Transluminal washout and debridement of extraluminal contamination as an adjunct to endoscopic defect repair

Abstract

Background and Aims: GI tract perforations and anastomotic dehiscence are increasingly effectively being repaired endoscopically; however, well-known and long-held surgical principles must still be honored. One important principle is that significant extraluminal contamination must be washed out, debrided, and drained in conjunction with repair of the defect if the wound is to effectively heal and resolve. Here we describe the use of endoscopic washout and debridement of extraluminal contamination at the time of luminal defect closure in a 7-patient series at our institution, with video demonstration of 2 patients in the series. Methods: We reviewed a series of 7 patients at our institution and provide a video demonstration of the described technique in 2 patients. A 50-year-old man with decompensated liver cirrhosis presented with a large distal esophageal disruption secondary to a severe Minnesota tube injury. Extensive thoracic and mediastinal contamination of solid and liquid debris was removed and washed out endoscopically, followed by esophageal defect repair. Closure of the defect with overlapping, fully covered, esophageal stents sutured in place was successful after attempts at repairing the primary disruption with suturing alone failed. A 49-year-old man with multiple endocrine neoplasia type 1 and multiple prior surgeries presented with an acute abdomen and sepsis secondary to a fully perforated duodenal ulcer. Extensive endoscopic washout and lavage of the purulent liquid and semiliquid debris covering the liver, stomach, and adjacent structures was performed, followed by closure of the perforation by endoscopic suturing. A percutaneous pigtailed drainage catheter was placed in the extraluminal cavity to facilitate postoperative drainage, followed by placement of a PEG with jejunal extension for enteric exclusion and nutrition. Results: The results for all 7 patients were reviewed. The overall rate of technical success, defined as effective repair of the luminal defect and drainage of extraluminal contamination, was 100%. The overall rate of clinical success, defined as clinical recovery and return to the patient’s previous state of health, was 86% because 1 patient died because of severe concomitant disease. The length of time from the described procedure to hospital discharge ranged from 8 to 52 days (mean, 27 days). Conclusion: Endoscopic washout and debridement can effectively and immediately address extraluminal contamination at the time of endoscopic luminal defect repair in appropriately selected patients. Therefore, it may represent a valuable option to address this clinical situation when a more conventional surgical approach is problematic. A more structured study should be considered for the development and validation of this approach.