C79-08 Sponge and Suction: The Utilization of Endoscopic Vacuum Therapy in Critical Mediastinal Effusion

Introduction Mediastinal effusions can be difficult to manage depending on anatomy and pathology. Utilization of bedside endoscopic vacuum therapy (EVT) in the ICU offers a versatile method to help manage complex processes involving the thoracic cavity avoiding re-operation. This case highlights the utilization of EVT in a challenging critical patient who developed post operative esophageal-mediastinal anastomosis with large mediastinal fluid collection with high risk for infection and complications of primary closure. Case Report 78-year-old male with esophageal gastric junction adenocarcinoma underwent a transmittal esophagectomy, pyloromyotomy, and feeding jejunostomy. His course was complicated by large emesis of sloughed tissue and clot prompting esophagogastroduodenoscopy, which showed evidence of a contained anastomotic dehiscence with a large mediastinal fluid filled cavity measuring approximately 7cm x 3cm. The area was deemed too large for endoscopic sutures, clips, pigtail, or axial stents. Surgery was not an option due to friability of tissue unlikely to hold sutures. VAC therapy, with subsequent interval downsizing, was pursued to promote internal drainage of the mediastinal space and ultimate healing of the dehiscence. Discussion Vacuum Therapy, or Negative Pressure Therapy, is used widely for wounds to promote healing and decrease infections. Endoscopic Vacuum Therapy is a relatively novel approach, with the first case documented in 2003. [1] It is commonly used for management of leaks and perforations, more in the upper GI tract compared to the lower. The indications for EVT are anastomotic leaks after GI or bariatric surgery, acute perforations, and duodenal/colonic wall defects. [2]As seen in our case, EVT can be employed as a temporizing measure where surgery or endoscopy are not feasible. It offers another avenue when surgical trauma lacks therapeutic benefit. A void in supportive literature for EVT for the mediastinum still exists. Studies on EVT for other wounds have shown it is effective, reducing wound healing time, without increased bleeding or infection risk. [3] Conclusion EVT is a novel approach to management of complex esophageal and gastric wounds and can be employed safely in the intensive care unit as a temporizing measure when there is a lack of other options. It remains prudent to assess every case individually. References: 1. Oral Abstracts - 2003 - Colorectal Disease - Wiley Online Library 2. Applications of endoscopic vacuum therapy in the uppergastrointestinal tract - PMC 3. Comparison of Vacuum-Assisted Closure Therapy and ConventionalDressing on Wound Healing in Patients with Diabetic Foot Ulcer: ARandomized Controlled Trial - PMC This abstract is funded by: none