Impact of Endoscopic Vacuum Therapy with Low Negative Pressure for Esophageal Perforations and Postoperative Anastomotic Esophageal Leaks

Abstract

Introduction: Management of esophageal anastomotic leaks (AL) and esophageal perforations (EP) remains difficult and often requires an interdisciplinary treatment modality. For primary endoscopic management, self-expanding metallic stent (SEMS) placement is often considered first-line therapy. Recently, endoscopic vacuum therapy (EVT) has emerged as an alternative or adjunct for management of these conditions. So far, data for EVT in the upper gastrointestinal-tract is restricted to single centre, non-randomized trials. No studies on optimal negative pressure application during EVT exist. The aim of our study is to describe our centre’s experience with low negative pressure (LNP) EVT for these indications over the past 5-years. Patients and Methods: Between January 2014 and December 2018, 30 patients were endoscopically treated for AL (n = 23) or EP (n = 7). All patients were primarily treated with EVT and LNP between –20 and –50 mm Hg. Additional endoscopic treatment was added when EVT failed. Procedural and peri-procedural data, as well as clinical outcomes including morbidity and mortality, were analysed. Results: Clinical successful endoscopic treatment of EP and AL was achieved in 83.3% (n = 25/30), with 73.3% success using EVT alone (n = 22/30). Mean treatment duration until leak closure was 16.1 days (range 2–58 days). Additional treatment modalities for complete leak resolution was necessary in 10% (n = 3/30), including SEMS placement and fibrin glue injection. Mean hospital stay for patients with EP was shorter with 33.7 days compared to AL with 54.4 days (p = 0.08). Estimated preoperative 10-year overall survival (Charlson comorbidity score) was 39.4% in patients with AL and 59.9% in patients with EP (p = 0.26). A mean of 5.1 EVT changes (range 1–12) was needed in EP and 3.6 changes (range 1–13) in AL to achieve complete closure, switch to other treatment modality, or reach endoscopic failure (p = 0.38). Conclusion: LNP EVT enables effective minimally – invasive endoluminal leak closure from anastomotic esophageal leaks and EP in high-morbid patients. In this study, EVT was combined with other endoscopic treatment options such as SEMS placement or fibrin glue injection in order to achieve leak or perforation closure in the vast majority of patients (83.3%). Low aspiration pressures led to slower but still sufficient clinical results.

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

“…13 The reduction of costs is an omnipresent challenge in the current medical landscape with ever-increasing economic pressure. Many study groups have examined the effectiveness of EVT and investigated different indications, [14][15][16] but data on economic ramifications is sparse. Therefore, the goal of this study was to quantify and compare costs incurred by the main complication management methods for AL after esophageal resection.…”

Gastric conduit perforation after Ivor Lewis esophagectomy successfully treated with endoscopic vacuum therapy (E-VAC): a case report

“…Even though there is no consensus on its optimal indications, all patients with acute or chronic GI defects can be theoretically candidates to E-VAC [ 5 ]. Literature lacks randomized controlled trial comparing E-VAC to other treatments [ 7 ] and the current evidence derives from single-center retrospective studies. E-VAC, compared to other endoscopic approaches such as clips and stents, other than an apposition of wound edges provides also simultaneous internal drainage of purulent collections.…”

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

“…[22,25] Eleven studies included patients with both postoperative leak and perforation. [12,16,27,29,30,32,33,36,38,39,42] Four studies included patients with stula. [34,35,43,45] Four studies compared EVT with SEMS.…”

“…The quality was poor in 15 of the included studies [22, 23, 25, 27, 30, 32, 34-36, 39-43, 45] and moderate in 14 studies. [11,12,16,20,21,24,26,28,29,31,33,37,38,44] 3.3. Primary and secondary outcomes 3.3.1.…”

“…[7][8][9] Recently, endoscopic vacuum therapy (EVT) has shown rather excellent e cacy in managing UGI defects. [10][11][12] This method applies continuous negative pressure to drain the infected uid and accelerate wound healing. [13] EVT is suitable for localised defects for which stent placement is not possible.…”