Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae

Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review

Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.

Comprehensive management of gastrointestinal fistulas in necrotizing pancreatitis: a review of diagnostic and therapeutic approaches

INTRODUCTION

Gastrointestinal fistula (GIF) is a rare but severe complication in patients with necrotizing pancreatitis (NP), significantly prolonging disease course and increasing morbidity and mortality. Its subtle and nonspecific early symptoms often delay diagnosis and intervention. Despite its clinical significance, the low incidence of GIF in NP has resulted in limited research and a lack of consensus on optimal diagnostic and therapeutic strategies.

AREAS COVERED

This review focuses on the epidemiology, pathophysiology, diagnostic approaches, and therapeutic management of GIF in NP patients. Imaging techniques, such as contrast-enhanced computed tomography and endoscopy, have been integral to early diagnosis. Advances in interventional and surgical techniques provide new avenues for treatment, but variability in clinical practice highlights the need for standardized protocols.

EXPERT OPINION

Recent advances in diagnostic imaging have improved the detection of GIF, while innovations in interventional and surgical treatments show promise. Current research is still insufficient and varied. Future research should focus on developing diagnostic methods and treatment measures for such complications. By improving early diagnosis and offering insights into effective management strategies, it is hoped that patient outcomes can be improved.

Ileoanal pouch salvage rates with endoluminal vacuum therapy for early vs late anastomotic leaks

BACKGROUND

Anastomotic leaks after ileal pouch-anal anastomosis (IPAA) significantly compromise patient outcomes and increase healthcare resource utilization. The aim of this study was to evaluate the outcomes of endoluminal vacuum therapy (EndoVac) for pouch leaks. We hypothesized that EndoVac for early compared with late leaks was associated with a higher pouch survival rate.

METHODS

We retrospectively reviewed consecutive pouch anastomotic leaks treated with EndoVac therapy at our institution between 2013 and 2023. Patients were stratified into early (≤30 days) and late (>30 days) leak groups. Anastomotic healing was defined as complete closure of the leak site and resolution of symptoms. Pouch failure was defined as a permanent ileostomy or pouch excision. The probability of pouch survival was estimated using the Kaplan-Meier method.

RESULTS

A total of 14 patients with IPAA were included: median age, 34 years; 71% were males; and median body mass index, 23.46 kg/m2. The following were the diagnoses made: ulcerative colitis (n = 12) and familial adenomatous polyposis (n = 2). The median (IQR) time from pouch construction to leak was 44.5 (12-192) days; of these, 6 (43%) were early, and 8 (57%) were late. All (100%) leaks were at the anastomosis; all (100%) were diverted at the time of EndoVac therapy: 10 (71%) still diverted, and 4 (29%) rediverted. Patients underwent a median of 5.5 EndoVac changes (3-7) over a 13.5 (6-21) day period from initiation of treatment to cessation of therapy. After EndoVac therapy, healing was observed in 10 (71%) patients; 2 of whom required a minor handsewn anastomotic revision but healed completely, and 4 did not heal; 3 had pouch excision, and 1 underwent redo pouch surgery. Anastomotic healing (66.7% vs 75%, P = .7) and pouch survival (83.3% vs 75%, P = .73) were not significantly different between the early and late leak groups. The overall pouch salvage rate was 78.5%.

CONCLUSION

EndoVac therapy was effective in achieving high rates of pouch salvage and anastomotic healing in patients with ileoanal pouch leaks, irrespective of the timing of intervention postoperatively. This supports the use of EndoVac as a viable treatment option for both early and late anastomotic leaks.

Endoscopic Through-the-Scope X-Tack Helix Suturing System for Complete Closure of a Large Full-Thickness After Surgical Gastric Perforation

Gastric perforation is considered a surgical emergency managed operatively; however, endoscopic repair techniques have gained popularity as they are cost-effective, improve mortality, and decrease hospital stay and recurrence. With increased prevalence of gastric defects postoperatively and after invasive endoscopic procedures, various endoscopic techniques were developed over the years, but special consideration should be given to the defect type, size, and location. Our case highlights the use of X-Tack through-the-scope suturing for closing a large, full-thickness gastric perforation in a difficult location where OverStitch is not feasible.

VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review

Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.

Management of fistulas in the upper gastrointestinal tract

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Endoscopic Internal Drainage Achieving Successful Closure of Iatrogenic Pharyngoesophageal Fistula

Endoscopic internal drainage (EID) is a minimally invasive endoscopic technique that effectively closes upper gastrointestinal fistulas. We report the successful closure of an oropharyngeal fistula in a 78-year-old man with a history of supraglottic squamous cell carcinoma. He presented with inspiratory stridor after biopsy of a lateral wall lesion in the piriformis sinus. Imaging showed a fistula tract between the piriformis sinus and the esophagus. EID was performed using a double-pigtail stent inserted inside the fistula. Eventually, repeat imaging showed evidence of fistula closure. To our knowledge, this is the first reported case of using EID for repairing an oropharyngeal fistula.

Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review

Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites.

Homemade endoscopic vacuum therapy device for the management of transmural gastrointestinal defects

OBJECTIVES

Endoscopic vacuum therapy (EVT) possesses a unique mechanism of action providing a less invasive alternative for the management of transmural gastrointestinal defects (TGID). This study evaluates the efficacy and safety of a novel homemade EVT (H-EVT) for the treatment of TGID.

METHODS

Retrospective multicenter study including patients who underwent H-EVT for TGID between January 2019 and January 2022. Main outcomes included technical and clinical success as well as safety outcomes. Subgroup analyses were included by defect location and classification. Logistic regression analyses were performed to determine predictors for successful closure.

RESULTS

A total of 144 patients were included. Technical success was achieved in all patients, with clinical success achieved in 88.89% after a mean of 3.49 H-EVT exchanges over an average of 23.51 days. After excluding 10 cases wherein it was not possible to achieve negative pressure, successful closure occurred in 95.52% of patients. Time to clinical success was less for defects caused by endoscopic (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.33-1.20) compared to surgical procedures and for patients with simultaneous intracavitary and intraluminal H-EVT placement (HR 0.70; 95% CI 0.55-0.91). Location and classification of defect did not impact clinical success rate. Simultaneous placement of both an intraluminal and intracavitary H-EVT (odds ratio 3.08; 95% CI 1.19-7.95) was a significant predictor of clinical success. Three device-related adverse events (2.08%) occurred.

CONCLUSIONS

The use of the H-EVT is feasible, safe, and effective for the management of TGID.

[Interventional endoscopy in gastroenterology]

Essential innovations in interventional endoscopy have significantly broadened the treatment armamentarium in gastroenterology. The treatment and complication management of intraepithelial neoplasms and early forms of cancer are increasingly being primarily addressed endoscopically. In cases of endoluminal lesions with no risk of lymph node or distant metastases, endoscopic mucosal resection and endoscopic submucosal dissection have become established as standards. For broad-based adenomas, coagulation of the resection margins should be performed in the case of a piecemeal resection. Submucosal lesions can be reached and resected by tunneling techniques. Peroral endoscopic myotomy in cases of achalasia is a new treatment option for hypertensive and hypercontractile motility disorders. In addition, endoscopic myotomy for gastroparesis has shown very promising results. In this article, new resection techniques and so-called third space endoscopy are presented and critically discussed.

Endoscopic management of low output recurrent colonic fistula or leak after anterior resection for rectal cancer: a randomized controlled trial

BACKGROUND

Colonic anastomotic leak and fistula following anterior resection surgery for rectal cancer are associated with high mortality rates. The incidence of occurrence varies from 2 to 25% and it is difficult to accurately calculate the incidence of fistula and leak post anterior resection, as most of them are asymptomatic. Endoscopic management of fistula and leak has become the first line of management after conservative management in many gastrointestinal surgical centers with the advantages of being less invasive, shorter length of post-operative hospital stay, effective and rapid recovery in comparison to revision surgery. Effective endoscopic management for colonic fistula or leak depends on the clinical status of the patient and fistula characters (time-to-occur and size and site of defect), and device availability.

METHODS

This prospective randomized controlled clinical trial included all patients who developed the manifestations of low output recurrent colonic fistula or leak after colonic anterior resection for rectal cancer at Zagazig University Hospital between (December 2020 and August 2022). Sample size was 78 patients divided into two equal groups. Endoscopic group (EG): included 39 patients who underwent endoscopic management. Surgical group (SG): included 39 patients who underwent surgical management.

RESULTS

The investigators randomized eligible 78 patients into two groups: 39 patients in SG and 39 patients in EG. The median size of the fistula or leak was nine (range: 7-14) mm in EG, versus ten (range: 7-12) mm in SG. Clipping and Endo-stitch device were used in 24 patients versus 15 patients, respectively, in EG while primary repair with ileostomy, and resection & anastomosis were used in 15 patients versus 24 patients, respectively, in SG. Recurrence, abdominal collection, and mortality were the post procedure's complications with incidence of occurrence of 10.3, 7.7 and 0%, respectively, in EG versus 20.5, 20.5 and 2.6%, respectively, in SG. Excellent, good, and poor were the parameters for quality of life with incidence of occurrence of 43.6, 54.6 and 0%, respectively, in EG versus 28.2, 33.3 and 38.5%, respectively, in SG. Median hospital stay was one (range: 1-2) day in endoscopic group, and seven (range: 6-8) days in SG.

CONCLUSION

Endoscopic intervention may offer a successful modality in managing low output recurrent colonic fistula or leak after anterior resection for rectal cancer that did not respond to conservative measures in stable patients.

CLINICALTRIALS

gov ID: NCT05659446.

Tube-in-tube endoscopic vacuum therapy for treatment of colorectal anastomotic leaks: A low-cost, patient-friendly, feasible and efficient technical modification of sponge-based endoscopic vacuum therapy

BACKGROUND AND AIMS

Colorectal endoscopic vacuum therapy (CR EVT) is usually performed using sponges passed through the anus. It may be associated with patient discomfort and displacement of the aspiration tube.

METHODS

With the tube-in-tube endoscopic vacuum therapy modification (CR TT-EVT), it is possible to position the aspiration tube in the pelvic cavity through the abdominal wall. In addition, it allows frequent cleaning of the fistula, eliminates the need for programmed device changes, and enables a standardized approach to such a wide variety of fistulas, leaks, and perforations.

RESULTS

Here is a technical note on how to perform CR TT-EVT, while we are at the early phase of our case series we have reached 100% of technical success.

Endoscopic management of postoperative fistulas using purse-string suture combined with cyanoacrylate

A 65-year-old man complained of choking and hoarseness for fifteen days, and was diagnosed with thyroid carcinoma infiltrating esophagus and trachea. Therefore, the patient underwent thyroidectomy, partial esophagectomy, and partial tracheal resection, and histopathology confirmed primary squamous cell carcinoma of the thyroid. Unfortunately, on the tenth postoperative day, an esophagogastroduodenoscopy showed a large fistula (25 mm*20 mm) in esophageal introitus, and diagnosed with tracheoesophageal fistula due to sustained choking. The patient failed to response to conservative treatment within 14 days. Consequently, endoscopic management was performed that the fistula was partly closed by purse-string suture using endoloop and hemostatic clips, then 1 ml of cyanoacrylate (Compon, China) was injected into the fistulous tract through a catheter. Interestingly, the patient's symptom was relieved after the procedure. And, esophagogastroduodenoscopy revealed healing of the fistula 14 days later.

Endoscopic closure of refractory upper GI-tracheobronchial fistulas with a novel occluder: a prospective, single-arm, single-center study (with video)

BACKGROUND AND AIMS

Upper GI-tracheobronchial fistula is a morbid condition with high mortality. It is a challenge for endoscopists because currently available treatments have severe limitations. In this study we assessed the efficacy and safety of an occluder we invented for endoscopic closure of refractory upper GI-tracheobronchial fistulas.

METHODS

This was a prospective, single-arm, single-center trial conducted between September 2020 and March 2022. All patients undergoing occluder placement were eligible to enroll. The primary endpoints were clinical success rate (CSR) and complete closure rate (CCR) at 3 months and safety. Secondary efficacy endpoints were technical success rates, CSRs and CCRs at 1 and 6 months, near-complete closure rates, change from baseline in body mass index (BMI), and health-related quality of life (HRQoL) at 1, 3, and 6 months.

RESULTS

Twenty-eight patients (mean age, 63.2 years; 23 men) were enrolled. Eighteen through-the-scope occluders (TTSOs) and 10 through-the-overtube occluders (TTOOs) were implanted, with a technical success rate of 100%. The mean procedure time for the TTSO and TTOO groups were 28.0 ± 8.0 minutes and 31.8 ± 7.7 minutes, respectively. The CSRs at 1, 3, and 6 months were 92.9%, 96.4%, and 92.0% and the CCRs were 60.7%, 60.7%, and 60.0%, respectively. The mean BMI at 3 and 6 months and HRQoL at 1, 3, and 6 months were significantly increased compared with baseline (P < .05). Two completely occluded fistulas had 1-sided or complete healing by coverage of granulation tissue and re-epithelialized mucosa at a follow-up of 6 and 12 months. All 14 adverse events were either mild and transient or easily corrected.

CONCLUSIONS

Our clinical outcomes suggest that this novel GI occluder is a safe and effective salvage option for patients with refractory upper GI-tracheobronchial fistulas. (Clinical trial registration number: ChiCTR2000038566.).

Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus

BACKGROUND

Anastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons.

METHOD

Seven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon.

RESULTS

Thirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks.

CONCLUSION

Although further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.

Endoscopic Internal Drainage with Double Pigtail Stents for Upper Gastrointestinal Anastomotic Leaks: Suitable for All Cases?

Background/Aims

Surgeons and endoscopists have started to use endoscopically inserted double pigtail stents (DPTs) in the management of upper gastrointestinal (UGI) leaks, including UGI anastomotic leaks. We investigated our own experiences in this patient population.

Methods

From March 2017 to June 2020, 12 patients had endoscopic internal drainage of a radiologically proven anastomotic leak after UGI surgery in two tertiary UGI centers. The primary outcome measure was the time to removal of the DPTs after anastomotic healing. The secondary outcome measure was early oral feeding after DPT insertion.

Results

Eight of the 12 patients (67%) required only one DPT, whereas four (33%) required two DPTs. The median duration of drainage was 42 days. Two patients required surgery due to inadequate control of sepsis. Of the remaining ten patients, nine (90%) did not require a change in DPT before anastomotic healing. Nine patients were allowed oral fluids within the first week and a soft diet in the second week. One patient was allowed clear oral feeds on the 8th day after DPT insertion.

Conclusions

Endoscopic internal drainage is becoming an established minimally invasive technique for controlling anastomotic leak after UGI surgery. It allows for early oral nutritional feeding and minimizes discomfort from conventional external drainage.

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.

Cost-effective modified endoscopic vacuum therapy for the treatment of gastrointestinal transmural defects: step-by-step process of manufacturing and its advantages

Video 1Cost-effective modified endoscopic vacuum therapy for GI transmural defects. Step-by-step process of manufacturing and potential advantages.1.Cut half gauze to the ideal size to cover only the fenestrated portion of the nasogastric tube (NGT).2.Wrap the gauze around the fenestrated portion of the NGT. The assistance of another person is important in this process.3.Cut the antimicrobial incise drape to match the size of the fenestrated portion of the NGT. Note that the incise drape is a very strong adhesive; therefore, 3 people are usually required to assemble it properly.4.Next, the suture is used to fix the gauze and drape to the NGT. Perform fixation of the modified sponge in 3 places. The first knot is in the proximal portion, just below the last fenestra of the NGT, as a marker of where the vacuum system starts. The second knot is at the distal end, to avoid migration of the modified sponge. The third knot is in the middle of the modified sponge, which is essential to serve as a guide during endoscopic placement. For example, in cases of defects without collection in which the sponge will be placed in an intraluminal position, it is ideal to place the vacuum system in the middle of the defect; in cases of intracavitary placement, it will work as a guide to how much of the modified sponge will be inside the collection.5.Finally, use a needle to make innumerable punctures in the modified sponge system to obtain adequate aspiration. An 18G needle is recommended because, in addition to having an adequate diameter, it is very sharp, which facilitates perforation of the modified sponge system.6.After creation of the modified endoscopic vacuum therapy, the functionality test is performed. Turn on the wall suction system, connect the distal end of the NGT to the tube of the canister connected on the wall, and place the NGT inside a bowl with a liquid solution. The aspiration of a large amount of liquid indicates proper functioning of the modified endoscopic vacuum therapy system.7.The device is then ready to be positioned endoscopically in the patient. After proper positioning, connect the NGT to the suction tube to avoid migration of the device upon removal of the scope.8.In addition to the cost-effective device as described, in our practice we also use wall suction to reduce costs associated with the use of the vacuum machine.9.Use the antimicrobial incise drape to seal the connection between the NGT and the suction tube to avoid leakage within the connection.10.Last, owing to instability of the negative wall pressure, a 20F intravenous catheter is connected to the tube to maintain a negative pressure between -75 and -150 mmHg, as confirmed by laboratory studies performed by our group.

Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis

BACKGROUND

Upper gastrointestinal fistulas, leaks, and perforations represent a high cost burden to health systems worldwide, with high morbidity and mortality rates for affected patients. Management of these transmural defects remains therapeutically challenging.

OBJECTIVES

The aim of this study is to perform a systematic review and meta-analysis to investigate the efficacy and safety of self-expanding metal stents (SEMS) versus endoscopic vacuum therapy (EVT) for treatment of upper gastrointestinal transmural defects.

METHODS

Searches were performed on MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events.

RESULTS

Five studies with a total of 274 patients were included. There was a 21% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.21, CI 0.10-0.32; P = 0.0003). EVT demonstrated a 12% reduction in mortality compared to stenting (RD 0.12, CI 0.03-0.21; P = 0.006) and an average reduction of 14.22 days in duration of treatment (CI 8.38-20.07; P < 0.00001). There was a 24% reduction in adverse events (RD 0.24, CI 0.13-0.35; P = 0.0001. There were no statistical differences between the studied therapies regarding the length of hospital stay.

CONCLUSION

Endoscopic vacuum therapy proves to be superior in successful defect closure, mortality, adverse events and duration of treatment.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BACKGROUND

Anastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.

CASE PRESENTATION

In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.

CONCLUSIONS

We reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Minimally invasive electroceutical catheter for endoluminal defect sealing

Surgical repair of lumen defects is associated with periprocedural morbidity and mortality. Endovascular repair with tissue adhesives may reduce host tissue damage, but current bioadhesive designs do not support minimally invasive deployment. Voltage-activated tissue adhesives offer a new strategy for endoluminal repair. To facilitate the clinical translation of voltage-activated adhesives, an electroceutical patch (ePATCH) paired with a minimally invasive catheter with retractable electrodes (CATRE) is challenged against the repair of in vivo and ex vivo lumen defects. The ePATCH/CATRE platform demonstrates the sealing of lumen defects up to 2 millimeters in diameter on wet tissue substrates. Water-tight seals are flexible and resilient, withstanding over 20,000 physiological relevant stress/strain cycles. No disruption to electrical signals was observed when the ePATCH was electrically activated on the beating heart. The ePATCH/CATRE platform has diverse potential applications ranging from endovascular treatment of pseudo-aneurysms/fistulas to bioelectrodes toward electrophysiological mapping.

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity

OBJECTIVES

The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG.

METHODS

One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases.

RESULTS

Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal).

CONCLUSION

This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.

Use of over-the-scope clips in the colon in clinical practice: results from a German administrative database

BACKGROUND : The efficacy and safety of over-the-scope (OTS) clips in the colon is limited. This study aimed to evaluate OTS clip use in the colon in routine colonoscopy.

METHODS

Using administrative data from a large health insurance company, patients with OTS clip placement during colonoscopy were identified and analyzed by specific administrative codes. Indication for OTS clipping was analyzed, and follow-up was evaluated for surgical and repeat endoscopic interventions.

RESULTS

In 505 patients, indications for OTS clips were iatrogenic perforations (n = 80; Group A), polypectomy (n = 315; Group B), colonic bleeding (n = 51; Group C), and various underlying diseases (n = 59; Group D). In 11 Group A patients (13.8 %), surgical interventions occurred, mostly within 24 hours after clipping (n = 9), predominantly overstitching (n = 8). OTS clipping during polypectomy (Group B) was for complications (e. g. bleeding in 27 %) or was applied prophylactically. Only five patients required early surgery, three of whom had colorectal cancer. In four Group C patients (7.8 %), surgical resections were performed (persistent bleeding n = 1, colorectal cancer n = 2), while six patients underwent early repeat colonoscopy for recurrent bleeding. During further follow-up (days 11-30), 17 patients underwent resection for colonic neoplasms (n = 12) or persistent bleeding (n = 4), but only one case could be directly traced back to local OTS clip complication.

CONCLUSION

Colonic OTS clipping appears safe and effective in selected indications and complications in clinical routine but must be anatomically and technically feasible, avoiding overuse.

Contralateral spontaneous rupture of the esophagus following severe emesis after non-intubated pulmonary wedge resection

Background

Non-intubated thoracoscopic lung surgery has been reported to be technically feasible and safe. Spontaneous rupture of the esophagus, also known as Boerhaave’s syndrome (BS), is rare after chest surgery.

Case presentation

A 60-year-old female non-smoker underwent non-intubated uniportal thoracoscopic wedge resection for a pulmonary nodule. Ultrasound-guided serratus anterior plane block was utilized for postoperative analgesia. However, the patient suffered from severe emesis, chest pain and dyspnea 6 h after the surgery. Emergency chest x-ray revealed right-sided hydropneumothorax. BS was diagnosed by chest tube drainage and computed tomography. Besides antibiotics and tube feeding, a naso-leakage drainage tube was inserted into the right thorax for pleural evacuation. Finally, the esophagus was healed 40d after the conservative treatment.

Conclusions

Perioperative antiemetic therapy is an indispensable item of fast-track surgery. Moreover, BS should be kept in mind when the patients complain of chest distress following emesis after thoracic surgery.

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

[Interventional endoscopy in the gastrointestinal tract : Indications and limitations]

The spectrum of endoscopic techniques has been greatly enlarged in recent years. Lesions and also (iatrogenic) complications that required surgical procedures in the past can now often be treated endoscopically. Advances in endoscopic mucosal resection and submucosal dissection also enable the resection of large or laterally spreading polyps in the gastrointestinal tract. Full-thickness resection is also possible by means of specially designed clips. By the creation of a submucosal tunnel submucosal lesions can be completely excised and the muscle fibers of the lower esophageal sphincter can be endoscopically severed in achalasia patients. Endosonography-guided interventions have developed into the standard procedure for complicated pancreatitis and the use of cholangioscopy offers new therapeutic procedures for the bile and pancreatic ducts. In this continuing medical education article interventional endoscopic techniques are presented and critically evaluated.

Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study

Background and study aims  Esophageal fistulas after esophagectomy are associated with high mortality and poor quality of life. They are sometimes intractable to conservative management and surgery that increases mortality. Few studies have assessed use of polyglycolic acid (PGA) sheets with fibrin glue for esophageal fistulas. We investigated the safety of using PGA sheets with fibrin glue for esophageal fistulas after esophagectomy. Patients and methods  This was a single-center prospective pilot study. Patients who had refractory esophageal fistulas after esophagectomy were included. PGA sheets were filled in the fistula using biopsy forceps. Fibrin glue was applied to the PGA sheets. We repeated the procedure 1 week later. The outcome measures were the incidence of adverse events (AEs) and closure of the fistula. Results  Five patients were assessed. No adverse events were observed. The esophageal fistula was closed with the application of PGA sheets four times in 40 % (2/5) of the cases. Conclusions  PGA sheets with fibrin glue were safe for esophageal fistula closure after esophagectomy and do not involve the risk of AEs.

Successful Closure of a Benign Refractory Tracheoesophageal Fistula Using an Over-the-Scope Clip after Failed Esophageal Stent Placement and Surgical Management

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.

Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation

BACKGROUND

Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success.

METHODS

A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed.

RESULTS

Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%.

CONCLUSIONS

The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.

[Endoscopic treatment of benign gastrointestinal fistulas]

OBJECTIVE

To evaluate the possibility and safety of modified endoscopic stent in the treatment of benign intestinal fistulas.

MATERIAL AND METHODS

Analysis of the experience of Sklifosovsky Research Institute for Emergency Care and recent numerous foreign reports confirms that staged treatment followed by delayed radical surgery is the most perspective approach. Modified endoscopic treatment of intestinal fistulas successfully used in 10 patients is reported in the article.

RESULTS

Endoscopic stenting of various parts of gastrointestinal tract is a minimally invasive treatment of this pathology and not followed by complications and mortality. An important advantage is early closure of fistula that reduces duration of treatment and improves further social and labor rehabilitation of patients.

Valuing innovative endoscopic techniques: endoscopic suturing to prevent stent migration for benign esophageal disease

BACKGROUND AND AIMS

Reimbursement often presents a significant barrier to widespread adoption of innovative endoscopic devices. We aimed to determine the value (defined as cost savings to a payer) of endoscopic suturing devices in preventing the migration of esophageal stents placed for benign esophageal diseases.

METHODS

A decision-analytic model was constructed from a payer perspective evaluating fully covered metal stent placement for benign esophageal diseases (fistula, leak, perforation, or stricture) in a hospital outpatient setting. The model compared 2 strategies: endoscopic suturing to anchor the stent or no suture. Health care outcomes and costs were derived from published systematic reviews and national databases (U.S. Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] for safety data; 2018 Medicare Physician Fee Schedule and Provider Utilization and Payment Data databases for reimbursement data).

RESULTS

From a payer perspective, reimbursement for care increased by US$1487.98 without endoscopic suturing per patient, compared with US$621.06 with endoscopic suturing, to cover the risk of stent migration in addition to usual professional and facility reimbursement for stent placement. Thus, an average cost saving of US$866.92 per patient was achieved with endoscopic suturing to reduce stent migration risks. Cost savings associated with suturing ranged from US$147.48 to US$1586.36 per patient, based on the indication for the procedure in sensitivity analysis. Cost savings increased with higher rates of technical success in suture placement.

CONCLUSIONS

Creating a defined reimbursement pathway for endoscopic suture fixation of a stent for the treatment of benign esophageal diseases appears to be justified from a payer perspective.

The Use of the Overstitch to Close Perforations and Fistulas

Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks

Background and study aims  A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods  A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results  A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions  There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

Endoscopic negative pressure therapy (ENPT) for duodenal leakage - novel repair technique using open-pore film (OFD) and polyurethane-foam drainages (OPD)

Background and study aims  Endoscopic negative pressure therapy (ENPT) is used to close transmural defects in the rectum and esophagus. Very few reports have described ENPT to manage duodenal defects. This study was designed to demonstrate ENPT in a population of 11 patients with transmural duodenal leakages. Patients and methods  The method of ENPT was adapted for duodenal use. Open-pore polyurethane-foam or a thin, open-pore double-layered film was wrapped around the distal end of a gastroduodenal tube. First, this open-pore element was placed on the inner wound in the duodenum with endoscopy. Second, continuous negative pressure of -125 mmHg was applied with an electronic pump. Drains were changed after 2 to 7 days. Results  Eleven patients were treated with duodenal leaks. Eight defects occurred after operative closure of perforated duodenal ulcers, papillectomy or stricturoplasty, one anastomotic leakage after Billroth - 1 distal gastric resection, one iatrogenic perforation in endoscopic retrograde cholangiopancreatography, and one by a surgical drain. Median duration of therapy was 11 days (range 7 - 24 days). Complete healing of defects was achieved in all patients. Conclusion  ENPT is an innovative endoscopic alternative for treatment of transmural duodenal defects.

Endoscopic management of post-surgical GI wall defects with the overstitch endosuturing system: a single-center experience

BACKGROUND AND AIMS

Post-GI surgical wall defects are frequent and life-threatening complications, with limited literature regarding current treatment. This case series aims to assess the safety, feasibility, and outcomes of endoluminal therapy with the overstitch endoscopic suturing system (Apollo Endosurgery Inc, Austin).

MATERIALS AND METHODS

All patients who underwent endoscopic suturing for post-surgical wall defect management at IRCCS-ISMETT Palermo from October 2017 until January 2019 were retrospectively enrolled. Stratification therapy was applied according to the clinical scenario, time from surgery to endoscopic intervention, and structural condition of the wall defect layers (tissue status and suture feasibility). The therapeutic endoscopic strategy was divided into three groups (A: pure endoscopic direct suture; B: combined therapy with endoscopic direct suture + FC-SEMS placement + anchoring; C: FC-SEMS placement + anchoring). Success was considered the resolution of symptoms and the presence of a regular intestinal transit after a period of 4-6 weeks.

RESULTS

Twenty (20) patients (male/female 7/13; mean age 54 ± 13.43 years) were included in the study (group A: 9 patients, group B: 7 patients, group C: 4 patients). The types of operative procedures were bariatric (9/20), post-tracheostomy (3/20), post-operative GI surgery (8/20). The post-surgical defects were predominantly intermediate and chronic (24-72 h: 1/20; 3-30 days: 13/20; > 30 days: 6/20). The overall clinical success was 80% (17/20 patients), with a success of 94% (16/17 patients) when excluding the three cases of tracheo-esophageal fistula. No evidence of migration was detected. The only complication was short stenosis of the distal esophagus, present in 4 patients (19%) and successfully treated with a novel lumen-apposing metal stent.

CONCLUSIONS

In our experience, considering the absence of clear guidelines, the endoluminal approach with the overstich endoscopic suturing system is a valid alternative to conventional therapy, offering mini-invasiveness, and presenting promising opportunities in terms of technical feasibility and clinical efficacy.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects

BACKGROUND

Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period.

METHODS

A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure.

RESULTS

We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.

CONCLUSIONS

Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Endoscopic Full-Thickness Defects and Closure Techniques

PURPOSE OF REVIEW

Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects.

RECENT FINDINGS

The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.