Endoscopic vacuum therapy for leaky cavities: is it possible?

A 71-year-old male patient with a history of bladder neoplasia underwent Bricker-type surgery, during which an iatrogenic rectal injury occurred. During surgery, an unsuccessful suture attempt was made, leading to the appearance of fecaluria after 48 hours. A computed tomography scan revealed a small continuity defect in the rectal wall, accompanied by a 25-mm adjacent collection. Percutaneous drainage was placed in an attempt to achieve spontaneous closure, but this was unsuccessful. A rectoscopy was performed, identifying a wall defect in the mid-rectum. A review with a paediatric gastroscope confirmed communication to a cavity drained by urethra (recto-urethral fistula). Endoscopic vacuum therapy (EVT) (Endo-SPONGE®, B.Braun; Melsungen, Hesse, Germany) was initiated, achieving negative pressures (KCI Acelity V.A.C.® ATS® Negative Pressure Wound Therapy Unit; -100 mmHg). An endoscopic review after 72 hours confirmed the appearance of granulation tissue and the initiation of cavity closure. After three replacements (a total of four sponges), cavity collapse was achieved, but complete closure of the orifice was not attained. An over-the-scope clip (OTSC® 11.5-14 mm type-t, Ovesco; Tübingen, Baden-Wurttemberg, Germany) was placed, but fecaluria persisted, albeit with lesser intensity. Ultimately, successful closure was achieved by placing a second over-the-scope clip, two conventional hemoclips (Novaclip-R3 16 mm, Vytil; Hangzhou, Zhejiang, China), and instilling endoscopic biodegradable cyanoacrylate adhesive (Glubran® 2, GEM; Viareggio, Lucca, Italy).