Endo-SPONGE pulley system for the treatment of chronic anastomotic leakage after rectal resection. A case report

AIM: Anastomotic leakage (AL) after anterior rectal resection unresponsive to diverting ileostomy is difficult to manage. Endoscopic vacuum-assisted (E-VAC) wound closure system is a new approach based on co-axial sponge positioning under endoscopic control. If the abscess is not co-axial, however, endoscopic positioning is not feasible. Aim is to report an original method of sponge positioning.CASE EXPEFUENCE: A 62-year-old woman with chronic AL after anterior rectal resection for cancer was referred. AL had been treated with diverting ileostomy without healing. Due to the peri-rectal abscess anatomy, standard E-VAC positioning was not possible. A combined endoscopic-interventional radiology procedure for Endo-SPONGE (R) (B. Braun Aesculap AG, Germany) positioning was thus employed. Under general anesthesia, a guidewire was passed after small counter-incision on the left gluteus and through the left levator muscle, reaching the anastomotic dehiscence and rectal lumen through the chronic abscess. The guidewire was retrieved through the anus and connected to a long silk thread. By retracting the trans-gluteal guidewire, the silk thread was pulled through the abscess to exit from the gluteal skin incision. A tailored Endo-SPONGE (R) was then connected to the trans-anal silk thread. By pulling on the gluteal silk thread, the sponge was positioned inside the abscess. The silk thread remained in place under a medication for sponge replacements.DISCUSSION AND RESULTS: Twelve Endo-SPONGE replacements under sedation were required until AL completely resolved after 35 days.CONCLUSION: When traditional endoscopic sponge insertion into AL is not possible, this original "pulley system" proved effective for sponge introduction and replacement.