Endoscopic closure of acute esophageal perforations

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.

Gastrointestinal Emergencies and the Role of Endoscopy

Many gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies.

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.

Usefulness of lavage and drainage using video-assisted thoracoscopic surgery for Boerhaave's syndrome: a retrospective analysis

Background

Boerhaave’s syndrome has a high mortality rate due to respiratory failure, septic shock, and multiple organ failure. We had previously carried out primary repair with laparotomy and postoperative computed tomography-guided drainage for mediastinal abscess and empyema. However, this treatment prolonged mechanical ventilator days and length of intensive care unit stay. Therefore, we decided to carry out primary repair with laparotomy and add lavage and drainage using video-assisted thoracoscopic surgery.

Methods

From April 2004 to September 2018, 18 patients with Boerhaave’s syndrome were treated; 6 patients treated conservatively were excluded. Thus, 12 patients who underwent surgical treatment were divided into the computed tomography-guided drainage group (D group) (6 patients) and the lavage and drainage using video-assisted thoracoscopic surgery group (VATS group) (6 patients), and the two groups were retrospectively compared.

Results

The VATS group had significantly longer operation time than the D group {359 [328, 387] vs. 220 [155, 235] min, P=0.004}, but the ventilator-free days (VFDs) were significantly extended {24 [21, 24] vs. 10 [0, 17] days, P=0.02}, and the length of intensive care unit stay was significantly shortened {14 [8, 14] vs. 35 [29, 55] days, P=0.01}.

Conclusions

Lavage and drainage using video-assisted thoracoscopic surgery is an effective surgical method for Boerhaave’s syndrome.

Oesophagobronchial perforations after placement of an oesophageal self-expanding metallic stent

An oesophageal fully covered self-expanding metallic stent (SEMS) was placed in a 54-year-old Japanese man to relieve dysphagia owing to a stage cT1bN3M1c lung adenocarcinoma. High expression of programmed cell death-ligand 1 was microscopically confirmed, and pembrolizumab was subsequently administered. Several days later, the patient was hospitalized with septic shock, and severe mediastinitis and pneumonia caused by oesophageal SEMS-induced oesophageal and bronchial perforations were observed. Thoracoscopic surgery was performed to drain the mediastinal abscess, and an additional oesophageal SEMS was placed to close the oesophageal perforation. The patient gradually recovered from the potentially fatal infection, and the SEMS was retrieved after confirming perforation closure. We re-initiated pembrolizumab administration, and the patient responded well. The present report reveals the potential risk and effectiveness of SEMS, especially when administered with immune checkpoint inhibitors.

Successful treatment of large cavity esophageal disruptions with transluminal washout and endoscopic vacuum therapy: a report of two cases

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy has proven to be a feasible, safe therapy for management of esophageal wall defects, but with limited success. We describe a retrospective single-center analysis of two patients who underwent endoscopic vacuum therapy for significant esophageal disruptions with a median cross-sectional diameter of 10.7 cm. The technique involved the use of a standard upper video endoscope, nasogastric tube, and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal or thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross-sectional diameter was 10.7 cm. The average number of endoscopic vacuum therapy performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. One patient died 6 weeks later due to severe sepsis from aspiration pneumonia. Endoscopic washout and debridement followed by endoscopic vacuum therapy can be effective for large, even multiple, thoracic and mediastinal contaminations following esophageal perforation and gastroesopagheal anastomotic dehiscence and leaks in appropriately selected patients.

Management of anastomotic leaks following esophagectomy: when to intervene?

Background

Esophagectomy is the mainstay treatment for early stage and locoregionally advanced esophageal cancer. Anastomotic leaks following esophagectomy are associated with numerous detrimental sequelae. The management of anastomotic leaks has evolved over time. The present study is a single-institution experience of esophageal leak management over an 11-year period, in order to identify when these can be managed nonoperatively.

Methods

All patients undergoing esophagectomy with gastric reconstruction at our institution between 2004 and 2014 were identified. Preoperative patient characteristics and perioperative factors were reviewed. Failure of initial leak treatment was defined as need for escalation of therapy. Length of stay (LOS) and postoperative mortality were the primary outcomes. Follow-up was obtained through institutional medical records and the Social Security Death Index.

Results

Sixty-one of 692 (8.8%) patients developed an anastomotic leak. Forty-six patients (75.4%) first underwent observation, which was successful in 35 patients. Predictors of successful observation included higher preoperative albumin (P=0.02), leak diagnosed by esophagram (P=0.004), and contained leaks (P=0.01). Successful observation was associated with shorter LOS (P=0.001). Predictors of mortality included lower preoperative serum albumin (P=0.01) and induction therapy (P=0.03). Thirty and 90-day mortality among patients who developed an anastomotic leak were 9.8% and 16.7%, respectively.

Conclusions

Over half of anastomotic leaks were managed successfully with observation alone and did not require additional interventions. We have identified factors that may predict successful therapy with observation in these patients. Further research is warranted to determine more timely interventions for patients likely to fail conservative management.

Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks

BACKGROUND

To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks.

METHODS

We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016.

RESULTS

In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure.

CONCLUSION

Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

New devices and techniques for endoscopic closure of gastrointestinal perforations

Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience

BACKGROUND

Endoscopic treatment for esophageal perforation with stenting is an alternative to surgery. There is no data on the impact of timing of esophageal stent placement and outcomes in patients with esophageal perforation.

OBJECTIVE

To determine the significance of timing of esophageal stent placement on short-term (30-day complications) and long-term clinical outcomes of patients with esophageal perforation.

METHODS

Patients with esophageal perforations who underwent endoscopic treatment with stenting from 2007 to 2012 at the Cleveland Clinic were included for the study. Main outcomes measurements were impact of time to esophageal stent placement on 30-day complications and long-term outcomes.

RESULTS

A total of 20 patients (males 40 % and females 60 %) were included. Mean age was 72.5 ± 10 years. The most common etiology for perforation was iatrogenic after endoscopy procedure in 10 (50 %) patients. The stent was in place for a median of 24.6 days in our cohort. Eight patients (40 %) had stent placement within 24 h, while the remaining 12 patients (60 %) had stent placement after 24 h. The mortality rate due to perforation related causes was 10 % (2/20) in our study. The 30-day complication rate was 10 %; 1 with stent migration and the other with chest pain. The 30-day readmission rates excluding patients who died during the initial hospitalization were 10 %. On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain. The timing of stent placement (within 24 h or later) did not impact the risk of complications (Odds Ratio [OR] 1.13, 95 % confidence interval 0.1-8.9, P = 0.91).

CONCLUSIONS

Endoscopic stent placement is safe and effective for treating esophageal perforations. However, the timing of stent placement on outcomes remains unclear.

Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm

BACKGROUND

The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients.

STUDY DESIGN

An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected.

RESULTS

We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945.

CONCLUSIONS

Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.