OGBN P12 Minimising the systemic effects of an oesophageal leak following high risk myotomy repair using Prophylactic Endoluminal Vacuum Therapy (EVT) - time for a change?

Abstract Background Endoluminal Vacuum Therapy (EVT) continues to gain momentum as a first line treatment for oesophageal perforations. Outside the emergency setting there is growing interest in using EVT prophylactically protect high-risk elective repairs. We present case which demonstrates benefit of prophylactic preventing extraluminal contamination, mediastinitis and sepsis following surgery. Methods An 80-year-old female underwent laparoscopic Hellers Myotomy Dor Fundoplication Type 2 Achalasia worsening symptoms including weight loss despite nutritional optimisation. She had multiple prior balloon dilatations without long term symptom control remained frail, with performance status 0 an ASA 2. During surgery myotomy was challenging due extensive scarring. Endoscopy performed on completion confirm adequacy 1cm perforation at 38cm noted. Primary repair 5 interrupted 3/0 maxon sutures. ad-hoc device constructed V.A.C granufoam (KCI) sutured end 18Fr nasogastric tube, placed intraluminally oesophagus across repair. Continuous negative pressure 75mmHg applied. Post operatively patient kept nil by mouth received parenteral nutrition. Her clinical biochemical parameters were monitored, progress her assessed endoscopically. Results The post-operative endoscopy day 4. On visual inspection full thickness defect seen proximal aspect There no associated leak cavity or other endoscopic evidence contamination. A further suture wall defect. second 10 completely healed. Despite having documented clinically well throughout recovery signs sepsis. highest recorded CRP 131 WCC 12.7 1 8 respectively. At point higher level care input required than general surgical ward. total LOS 14 days. Conclusions serious complication may result mediastinitis, death. This utility reducing impact patients where breakdown occurs. Without this case, we are certain would have resulted significant limited physiological reserve not survived. While substitute sound technique, it should be considered undergoing reduce prevent septic hit consequent if