Laparoendoscopic mediastinal vacuum therapy of a gastric perforation through the diaphragm

uum therapy using polyurethane sponges has become an established method for treating rectal anastomotic leaks [1] and is now increasingly also used in the upper gastrointestinal tract [2–4]. We report on transhiatal placement of an Endo-Sponge (Braun Medical, Melsungen, Germany) into the mediastinum using the Gastrotrokar described in an earlier paper [5]. A 54-year-old man was referred by the emergency doctor after a 2-day history of thoracolumbar pain on violent coughing. Immediate intubation was necessary because the patient presented a complete picture of sepsis. A laparoscopic fundoplication had been performed 6 years earlier due to gastroesophageal reflux disease. Gastroscopy revealed a satisfactory fundoplication. However, a transhiatal perforation of the funduswas observed (●" Fig. 1). The necrosis cavity, which was located para-aortally in the mediastinum, was measured during computed tomography (CT) as 5.4 × 5 × 3.2 cm. Free intra-abdominal air and subcutaneous emphysema were found (●" Fig. 2). Transesophageal endoscopic placement of an Endo-Sponge was not possible, because of the need for a maximally retroflexed scope position. A Gastrotrokar (Storz, Tuttlingen, Germany) was introduced through a 20-Fr percutaneous endoscopic gastrostomy (PEG) tube (Fresenius Kabi AG, Bad Homburg, Germany) into the body of the stomach. The Endo-Sponge introduced transesophageally into the stomach using an overtube was then introduced easily into the cavity using a laparoscopic forceps (●" Figs. 3 and 4). The Endo-Sponge tube was drained through the PEG tube and kept under continuous negative pressure of 125mmHg using a negative pressure therapy system (KCI, USA Inc., San Antonio, Texas, USA). Broad-spectrum antibiotics (cefuroxime and metronidazol) were delivered. After 48 h, the patient showed marked improvement both clinically and in laboratory test values. The patient was extubated. The Endo-Sponge was replaced on days 2 and 8, cleansing the wound and reducing the cavity by 50% (●" Fig. 5), so Laparoendoscopic mediastinal vacuum therapy of a gastric perforation through the diaphragm