Endoluminal Negative Pressure Wound Therapy (E-NPWT) for anastomotic leakage after rectal resection

Background Local management of anastomotic leakage after rectal cancer resection has traditionally consisted of rinsing and drainage. Transanal endoluminal application of NPWT (E-NPWT or endo-VAC or endo-sponge) is an interesting novel concept that has been explored in a few studies and case series over the last decade. We report herein our institutional experience over a three year period during which E-NPWT was the local treatment of choice for all cases with anastomotic leakage after rectal resection.Patients and MethodsThis study retrospectively evaluated the clinical charts of 147 consecutive patients who underwent anterior rectal resection from 2011-2013. A postoperative anastomotic leak occurred in eight (5%) patients from two straight anastomoses, one side-to-end construction, and five colonic pouches. All patients had undergone curative anterior resection with diverting ostomy. Transanal debridement and application of a trimmed foam were performed by rigid or fexibel endoscopy and started without delay after confirmation of diagnosis in seven patients 8-15 days postoperatively. In one patient E-NPWT began after failed fibrin-glue treatment 6 weeks later. The foams were connected to a standard vacuum pump with the pressure set at -70mmHg in a continuous mode. E-NPWT was maintained for a median period of 10 (5-25) days. The treatment intervals were typically 2-3 days.ResultsComplete healing was achieved in three cases during E-NPWT. In the remaining five patients, the defect reduced in size to allow further spontaneous healing. This occurred twice. One persistent sinus was successfully sealed with fibrin glue.  One persisting recto-vaginal fistula required surgical closure. One large defect secondary to ischemic pouch necrosis required secondary pouch explantation and permanent colostomy. The overall ileostomy reversal rate was 75%.ConclusionE-NPWT is feasible and without severe side effects. Early initiation prevents septic progression and results in a high closure rate in patients with pelvic leakage. Although complete healing is not achieved in recto-vaginal fistulas or ischemic necrosis of the neorectum, E-NPWT may play a potential role in bridging and damage control.

BariSurg trial: Sleeve gastrectomy versus Roux-en-Y gastric bypass in obese patients with BMI 35–60 kg/m2 – a multi-centre randomized patient and observer blind non-inferiority trial

Background: Roux-en-Ygastric bypass (RYGB) and sleeve gastrectomy (SG) rank among the most frequently applied bariatric procedures worldwide due to their positive risk/benefit correlation. A systematic review revealed a similar excess weight loss (EWL) 2 years postoperatively between SG and RYGB. However, there is a lack of randomized controlled multi-centre trials comparing SG and RYGB, not only concerning EWL, but also in terms of remission of obesity-related co-morbidities, gastroesophageal reflux disease (GERD) and quality of life (QoL) in the mid- and long-term. Methods: The BariSurg trial was designed as a multi-centre, randomized controlled patient and observer blind trial. The trial protocol was approved by the corresponding ethics committees of the centres. To demonstrate EWL non-inferiority of SG compared to RYGB, power calculation was performed according to a non-inferiority study design. Morbidity, mortality, remission of obesity-related co-morbidities, GERD course and QoL are major secondary endpoints. 248 patients between 18 and 70 years, with a body mass index (BMI) between 35–60 kg/m2 and indication for bariatric surgery according to the most recent German S3-guidelines will be randomized. The primary and secondary endpoints will be assessed prior to surgery and afterwards at discharge and at the time points 3–6, 12, 24, 36, 48 and 60 months postoperatively. Discussion: With its five year follow-up, the BariSurg-trial will provide further evidence based data concerning the impact of SG and RYGB on EWL, remission of obesity-related co-morbidities, the course of GERD and QoL. Trial registration: The trial protocol has been registered in the German Clinical Trials Register DRKS0000476