscopically across the repair (Figure 1). Continuous negative pressure of 75 mmHg was applied. The patient was managed nil by mouth with parenteral nutrition, intravenous antibiotics and antifungals. Planned endoscopic reassessment on postoperative day 4 demonstrated slough at the repair site with a full thickness mucosal defect at the proximal suture line. There was no extraluminal cavity, mediastinal contamination or purulence. Clinically she remained afebrile and haemodynamically stable. CRP peaked at 131 mg/L on day 1 and white cell count at 12.7 ×109/L on day 8. No haemodynamic or respiratory compromise occurred. Given these findings, the device was changed and therapy was escalated to therapeutic EVT at 125 mmHg continuous suction to promote granulation. Repeat endoscopy on day 10 demonstrated complete closure with healthy granulation tissue and no cavity formation, and therapy was discontinued (Figure 2). No intensive care admission, radiological drainage or reoperation was required. Oral intake was recommenced following device removal. She was discharged on postoperative day 14. At six month follow up she was asymptomatic, tolerating a normal diet and had regained weight without evidence of stricture or reflux. This case highlights the role of prophylactic EVT as an adjunct in selected high risk repairs. Early negative pressure may alter the trajectory of repair breakdown by limiting mediastinal contamination and promoting controlled intraluminal healing. Careful patient selection is essential, particularly in individuals in whom septic complications would carry substantial morbidity. Prophylactic EVT warrants consideration within the management algorithm for high risk oesophageal mucosal injury.