Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract

Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study

BACKGROUND

Traumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP.

METHODS

Retrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome.

RESULTS

Patients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant.

CONCLUSION

E-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.

Endoscopic Intervention for Anastomotic Leakage After Gastrectomy

Anastomotic leaks and fistulas are significant complications of gastric surgery that potentially lead to increased postoperative morbidity and mortality. Surgical intervention is reserved for cases with severe symptoms or hemodynamic instability; however, surgery carries a higher risk of complications. With advancements in endoscopic treatment options, endoscopic approaches have emerged as the primary choice for managing these complications. Endoscopic clipping is a traditional method comprising 2 main categories: through-the-scope clips and over-the-scope clips. Through-the-scope clips are user friendly and adaptable to various clinical scenarios, whereas over-the-scope clips can close larger defects. Another promising approach is endoscopic stent insertion, which has shown a high success rate for leak closure, although vigilant monitoring is required to monitor stent migration. Infection control is essential in post-surgical leakage cases, and endoscopic internal drainage provides a relatively safe and noninvasive means to manage fluids, contributing to infection control and wound healing promotion. Endoscopic suturing offers full-thickness wound closure, but requires additional training and endoscopic versatility. As a promising tool, endoscopic vacuum therapy potentially surpasses stent therapy by draining inflammatory materials and closing defects. Furthermore, the use of tissue sealants, such as fibrin glue and cyanoacrylate, has been reported to be effective in selected situations. The choice of endoscopic device should be tailored to individual cases and specific patient conditions, with careful consideration of the nature of the defect. Further extensive studies involving larger patient populations are required to provide more robust evidence on the efficacy of endoscopic approach in managing post-gastric anastomotic leaks.

Outcome after stent and endoscopic vacuum therapy-based treatment for postemetic esophageal rupture

OBJECTIVES

Extent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment.

MATERIALS AND METHODS

17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie's score).

RESULTS

Seventeen patients aged median 67 years (range 34-88), had a primary hospital stay of 38 days (7-68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2-62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population.

CONCLUSION

Mortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.

Understanding Post-Esophagectomy Complications and Their Management: The Early Complications

Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks.

Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects

BACKGROUND/AIMS

Endoscopic vacuum therapy (EVT) can heal a variety of defects within the gastrointestinal (GI) tract via applying negative pressure, which reduces the defect size, aspirates the infected fluid, and promotes granulation tissue. Here we present our experience with EVT as it relates to both spontaneous and iatrogenic upper GI tract perforations, leaks, and fistulas.

METHODS

This retrospective study was conducted at four large hospital centers. All patients who underwent EVT between June 2018 and March 2021 were included. Data on multiple variables were collected, including demographics, defect size and location, number and intervals of EVT exchanges, technical success, and hospital length of stay. Student t-test and the chi-squared test were used to analyze the data.

RESULTS

Twenty patients underwent EVT. The most common defect cause was spontaneous esophageal perforation (50%). The most common defect location was the distal esophagus (55%). The success rate was 80%. Seven patients were treated with EVT as the primary closure method. The mean number of exchanges was five with a mean interval of 4.3 days between exchanges. The mean length of hospital stay was 55.8 days.

CONCLUSION

EVT is a safe and effective initial management option for esophageal leaks and perforations.

Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry

INTRODUCTION

Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality.

METHODS

This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022.

RESULTS

We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality.

DISCUSSION

EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

Outcomes of Endoscopic Intervention Using Over-the-Scope Clips for Anastomotic Leakage Involving Secondary Fistula after Gastrointestinal Surgery: A Japanese Multicenter Case Series

BACKGROUND

The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions.

METHODS

We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020.

RESULTS

The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates.

CONCLUSION

OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.

Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience

BACKGROUND

Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery.

OBJECTIVE

The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed.

SETTING

This study was performed at a tertiary clinic and certified center of reference for bariatric surgery.

METHODS

In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay.

RESULTS

A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015).

CONCLUSIONS

EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.

Endoscopic vacuum therapy: 2 methods of successful endosponge placement for treatment of anastomotic leak in the upper GI tract

Video 1Presentation of 2 methods of successful endosponge placement for treatment of anastomotic leak in the upper GI tract.

Applications of endoscopic vacuum therapy in the upper gastrointestinal tract

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.

Multimodal Endoscopic Management of Esophageal Perforations as a Complication of Peroral Endoscopic Myotomy for a Zenker's Diverticulum

Zenker's diverticulum develops because of a weakness in Killian's triangle, leading to a mucosal and submucosal herniation. Its treatment has evolved from morbid surgical interventions to safer endoscopic techniques such as peroral endoscopic myotomy (Z-POEM). Despite being a safe technique, Z-POEM is not free of complications such as perforations, bleeding, pneumoperitoneum, and pneumothorax, for which new endoscopic techniques have been developed. We present the case of a 53-year-old man taken to a Z-POEM who postoperatively presented dehiscence of the mucosotomy and a mediastinal collection, managed with a vacuum-assisted endoscopic closure device.

Challenges in the interdisciplinary treatment of leakages after left-sided colorectal surgery: endoscopic negative pressure therapy, open-pore film drainage therapy and beyond

PURPOSE

The treatment of anastomotic leakage after left colorectal surgery remains challenging. Since its introduction, endoscopic negative pressure therapy (ENPT) has proven to be advantageous, reducing the necessity of surgical revision. The aim of our study is to present our experience with endoscopic treatment of colorectal leakages and to identify potential factors influencing treatment outcome.

METHODS

Patients who underwent endoscopic treatment of colorectal leakage were retrospectively analyzed. Primary endpoint was the healing rate and success of endoscopic therapy.

RESULTS

We identified 59 patients treated with ENPT between January 2009 and December 2019. The overall closure rate was 83%, whereas only 60% of the patients were successfully treated with ENPT and 23% needed further surgery. The time between diagnosis of leakage and uptake of endoscopic treatment did not influence the closure rate, but patients with chronic fistula (> 4 weeks) showed a significantly higher reoperation rate than those with an acute fistula (94% vs 6%, p = 0.01).

CONCLUSION

ENPT is a successful treatment option for colorectal leakages, which appears to be more favorable when started early. Further studies are still needed to better describe its healing potential, but it deserves an integral role in the interdisciplinary treatment of anastomotic leakages.

Don't be afraid of black holes: Vacuum sponge and vacuum stent treatment of leaks in the upper GI tract-a case series and mini-review

The treatment of leaks in the upper gastrointestinal tract has been revolutionized by the advent of covered self-expanding metal stents (cSEMS), endoscopic vacuum therapy (EVT), and recently, vacuum stent therapy (VST). In this retrospective study, we report the experiences with EVT and VST at our institution.

Patients and methods

Twenty-two patients (15 male, 7 female) with leaks in the esophagus, at the esophago-gastric junction or anastomotic leaks underwent EVT by placing a sponge connected to a negative pressure pump into or near the leak. VST was applied in three patients.

Results

EVT led to closure of the leak in 18 of 22 Patients (82%). In 9 patients (41%), EVT was followed by application of a cSEMS. One patient (5%) died during the hospital stay due to an aorto-esophageal fistula near the leak, four others (18%) due to underlying disease. The stricture rate was 3/22 (14%). All three patients in whom VST was applied had closure of the leak and recovered. Reviewing the literature, we identified sixteen retrospective series of ten or more patients (n = 610) with an overall closure rate for EVT of 84%. In eight additional retrospective observations, a comparison between the efficacy of EVT and cSEMS therapy was performed that revealed a success rate of 89% and 69%, respectively (difference not significant, chi-square test). For VST, two small series show that closure is possible in the majority of patients.

Conclusion

EVT and VST are valuable options in the treatment of leaks in the upper gastrointestinal tract.

Endoluminal wound VAC therapy for the management of esophageal trauma: A case series

Esophageal trauma is rare and associated with high morbidity and mortality. Management can be challenging. Operative intervention involves exposure of the esophageal injury followed by primary two-layer repair with or without a buttressing muscle flap and wide local drainage. Repair can be complicated by post-operative leak and esophagocutaneous fistula. Endoluminal wound VAC therapy in the management of non-traumatic and iatrogenic esophageal perforations has shown efficacy. Presented here is a case series of four patients who sustained penetrating trauma to the esophagus and were managed successfully with endoluminal wound VAC therapy following primary repair. Therefore, endoscopic placement of an endoluminal wound VAC over the site of esophageal injury can serve as a safe and effective adjunct to primary repair of penetrating esophageal trauma. This procedure allows for frequent direct visualization of the injury as it heals, controls leakage of luminal contents, and promotes granulation for local wound healing.

Update on therapeutic strategy for esophageal anastomotic leak: A systematic literature review

Anastomotic leak is still a severe complication in esophageal surgery due to high mortality. This article reviews the updates on the treatment of anastomotic leak after esophagectomy in order to provide reference for clinical treatment and research. The relevant studies published in the Chinese Zhiwang, Wanfang, and MEDLINE databases to December 21, 2021 were retrieved, and esophageal carcinoma, esophagectomy, anastomotic leakage, and fistula selected as the keywords. A total of 78 studies were finally included. The treatments include traditional surgical drainage, new reverse drainage trans-fistula, stent plugging, endoscopic clamping, biological protein glue injection plugging, endoluminal vacuum therapy (EVT), and reoperation, etc. Early diagnosis, accurate classification and optimal treatment can promote the rapid healing of anastomotic leaks. EVT may be the most valuable approach, simultaneously with good commercial prospects. Reoperation should be considered in patients with complex fistula in which conservative treatment is insufficient or has failed.

Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

Introduction

Anastomotic leakage after esophagectomy with gastric-pullup is the most feared postoperative complication associated with high morbidity and mortality rates. Management of anastomotic leakage underwent an evolution in the last decade from surgical and conservative to an endoscopic management. However, to date there is no clear consensus on management and if endoluminal vacuum therapy (EVT) is the most superior therapy.

Material and methods

Between 2012 and 2022 all patients that underwent Ivor-Lewis esophagectomy for an underlying malignancy were included in this study. Patients that developed an anastomotic leakage and received endoscopic vacuum therapy were further analysed.

Results

A total of 17 patients were treated with EVT following AL after esophagectomy. The median duration of EVT was 23 days with a median number of 5,5 vacuum sponge changes per patient. EVT-systems were placed 12 times intraluminal and 5 times extraluminal. Successful closure of the defect was achieved in 14 patients.

Conclusion

Endoscopic vacuum therapy can be successfully applied in the treatment of anastomotic leakage after esophagectomy even in septic patients with an extraluminal cavity. Event-related complications are present but rare.

Differences in fluid removal of different open-pore elements for endoscopic negative pressure therapy in the upper gastrointestinal tract

Endoscopic negative pressure therapy is an effective treatment strategy for various defects of the gastrointestinal tract. The functional principle is based on an open-pore element, which is placed around a perforated drainage tube and connected to a vacuum source. The resulting open-pore suction device can undergo endoluminal or intracavitary placement. Different open-pore suction devices are used for endoscopic negative pressure therapy of upper gastrointestinal tract defects. Comparative analyses for features and properties of these devices are still lacking. Eight different (six hand-made devices and two commercial devices) open-pore suction devices for endoscopic negative pressure therapy of the upper gastrointestinal tract were used, amount fluid removed was evaluated. The evaluation parameters included the time to reach the target pressure, the time required to remove 100 ml of water, and the material resistance of the device. All open-pore suction devices are able to aspirate the target volume of fluids. The time to reach the target volume varied considerably. Target negative pressure was not achieved with all open-pore suction devices during the aspiration of fluids; however, there was no negative effect on suction efficiency. Of the measurement data, material resistance could be calculated for six open-pore elements. We present a simple experimental, nonphysiologically setup for open-pore suction devices used for endoscopic negative pressure therapy. The expected quantity of fluids secreted into the treated organs should affect open-pore suction device for endoscopic negative pressure therapy.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

Endoscopic Vacuum Therapy (EVT) for the Treatment of Post-Bariatric Surgery Leaks and Fistulas: a Systematic Review and Meta-analysis

Bariatric surgery remains the most effective treatment for morbid obesity and its comorbidities. However, post-surgical leaks and fistulas can occur in about 1-5% of patients, with challenging treatment approaches. Endoscopic vacuum therapy (EVT) has emerged as a promising tool due to its satisfactory results and accessibility. In this first systematic review and meta-analysis on the subject, EVT revealed rates of 87.2% clinical success, 6% moderate adverse events, and 12.5% system dislodgements, requiring 6.47 EVT system exchanges every 4.39 days, with a dwell time of 25.67 days and a total length of hospitalization of 44.43 days. Although our results show that EVT is a safe and effective therapy for post-surgical leaks and fistulas, they should be interpreted with caution due to the paucity of available data.

Retrospective analysis of different therapeutic approaches for retroperitoneal duodenal perforations

Surgical therapy of duodenal perforation into the retroperitoneum entails high morbidity. Conservative treatment and endoscopic negative pressure therapy have been suggested as promising therapeutic alternatives. We aimed to retrospectively assess outcomes of patients treated for duodenal perforation to the retroperitoneum at our department. A retrospective analysis of all patients that were treated for duodenal perforation to the retroperitoneum at our institution between 2010 and 2021 was conducted. Different therapeutic approaches with associated complications within 30 days, length of in-hospital stay, number of readmissions and necessity of parenteral nutrition were assessed. We included thirteen patients in our final analysis. Six patients underwent surgery, five patients were treated conservatively and two patients received interventional treatment by endoscopic negative pressure therapy. Length of stay was shorter in patients treated conservatively. One patient following conservative and surgical treatment each was readmitted to hospital within 30 days after initial therapy whereas no readmissions after interventional treatment occurred. There was no failure of therapy in patients treated without surgery whereas four (66.7%) of six patients required revision surgery following primary surgical therapy. Conservative and interventional treatment were associated with fewer complications than surgical therapy which involves high morbidity. Conservative and interventional treatment using endoscopic negative pressure therapy in selected patients might constitute appropriate therapeutic alternatives for duodenal perforations to the retroperitoneum.

Comparison of Two Endoscopic Therapeutic Interventions as Primary Treatment for Anastomotic Leakages after Total Gastrectomy

Simple Summary

An esophagojejunal anastomotic leak after oncological gastrectomy is a life-threatening complication. Endoscopic treatment offers the possibility of minimally invasive diagnosis and immediate effective therapy in one session. A retrospective, single-center analysis of two different endoscopic strategies as first-line treatment options was performed.

Abstract

Introduction: An esophagojejunal anastomotic leak following an oncological gastrectomy is a life-threatening complication, and its management is challenging. A stent application and endoscopic negative pressure therapy are possible therapeutic options. A clinical comparison of these strategies has been missing until now. Methods: A retrospective analysis of 14 consecutive patients endoscopically treated for an anastomotic leak after a gastrectomy between June 2014 and December 2019 was performed. Results: The mean time of the diagnosis of the leakage was 7.14 days after surgery. Five patients were selected for a covered stent, and nine patients received endoscopic negative pressure therapy. In the stent group, the mean number of endoscopies was 2.4, the mean duration of therapy was 26 days, and the mean time of hospitalization was 30 days. In patients treated with endoscopic negative pressure therapy, the mean number of endoscopies was 6.0, the mean days of therapy duration was 14.78, and the mean days of hospitalization was 38.11. Treatment was successful in all patients in the stent-based therapy group and in eight of nine patients in the negative pressure therapy group. Discussion: Good clinical results in preserving the anastomosis and providing sepsis control was achieved in all patients. Stent therapy resulted in anastomosis healing with a lower number of endoscopies, a shorter time of hospitalization, and rapid oral nutrition.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Postoperative Leckagen im Gastrointestinaltrakt – Diagnostik und Therapie

Postoperative Leckagen nach Ösophagus‑, Magen- oder Kolon- bzw. Rektumchirurgie stellen schwerwiegende chirurgische Komplikationen mit einer hohen Morbidität und Mortalität dar. Leckagen werden zumeist durch eine Kombination aus klinischer Beobachtung, Infektionsparametern sowie endoskopischen und schnittbildgebenden Verfahren diagnostiziert. Die Therapie ist bei intraperitonealen Leckagen chirurgisch, bei retroperitonealen bzw. mediastinalen Leckagen in einem interdisziplinären Setting überwiegend interventionell endoskopisch. Hier stehen der Defektverschluss durch die Abdichtung mittels selbstexpandierender gecoverter Stents mit gleichzeitiger externer extraluminaler Drainage sowie der Defektverschluss mit simultaner innerer Drainage und endoskopischer Unterdrucktherapie als vorrangige Methoden zur Verfügung.

Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video)

BACKGROUND AND AIMS

The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates.

METHODS

Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract.

RESULTS

Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself.

CONCLUSIONS

EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.

Treatment of Oesophagojejunostomy Leakage With the Use of Fibrin Glue: Case Report

Oesophagojejunostomy leakage after total gastrectomy with D2 lymphadenectomy remains a significant clinical issue. In this paper, we present a case of a 63-year-old female patient who, on the first day after surgery, was diagnosed with oesophagojejunostomy leakage in the chest. The general condition of the patient was stabilized by the implementation of conservative treatment and thoracic drainage. Thanks to covered oesophageal stents, the leakage from the fistula between the anastomotic connection, pleura, and skin was reduced. In the subsequent step, treatment with fibrin glue resulted in complete closure of the fistula. The complementary use of fibrin glue may be effective in the treatment of small oesophagojejunostomy leakages when other endoscopic methods are not sufficient.

OUP accepted manuscript

Background

Anastomotic leakage (AL) after oesophagectomy and oesophageal perforations are associated with significant morbidity and mortality. Minimally invasive endoscopy is often used as first-line treatment, particularly endoluminal vacuum therapy (EVT). The aim was to assess the performance of the first commercially available endoluminal vacuum device (Eso-Sponge®) in the management of AL and perforation of the upper gastrointestinal tract (GIT).

Methods

The Eso-Sponge® registry was designed in 2014 as a prospective, observational, national, multicentre registry. Patients were recruited with either AL or perforation within the upper GIT. Data were collected with a standardized form and transferred into a web-based platform. Twenty hospitals were enrolled at the beginning of the study (registration number NCT02662777; http://www.clinicaltrials.gov). The primary endpoint was successful closure of the oesophageal defect.

Results

Eleven out of 20 centres recruited patients. A total of 102 patients were included in this interim analysis; 69 patients with AL and 33 with a perforation were treated by EVT. In the AL group, a closure of 91 per cent was observed and 76 per cent was observed in the perforation group. The occurrence of mediastinitis (P = 0.002) and the location of the defect (P = 0.008) were identified as significant predictors of defect closure.

Conclusions

The Eso-Sponge® registry offers the opportunity to collate data on EVT with a uniform, commercially available product to improve standardization. Our data show that EVT with the Eso-Sponge® is an option for the management of AL and perforation within the upper GIT.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

Role of Rendezvous-Procedure in the Treatment of Complications after Laparoscopic Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy is one of the most commonly performed bariatric procedures worldwide with good results, high patient acceptance, and low complication rates. The most relevant perioperative complication is the staple line leak. For the treatment of this complication, endoscopic negative pressure therapy has proven particularly effective. The correct time to start endoscopic negative pressure therapy has not been the subject of studies to date. Methods: Twelve patients were included in this retrospective data analysis over three years. Endoscopic negative pressure therapy was carried out using innovative open pore suction devices. Patients were treated with simultaneous surgery and endoscopy, so called rendezvous-procedure (Group A) or solely endoscopically, or in sequence surgically and endoscopically (Group B). Therapy data of the procedures and outcome measures, including duration of therapy, therapy success, and change of treatment strategy, were collected and analysed. Results: In each group, six patients were treated (mean age 52.96 years, 4 males, 8 females). Poor initial clinical situation, time span of endoscopic negative pressure therapy (Group A 31 days vs. Group B 18 days), and mean length of hospital stay (Group A 39.5 days vs. Group B 20.17 days) were higher in patients with rendezvous procedures. One patient in Group B died during the observation time. Discussion: Rendezvous procedures for patients with staple line leaks after sleeve gastrectomy is indicated for serious ill patients with perigastric abscesses and in need of laparoscopic lavage. The one-stage complication management with the rendezvous procedure seems not to result in an obvious advantage in the further outcome in patients with staple line leaks after laparoscopic sleeve gastrectomy.

AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review

BEST PRACTICE ADVICE 1: For all procedures, especially procedures carrying an increased risk for perforation, a thorough discussion between the endoscopist and the patient (preferably together with the patient's family) should include details of the procedural techniques and risks involved. BEST PRACTICE ADVICE 2: The area of perforation should be kept clean to prevent any spillage of gastrointestinal contents into the perforation by aspirating liquids and, if necessary, changing the patient position to bring the perforation into a non-dependent location while minimizing insufflation of carbon dioxide to avoid compartment syndrome. BEST PRACTICE ADVICE 3: Use of carbon dioxide for insufflation is encouraged for all endoscopic procedures, especially any endoscopic procedure with increased risk of perforation. If available, carbon dioxide should be used for all endoscopic procedures. BEST PRACTICE ADVICE 4: All endoscopists should be aware of the procedures that carry an increased risk for perforation such as any dilation, foreign body removal, any per oral endoscopic myotomy (Zenker's, esophageal, pyloric), stricture incision, thermal coagulation for hemostasis or tumor ablation, percutaneous endoscopic gastrostomy, ampullectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoluminal stenting with self-expanding metal stent (SEMS), full-thickness endoscopic resection, endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy, endoscopic ultrasound (EUS)-guided biliary and pancreatic access, EUS-guided cystogastrostomy, and endoscopic gastroenterostomy using a lumen apposing metal stent (LAMS). BEST PRACTICE ADVICE 5: Urgent surgical consultation should be highly considered in all cases with perforation even when endoscopic repair is technically successful. BEST PRACTICE ADVICE 6: For all upper gastrointestinal perforations, the patient should be considered to be admitted for observation, receive intravenous fluids, be kept nothing by mouth, receive broad-spectrum antibiotics (to cover Gram-negative and anaerobic organisms), nasogastric tube (NGT) placement (albeit some exceptions), and surgical consultation. BEST PRACTICE ADVICE 7: For upper gastrointestinal tract perforations, a water-soluble upper gastrointestinal series should be considered to confirm the absence of continuing leak at the perforation site before initiating a clear liquid diet. BEST PRACTICE ADVICE 8: Endoscopic closure of esophageal perforations should be pursued when feasible, utilizing through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for perforations <2 cm and endoscopic suturing for perforations >2 cm, reserving esophageal stenting with SEMS for cases where primary closure is not possible. BEST PRACTICE ADVICE 9: Endoscopic closure of gastric perforations should be pursued when feasible, utilizing TTSCs or OTSCs for perforations <2 cm and endoscopic suturing or combination of TTSCs and endoloop for perforations >2 cm. BEST PRACTICE ADVICE 10: For large type 1 duodenal perforations (lateral duodenal wall tear >3 cm), being cognizant of the difficulty in closing them endoscopically, urgent surgical consultation should be made while the feasibility of endoscopic closure is assessed. BEST PRACTICE ADVICE 11: Because type 2 periampullary (retroperitoneal) perforations are subtle and can be easily missed, the endoscopist should carefully assess the gas pattern on fluoroscopy to avoid delays in treatment and request a computed tomography scan if there is a concern for such a perforation; identified perforations of this type at the time of ERCP may be closed with TTSCs if feasible and/or by placing a fully covered SEMS into the bile duct across the ampulla. BEST PRACTICE ADVICE 12: For the management of large duodenal polyps, endoscopic mucosal resection (EMR) should only be performed by experienced endoscopists and endoscopic submucosal dissection (ESD) only by experts because both EMR and ESD in the duodenum require proficiency in resection and mucosal defect closure techniques to manage immediate and/or delayed perforations (caused by the proteolytic enzymes of the pancreas). BEST PRACTICE ADVICE 13: Endoscopists should be aware that colon perforations occurring during diagnostic colonoscopy are most commonly located in the sigmoid colon due to direct trauma from forceful advancement of the colonoscope. Such tears recognized at the time of colonoscopy may be closed by TTSCs or OTSCs if the bowel preparation is good and the patient is stable. BEST PRACTICE ADVICE 14: Although colon perforation is responsive to various endoscopic tools such as TTSC, OTSC, and endoscopic suturing, perforations in the right colon, especially in the cecum, have been relegated to using only TTSCs because of inability to reach the site of the perforation with an endoscopic suturing device or OTSC if the colon is tortuous or unclean. Recently a new suture-based device for defect closure has been introduced allowing deep submucosal and intramuscular enhanced fixation through a standard gastroscope or colonoscope. BEST PRACTICE ADVICE 15: Patients with perforations who are hemodynamically unstable or who have suffered a delayed perforation with peritoneal signs or frank peritonitis should be surgically managed without any attempt at endoscopic closure. BEST PRACTICE ADVICE 16: In any adverse event including perforation, it is paramount to ensure accurate documentation, prompt discussion with the patient and family, and swift reporting to the quality officer (or equivalent) and risk management team of the institution (in major adverse events).

Endoscopic vacuum assisted closure (E-VAC) of upper gastrointestinal leakages

OBJECTIVES

Endoscopic vacuum-assisted closure (E-VAC) of leaks of the upper gastrointestinal tract is an increasingly applied endoscopic technique. Data on indication, clinical success, complications and prognostic factors are still sparse.

METHODS

Patients treated with E-VAC between 2012 and 2019 at a tertiary referral center have been retrospectively analyzed.

RESULTS

Overall, 116 patients treated with E-VAC were identified. Indication for E-VAC placement was postoperative leakage in 94/116 (81%), iatrogenic perforations 7/116 (6%) and others 15/116 (13%). In 92/116 (79%) of the patients E-VAC therapy showed successful wound closure. The first E-VAC after detection of insufficiency was significantly more often placed intracavitary in patients with E-VAC failure (p = .031). There was a trend for longer intensive care unit treatment for patients with E-VAC failure (p = .069). Complications occurred significantly more often in patients with E-VAC failure (p = .009). Platelet count was significantly higher in patients with E-VAC success at day of insufficiency detection (257/Thsd/µL (interquartile range [IQR], 185-362) vs. 195 (IQR, 117-309); p = .039). Platelet count (375 Thsd/µL (IQR, 256-484) vs. 190 (IQR, 129-292)), hemoglobin (9.5 g/dL (IQR, 8.8-10.1) vs. 8.7 g/dL (IQR, 8.15-9.35)) and C-reactive protein level (79 mg/L (IQR, 39.7-121.9) vs. 152 mg/L (IQR, 73.7-231)) at day 14 differed significantly. The 30 days mortality rate was 33.3% (8/24) in E-VAC failure compared with 2.2% in patients with E-VAC success (p = .001).

CONCLUSIONS

E-VAC is an emerging highly effective interventional endoscopic technique for gastrointestinal wound closure even in highly selected patients.

Endoscopic Management of Anastomotic Leakage after Esophageal Surgery - Ten Year Analysis in a Tertiary University Center

Background/Aims

Anastomotic leakage after esophageal surgery remains a feared complication. During the last decade, management of this complication changed from surgical revision to a more conservative and endoscopic approach. However, the treatment remains controversial as the indications for conservative, endoscopic, and surgical approaches remain non-standardized.

Methods

Between 2010 and 2020, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. The data of 28 patients diagnosed with anastomotic leak were further analyzed.

Results

Among 141 patients who underwent resection, 28 (19.9%) developed an anastomotic leak, eight (28.6%) of whom died. Thirteen patients were treated with endoluminal vacuum therapy (EVT), seven patients with self-expanding metal stents (SEMS) four patients with primary surgery, one patient with a hemoclip, and three patients were treated conservatively. EVT achieved closure in 92.3% of the patients with a large defect and no EVT-related complications. SEMS therapy was successful in clinically stable patients with small defect sizes.

Conclusions

EVT can be successfully applied in the treatment of anastomotic leakage in critically ill patients, while SEMS should be limited to clinically stable patients with a small defect size. Surgery is only warranted in patients with sepsis with graft necrosis.

Endoscopic negative pressure therapy (ENPT) of a spontaneous oesophageal rupture (Boerhaave's syndrome) with peritonitis - a new treatment option

Objectives

Boerhaave’s syndrome is a life-threatening disease with high mortality and morbidity. Endoscopic negative pressure therapy (ENPT) can be used to treat oesophageal perforations.

Case presentation

We report on a case of oesophageal rupture with peritonitis in a 35-year-old male patient. The start of treatment was 11 h after the perforation event. The treatment of the perforation defect was performed exclusively by intraluminal ENPT, the treatment of peritonitis was performed by laparotomy with abdominal lavage. For ENPT we used two different types of open-pore drains. The first treatment cycle of four days was performed with an open-pored polyurethane foam drainage (OPD), which was placed intraluminal to cover the perforation defect and to empty the stomach permanently. The second treatment cycle of nine days was performed with a thin nasogastric tube like double-lumen open-pored film drainage (OFD). For suction OPD and OFD were connected with an electronic vacuum pump (−125 mmHg). OFD enables active gastric emptying with simultaneous intestinal feeding via an integrated feeding tube. Intraluminal ENPT with a total treatment duration of 13 days was able to achieve the complete healing of the defect. Surgical treatment of the perforation defect was not necessary. The patient was discharged 20 days after initial treatment with a non-irritating abdominal wound and a closed perforation.

Conclusions

In suitable cases, endoscopic negative pressure therapy is a minimally invasive, organ-preserving procedure for the treatment of spontaneous oesophageal rupture.

Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience

Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.

Advancing flexible endoscopy to natural orifice transluminal endoscopic surgery

PURPOSE OF REVIEW

This review is an update on the recent advancements and clinical applications of flexible endoscopy in the context of natural orifice translumenal endoscopic surgery (NOTES). We focus on recent developments in gastrointestinal luminal and transluminal NOTES.

RECENT FINDINGS

NOTES has evolved from a hybrid approach utilizing a laparoscopic assistant to pure NOTES without laparoscopic assistance. Current experimental and clinical studies focus on the implementation of new minimally invasive approaches as well as on the training in the use of these procedures. In recent years, flexible endoscopic-NOTES and endoluminal surgery have increasingly reported favorable results in preclinical and experimental settings using flexible endoscopic cholecystectomy, cholecystolithotomy, and appendectomy. Additionally, flexible endoscopic lymphadenectomy and thyroidectomy are among the new interventions that are opening new frontiers for endoscopists to explore.

SUMMARY

Flexible endoscopy has paved way to new frontiers for endoscopists and surgeons. As the armamentarium of interventional endoscopy increases and the ability of endoscopists to perform advanced interventions safely fosters an inevitable step forward that will involve the integration of new technology with innovative thinking.

Endoscopic Management of Bariatric Surgery Complications According to a Standardized Algorithm

BACKGROUND AND AIMS

Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the effectiveness of a standardized algorithm for the treatment of BS-AE.

PATIENTS AND METHODS

We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS.

RESULTS

In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29-38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients.

CONCLUSIONS

Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate.

Endoscopic management of anastomotic leak after esophageal or gastric resection for malignancy: a multicenter experience

BACKGROUND

Most anastomotic leaks after surgical resection for esophageal or esophagogastric junction malignancies are treated endoscopically with esophageal stents. Internal drainage by double pigtail stents has been used for the endoscopic management of leaks following bariatric surgery, and recently introduced for anastomotic leaks after resections for malignancies. Our aim was to assess the overall efficacy of the endoscopic treatment for anastomotic leaks after esophageal or gastric resection for malignancies.

METHODS

We conducted a multicenter retrospective study in four digestive endoscopy tertiary referral centers in France. We included consecutive patients managed endoscopically for anastomotic leak following esophagectomy or gastrectomy for malignancies between January 2016 and December 2018. The primary outcome was the efficacy of the endoscopic management on leak closure.

RESULTS

Sixty-eight patients were included, among which 46 men and 22 women, with a mean ± SD age of 61 ± 11 years. Forty-four percent had an Ivor Lewis procedure, 16% a tri-incisional esophagectomy, and 40% a total gastrectomy. The median time between surgery and the diagnosis of leak was 9 (6-13) days. Endoscopic treatment was successful in 90% of the patients. The efficacy of internal drainage and esophageal stents was 95% and 77%, respectively (p = 0.06). The mortality rate was 3%. The only predictive factor of successful endoscopic treatment was the initial use of internal drainage (p = 0.002).

CONCLUSION

Endoscopic management of early postoperative leak is successful in 90% of patients, preventing highly morbid surgical revisions. Internal endoscopic drainage should be considered as the first-line endoscopic treatment of anastomotic fistulas whenever technically feasible.

Efficacy of endoscopic filling with polyglycolic acid sheets and fibrin glue for anastomotic leak after esophageal cancer surgery: identification of an optimal technique

BACKGROUND

Anastomotic leak is a potentially life-threatening complication following esophageal cancer surgery. In this study, we aimed to clarify the efficacy of endoscopic filling with polyglycolic acid (PGA) sheets and fibrin glue for anastomotic leak after esophageal cancer surgery.

METHODS

Consecutive patients who underwent endoscopic filling with PGA sheets and fibrin glue for anastomotic leak after esophageal cancer surgery between August 2014 and January 2020 were included in the study, with its efficacy retrospectively reviewed. We performed endoscopic filling using two methods: (1) filling the fistula with PGA sheets, followed by the application of a fibrinogen and thrombin solution (conventional method) and (2) filling the fistula with PGA sheets pre-soaked in a fibrinogen solution, followed by the application of a thrombin solution (pre-soak method).

RESULTS

A total of 14 patients underwent endoscopic filling procedures within the study period. The endoscopic filling procedures were successfully performed in all cases and no adverse events associated with the procedures were observed. Fistula closure was obtained in 10 (71%) cases. In the 10 successful cases, the median number of procedures was 1 (range 1-3) and the median time from the first procedure to oral intake was 7.5 days (range 4-36 days). The success rate of the pre-soak method was significantly higher than that of the conventional method (90% vs. 25%, P = 0.041).

CONCLUSIONS

Endoscopic filling with PGA sheets and fibrin glue is a safe and effective treatment for the closure of an anastomotic leak. The pre-soak method can achieve successful endoscopic filling.

Endoscopic vacuum therapy versus stent treatment of esophageal anastomotic leaks (ESOLEAK): study protocol for a prospective randomized phase 2 trial

BACKGROUND

Intrathoracic anastomotic leaks represent a major complication after Ivor Lewis esophagectomy. There are two promising endoscopic treatment strategies in the case of leaks: the placement of self-expanding metal stents (SEMS) or endoscopic vacuum therapy (EVT). Up to date, there is no prospective data concerning the optimal endoscopic treatment strategy. This is a protocol description for the ESOLEAK trial, which is a first small phase 2 randomized trial evaluating the quality of life after treatment of anastomotic leaks by either SEMS placement or EVT.

METHODS

This phase 2 randomized trial will be conducted at two German tertiary medical centers and include a total of 40 patients within 2 years. Adult patients with histologically confirmed esophageal cancer, who have undergone Ivor Lewis esophagectomy and show an esophagogastric anastomotic leak on endoscopy or present with typical clinical signs linked to an anastomotic leak, will be included in our study taking into consideration the exclusion criteria. After endoscopic verification of the anastomotic leak, patients will be randomized in a 1:1 ratio into two treatment groups. The intervention group will receive EVT whereas the control group will be treated with SEMS. The primary endpoint of this study is the subjective quality of life assessed by the patient using a systematic and validated questionnaire (EORTC QLQ C30, EORTC QLQ-OES18 questionnaire). Important secondary endpoints are healing rate, period of hospitalization, treatment-related complications, and overall mortality.

DISCUSSION

The latest meta-analysis comparing implantation of SEMS with EVT in the treatment of esophageal anastomotic leaks suggested a higher success rate for EVT. The ESOLEAK trial is the first study comparing both treatments in a prospective manner. The aim of the trial is to find suitable endpoints for the treatment of anastomotic leaks as well as to enable an adequate sample size calculation and evaluate the feasibility of future interventional trials. Due to the exploratory design of this pilot study, the sample size is too small to answer the question, whether EVT or SEMS implantation represents the superior treatment strategy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03962244 . Registered on May 23, 2019. DRKS-ID DRKS00007941.

VACStent: Combining the benefits of endoscopic vacuum therapy and covered stents for upper gastrointestinal tract leakage

Background and study aims  Endoscopic treatment has markedly improved the high morbidity and mortality in patients with upper gastrointestinal tract leakage. Most procedures employ either covered self-expanding metal stents (SEMS) or endoscopic vacuum therapy (EVT), both with good clinical success but also with concomitant significant shortcomings inherent in each technique. A newly developed device, the VACStent, combines the fully covered SEMS with a polyurethane sponge cylinder anchored on the outside. This allows endoluminal EVT while keeping the intestinal lumen patent. The benefit is prevention of stent migration because the suction force of the sponge-cylinder immobilizes the VACStent on the intestinal wall, while at the same time, the attached external vacuum pump suctions off any secretions and improves healing with negative-pressure wound treatment (NPWT). Patients and methods  In this pilot study, the first patients to receive the VACStent were assessed. Outcomes included the applicability and stability of the VACStent system together with the clinical course. Results  Three patients with different clinical courses were managed with the VACStent. The first patient suffered anastomotic leakage following subtotal esophagectomy and was successfully treated with two postoperative VACStents for 12 days. The second patient received a covered SEMS for 14 days for acute Boerhaave syndrome. Due to persistent leakage, management was converted to EVT. Seven days, later a VACStent was inserted to allow oral nutrition while the leak finally closed. In the third patient, a LINX Reflux Management System had to be removed for erosion, leaving the gastroesophageal junction (GEJ) with a full-thickness gap. After VACstent insertion, successful closure was achieved within 4 days. Conclusions  These clinical cases demonstrate the applicability and efficacy of the VACstent in management of esophageal and anastomotic leakage. With its vacuum sponge, the stent fosters wound healing while the covered SEMS keeps the passage patent for nutrition.

Endoscopic Vacuum Therapy in Patients with Transmural Defects of the Upper Gastrointestinal Tract: A Systematic Review with Meta-Analysis

A transmural defect of the upper gastrointestinal (UGI) tract is a life-threatening condition associated with high morbidity and mortality. Recently, endoscopic vacuum therapy (EVT) was used for managing UGI defects and showed promising results. We conducted a systematic review and meta-analysis to synthesize evidence on the efficacy of EVT in patients with transmural defects of the UGI tract. We searched the PubMed, Cochrane Library, and Embase databases for publications on the effect of EVT on successful closure, mortality, complications, and post-EVT strictures. Methodological quality was assessed using the Newcastle-Ottawa quality assessment scale. This meta-analysis included 29 studies involving 498 participants. The pooled estimate rate of successful closure with EVT was 0.85 (95% confidence interval [CI]: 0.81-0.88). The pooled estimate rates for mortality, complications, and post-EVT strictures were 0.11, 0.10, and 0.14, respectively. According to the etiology of the transmural defect (perforation vs. leak and fistula), no significant difference was observed in successful closure (odds ratio [OR]: 1.45, 95% CI: 0.45-4.67, p = 0.53), mortality (OR: 0.77, 95% CI: 0.24-2.46, p = 0.66), complications (OR: 0.94, 95% CI: 0.17-5.15, p = 0.94), or post-EVT stricture rates (OR: 0.70, 95% CI: 0.12-4.24, p = 0.70). The successful closure rate was significantly higher with EVT than with self-expanding metal stent (SEMS) placement (OR: 3.14, 95% CI: 1.23-7.98, p = 0.02). EVT is an effective and safe treatment for leaks and fistulae, as well as for perforations in the UGI. Moreover, EVT seems to be a better treatment option than SEMS placement for UGI defects.

The modern approach to esophageal palliative and emergency surgery

Thoracic surgeons currently have multiple options and strategies to guide treatment in esophageal palliative and emergency conditions. To guide the selection of an individualized palliative approach, physicians, including thoracic surgeons, must take into consideration many factors including prognosis, performance status and comorbidities of patients. For dysphagia more specifically, esophageal stent placement is the most widely used intervention for rapidly relieving dysphagia in inoperable esophageal cancer patients. The combination of esophageal stent placement with other therapies has an impact on palliative care. Innovations including radioactive stents, drug-eluding stents and biodegradable stents will require further evaluation and validation studies. Currently, patients with inoperable esophageal cancer have access to oncological and biological therapies that are improving their prognosis. A shift toward restaging and potential curative intent is occurring in current clinical practice. In acute intrathoracic esophageal perforation cases, high index of suspicion, multidisciplinary team expertise, antibiotics and hybrid treatment strategies, have significantly improved outcomes of patients in recent years. Hybrid treatment strategies denote the combination of minimally invasive interventions for source control and endoluminal procedures to seal the esophageal perforation. Endoluminal procedures as treatment of acute intrathoracic esophageal perforation include stent placement, over-the-scope clip and endoluminal vacuum therapy. Future perspective in the management of esophageal perforation seems to be the combination of endoluminal therapies tailored to the specific clinical scenario. Thoracic surgeons benefit from mastering endoluminal therapies and advanced endoscopic techniques. An understanding of these rapidly evolving therapies, i.e., outcomes, limitations and innovations, is required to optimally manage esophageal palliative and emergency conditions.

Endoscopic negative pressure therapy (ENPT) in head and neck surgery: first experiences in treatment of postoperative salivary fistulas and cervical esophageal perforations

INTRODUCTION

Iatrogenic cervical esophageal perforations (CEP) and postoperative salivary fistulas (PSF) are some of the complications requiring treatment in head and neck surgery. Conservative, surgical and endoscopic therapeutic techniques are used. Both CEP and PSF are potentially life-threatening complications and require intensive treatment. Endoscopic negative pressure therapy (ENPT) is an innovative endoscopic surgical procedure for the treatment of transmural intestinal defects throughout the gastrointestinal tract (GIT). In this retrospective study, we demonstrate its application in head and neck surgery.

MATERIALS AND METHODS

In ENPT, open-pore drains are placed endoscopically in the wound area. The drains can be inserted in an intraluminal position spanning the length of the defect (intraluminal ENPT), or through the defect into the extraluminal wound cavity (intracavitary ENPT). An electronic suction pump applies and maintains a continuous negative pressure of - 125 mmHg over a period of several days. The endoscopic drains are changed at regular intervals every few days until stable intracorporeal wound healing by secondary intention or defect closure is achieved. Between 06/2008 and 05/2019 ten patients (f = 3, m = 7; 46-78 years old) were treated with ENPT for CEP or PSF. Five patients had postoperative wound defects with consecutive PSF after total laryngectomy or floor of mouth resection. In five patients iatrogenic CEP was found following endoscopic procedures.

RESULTS

In all patients treated with ENPT, healing of the perforation defect or fistula was achieved (cure rate 100%). The median treatment duration was 13.7 days (range 4-42 days). No relevant treatment-associated complications were observed.

CONCLUSION

ENPT is a new, minimally invasive method for treating PSF and CEP.

Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection

Background

Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection.

Methods

From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included.

Results

Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest.

Conclusions

EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities.

Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).

Endoscopic negative pressure therapy for leaks with large cavities in the upper gastrointestinal tract: is it a feasible therapeutic option?

BACKGROUND

Endoscopic negative pressure therapy (ENPT) is an increasingly popular method for the treatment of various defects of the upper and lower gastrointestinal (GI) tract and has been associated with high success rates. The largest reported series focus on intraluminal therapy of local defects, whereas larger defects connected to the abdominal or pleural cavity are still regarded as indications for surgical revision in many units. The aim of our study is to assess the efficacy and the periinterventional characteristics of ENPT applications in patients with defects with large cavities in the upper GI tract.

METHODS

We retrospectively analysed all cases of ENPT applications in the upper gastrointestinal tract performed in our clinic between 1 January 2010 and 31 December 2019 and identified the patients with defects leading to large cavities with a length of at least 7 cm. The procedural characteristics, intraprocedural and late complications and overall clinical success were analysed.

RESULTS

We identified 14 cases meeting our inclusion criteria. In all cases, an intracavitary or combined intracavitary and intraluminal ENPT was applied. The average duration of therapy was 47.5 days and included an average of 10.4 changes per patient in an interval of 4.5 days. Clinical success rate was 92.9%, average hospital stay was 74.5 days. In three cases, a late stenosis occurred, which could be treated endoscopically.

CONCLUSION

Based on the data of our case series, we conclude that ENPT is a feasible and promising therapeutic option for upper GI defects with contact to large cavities.

Esophageal Perforation and EVAC in Pediatric Patients: A Case Series of Four Children

Introduction: In pediatric patients, esophageal perforation (EP) is rare but associated with significant morbidity and mortality rates of up to 20-30%. In addition to standard treatment options, endoscopic esophageal vacuum-assisted closure (EVAC) therapy has shown promising results, especially in adult patients. Thus far, the only data on technical success and effectiveness of EVAC in pediatric patients were published in 2018 by Manfredi et al. at Boston Children's Hospital. The sparse data on EVAC in children indicates that this promising technique has been barely utilized in pediatric patients. More data are needed to evaluate efficacy and outcomes of this technique in pediatric patients. Method: We reviewed five cases of therapy using EVAC, ArgyleTM Replogle Suction Catheter (RSC), or both on pediatric patients with EP in our institution between October 2018 and April 2020. Results: Five patients with EP (median 3.4 years; 2 males) were treated with EVAC, RSC, or a combination. Complete closure of EP was not achieved after EVAC alone, though patients' health stabilized and inflammation and size of EP decreased after EVAC. Four patients then were treated with RSC until the EP healed. One patient needed surgery as the recurrent fistula did not heal sufficiently after 3 weeks of EVAC therapy. Two patients developed stenosis and were successfully treated with dilatations. One patient treated with RSC alone showed persistent EP after 5 weeks. Conclusion: EVAC in pediatric patients is technically feasible and a promising method to treat EP, regardless of the underlying cause. EVAC therapy can be terminated as soon as local inflammation and C-reactive protein levels decrease, even if the mucosa is not healed completely at that time. A promising subsequent treatment is RSC. An earlier switch to RSC can substantially reduce the need of anesthesia during subsequent treatments. Our findings indicate that EVAC is more effective than RSC alone. In some cases, EVAC can be used to improve the tissues condition in preparation for a re-do surgery. At 1 year after therapy, all but one patient demonstrated sufficient weight gain. Further prospective studies with a larger cohort are required to confirm our observations from this small case series.