SPECIAL INTERVIEW with the pioneer in EVT Dr. Gunnar Loske: Endoscopic vacuum therapies (EVT)

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I had the priviledge and pleasure of meeting Gunnar Loske about 10 years ago during a hands-on course where he and his team were demonstrating how to close complex gastrointestinal defects such as leaks,...

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I had the priviledge and pleasure of meeting Gunnar Loske about 10 years ago during a hands-on course where he and his team were demonstrating how to close complex gastrointestinal defects such as leaks, perforations and fistulae. Since then we have become collaborators and friends. 

For those who have not used endoscopic negative pressure therapy or endoscopic vacuum therapy, discovering the simple steps of this technique is truly eye-opening and game-changing. Suddenly, one realizes that patients that were destined to succumb due to non-healable illness have a chance to recuperate their GI tract and life! I was fortunate and honored to introduce this technique at the University of Alabama, USA back in 2012. 

Interview:

Question No. 1. What are the principles of endoscopic vacuum therapy?

Endoscopic negative pressure therapy (ENPT) (also known as endoscopic vacuum therapy, EVT) was developed to close anastomotic intestinal leaks. Open-pored drains (made of polyurethane foam or a open-pored double-layer membrane) are placed endoscopically on the wound region and a continuous negative pressure is applied by means of an electronic vacuum pump. Two therapy variants can be distinguished, which can also be combined with each other: Intraluminal and intracavitary ENPT.

The three most important treatment principles of ENPT are 1) closure of the defect and drainage of secretions, 2) active drainage and removal of secretionsremoval of aggressive secretions, 3) promotion of granulation and healing. Interestingly, the principles of ENPT are the essential surgical characteristics defined by Kirschner 1926 for treatment of peritonitis (blocking the origin of infection and the elimination of exudate)! 

1. Closure is achieved by two aspects a) occluding (i.e. collapsing) the intestinal lumen or the extraluminary cavity and b) covering the defect zone.

2. Active permanent drainage of fluids is performmed by continuous centripetal luminal suction. Immediately after starting ENPT, further contact of the endoluminal wound with aggressive digestive or infective secretions is eliminated.

3. Promotion of granulation tissue, enhancement of perfusion, reduction of inflammatory interstitial oedema, and collapse of wound margins as well as local wound debridement is further stimulated by negative pressure along the open-pored sponge or membrane surface.

Question No. 2. What are the indications for EVT?

ENPT was initially used to treat anastomotic insufficiencies in the rectum, and was subsequently adapted to treat esophageal leakages ranging from perforations, anastomotic leaks and fistulae. Nowadays, ENPT has been used to treat almost any endoluminal defect, including duodenal perforations, Booerhaave's syndrome. One of the most exciting aspects of ENPT is its expansion from active therapy to prophylaxis. We are now using ENPT to as a pre-emptive therapy in patients undergoing Ivor-Lewis surgery. Instead of a passive gastric drainage tube, we already place an open-pored film drainage in the stomach intraoperatively. In the first postoperative days, complete gastric emptying and elimination of gastric reflux is actively ensured by applying negative pressure. Aggressive digestive secretions are permanently kept away to protect the healing of the anastomosis. By doing this we diminish the risks of anastomoitic dehiscence in this high-risks surgery.

www.endoscopicvacuumtherapy.de

https://endoscopicvacuumtherapy.jimdofree.com/esophagus/

https://www.thieme-connect.com/products/ejournals/html/10.1055/a-0599-5886

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