Introduction

Esophageal or gastric perforation is associated with systemic inflammatory response syndrome (SIRS), which can lead to multi-organ dysfunction and mortality in up to 50% of cases. Endoscopic vacuum therapy involves the use of a catheter with a sponge attached to its distal end, connected to a machine that applies negative pressure, allowing for continuous drainage of the perforation site and potentially promoting healing of the transmural defect. Previous series have reported promising results, indicating the potential effectiveness of this therapy in managing esophageal perforations. To evaluate the efficacy of endoscopic vacuum treatment in patients with primary or secondary gastroesophageal perforations.

Aims & Methods

Single-center retrospective cohort study on patients treated for gastroesophageal perforation between March 2019 and September 2022. The inclusion criteria for the study were patients with gastroesophageal perforation resulting from spontaneous rupture or iatrogenic damage (post-surgical or post-endoscopic treatment). The primary outcomes of the study were the success rate of endoscopic therapy, the length of hospital stay, and the specific survival at 30 and 90 days. The success rate of endoscopic therapy was assessed by considering the treatment successful if it led to the resolution of the fistula following vacuum endoscopic therapy. Secondary endpoints included the need for intensive care unit (ICU) stay between the start of vacuum endoscopic therapy and the patient's discharge.

Results

27 patients, with a mean age of 69.8 years (95% CI 65.4-74.3), including 9 (33.3%) women, underwent endoscopic treatment with vacuum therapy for esophageal perforation. The causes of perforation were as follows: 6 (22.2%) cases were primary (Boerhaave syndrome), 15 (55.5%) cases were post-surgical (post-surgical anastomosis), and 6 (22.2%) cases were post-endoscopic treatment (endoscopic dilatation). Among the patients, 13 (48.1%) had previously undergone surgery for cancer, with 69.2% of them receiving intrathoracic stomach interposition reconstruction and the remaining patients undergoing reconstruction according to Roux-en-Y procedure. The treatment was successful in 21 (77.7%) patients, with a 14 days (9.0-24.4, 95% CI) median duration of treatment, and 4 (3-7, 95% CI) median number of endoscopic devices used per patient. One patient (3.7%) died within 30 days, and another one (3.7%) within 90 days. A total of 10 (38.4%) patients required an ICU stay, and there were no readmissions within 30 days. No procedure-related complication was reported.

Conclusion

In the current pilot study, the findings support the feasibility and safety of endoscopic vacuum therapy as a treatment modality for both primary and secondary gastro-esophageal perforations.

References

• Kuehn F, Schiffmann L, Rau BM, Klar E. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg 2012
• Pattynama LMD, Eshuis WJ, van Berge Henegouwen MI, Bergman J, Pouw RE. Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects. Front Surg 2023
• Luttikhold J, Pattynama LMD, Seewald S, et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023

Disclosure

Dr Valente and Dr Arnelo are consultant to Boston Scientific. Dr Arnelo is Consultant to Ambu

Clinical Case Summary

We present a case, which demonstrates endoluminal vacuum (EndoVac) therapy as an efficient technique when used for postoperative esophago-jejunal anastomotic leakage. A 59-year-old male, who underwent a total gastrectomy with esophago-jejunal Roux-en-Y anastomosis for stomach adenocarcinoma, presented with abdominal pain, tachycardia, fever and dyspnea a few days after the operation. A CT demonstrated a large anastomotic leakage in the esophago-jejunoanastomosis. An upper endoscopy was performed, revealing an anastomotic defect with a diameter up to 20mm. A 120mm fully covered esophageal stent was inserted. The stent was fixated with three 16mm clips. Due to clinical deterioration a follow up CT was performed. The images showed proximal migration of the stent with a perianastomotic inflammatory cavity. The stent was retrieved and 2.5L of pus-like fluid was evacuated, followed by placement of EndoVac System. During the procedure, a 15fr PEG-J feeding tube was placed, ensuring enteral nutrition. Additionally VATS was performed immediately after the endoscopy and two redon drains were placed.
Four EndoVac sponges were exchanged in a period of 12 days, during which a significant clinical improvement was observed and the patient was discharged shortly after. Eight weeks later gastroscopy and CT were performed with no evidence of a fistula and complete recovery of the patient, the PEG-J was removed. We demonstrate with our case that EndoVac therapy is an effective method in managing postoperative esophageal leaks and it should be considered as an initial technique when dealing with such complications.

References

Endoscopy photo of the ansatomotic leak
Endoscopy photo EndoVac
Endoscopy photo of the PEG-J
Endoscopy photo of the final result

Introduction

Managing leaks and defects of the upper gastrointestinal (UGI) tract remains challenging. Endoscopic Vacuum Therapy (EVT) is a promising option^1-3; However, data on its efficacy in large cohorts remain limited.

Aims & Methods

This retrospective study with prospectively collected data enrolled all consecutive patients with UGI defects treated by EVT at a single academic center (San Raffaele Hospital, Milan, Italy) from March 2015 to September 2024. The primary outcome was clinical success (CS). Secondary outcomes included median treatment duration/devices, technical success (TS) and adverse events (AEs). Clinical success (CS) was defined as complete endoscopic and/or radiologic defect healing, with the patient remaining asymptomatic. Adverse events (AEs) were classified according to the AGREE classification.

Results

Over a period of 114 months, 96 patients [72.9% male, median age 67 years (IQR 57-75), 49% ASA 3] were included. Among them, 66 patients (68.7%) had anastomotic leaks after Ivor-Lewis esophagectomy, with 57% undergoing neoadjuvant chemotherapy. The median leak size was 7 mm (IQR 4-10), with a median circumferential involvement of 20% (IQR 10-40). A fistula involving the airways was present in 28.1% of cases. EVT was the first-line treatment in 78.1% of patients, with a median time from surgery to EVT of 7 days (IQR 4-9).
The overall clinical success (CS) rate was 72.9% (70/96 patients). Of the remaining patients, 20 underwent redo-surgery. Technical success for all procedures was 100% (302/302 procedures). The median treatment duration was 11 days (IQR 5-18), with a median of 3 EVT sessions (IQR 2-4). Three adverse events (AEs) (3/302, 1%) were recorded, including one bleeding episode and two sponge dislodgments, all managed endoscopically (AGREE IIIa). During a median follow-up of 62 days (IQR 33-155), two cases (2.1%) of esophageal strictures were reported (Table 1)
In the subgroup analysis, the intraluminal (IL) group (n=70) had a lower mean number of EVT sessions (3±2 vs. 5±3, p<0.001) and a shorter mean treatment duration (11±10 vs. 21±16 days, p<0.001) compared to the intracavitary (IC) group (n=26).

Table 1: Outcomes

Conclusion

EVT is a safe and effective treatment for UGI defects. The IL approach was associated with shorter treatment duration and fewer sessions compared to the IC approach. Further controlled studies are needed to optimize EVT application and outcomes.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x

Introduction

Esophageal perforation is a rare condition with a high mortality rate. Often it has an iatrogenic origin, being caused by transesophageal echocardiography, different endoscopic and surgical procedures. Furthermore, there are other causes such as foreign body ingestion, tumor associated perforation and Boerhaave’s syndrome. Esophageal perforation can be difficult to diagnose since the clinical presentation is often unspecific. This can lead to a delay in appropriate treatment. Optimal management of this condition challenges clinicians in daily practice. Therefore, we present a monocentric retrospective study, evaluating our experience in treating esophageal perforations over more than a decade as a tertiary referral University Medical Center in Germany.

Aims & Methods

This study comprises the retrospective analysis of data from all patients treated for esophageal perforation in our clinic in the departments of general and visceral surgery and gastroenterology between 2012 and 2024. Only patients with confirmed esophageal perforation were included. Data was collected by means of a retrospective analysis of digital and analogous data archives as well as information from the physicians providing further treatment.

Results

A total of 78 cases (47 male, 31 female) of esophageal perforation were included. The leading cause was iatrogenic (n=45), consisting of endoscopic procedures (n=22), operative complications (n=11), TEE (n=6), diagnostic EGD (n=5) and one case of endotracheal intubation. The second most common cause of perforation was Boerhaave’s syndrome (n=23), followed by perforations associated with foreign body ingestion (n=5) or tumors of the esophagus (n=4). Traumatic perforations were rare (n=1). Most perforations occurred in the lower third of the esophagus (58 cases), 11 perforations were located in the mid esophagus and 9 in the upper third. Primary treatment consisted of direct surgical management in 26 cases (suture of the esophagus, gastrectomy, esophagectomy, definitive cervical esophagostomy, thoracic drainage, lavage), endoscopic therapy in 38 cases (Endo-VAC, stenting and application of OTSC or TTSC clips) and a conservative approach in 14 cases. Eventually a total of 48 patients underwent surgical treatment. Survival was poorest in spontaneous and tumor associated perforations (mean survival 22 and 23 months). Iatrogenic perforations showed an intermediate outcome. The best outcome was observed in perforations associated with foreign body ingestion (mean survival 50 months). In correlation with perforation location, the survival was best for perforations in the upper esophagus, followed by those in the lower esophagus, while lesions in the mid esophagus showed the worst outcome. Perforation associated death was recorded in 17 cases.

Conclusion

Esophageal perforations are a life-threatening event that require immediate and adequate treatment. Our analysis identified risk groups resulting in poorer survival: perforations in the mid esophagus, primary surgical treatment, advanced age. Within the last years, endoscopic techniques have reduced the need for surgical interventions. Nevertheless, surgical treatment remains the therapy of choice for patients not eligible for endoscopic treatment or after failure of endoscopic therapy. Our analysis emphasizes the importance of multidisciplinarity, close monitoring and continuous reassement of treatment strategy. Further investigation will help to improve the outcome via prospective studies or the establishment of a local or interregional database seem promising to underline suggestions derived from our analysis.

Introduction

Endoscopic resection (ER) of duodenal tumors carries a high risk of intraoperative or delayed perforation because of the thin duodenal wall and exposure to bile and pancreatic juice. Delayed perforation can particularly cause serious condition due to the leakage of the digestive fluids. The detailed management and clinical course following duodenal perforation remains unclear. This study aimed to clarify the optimal management of duodenal perforation following ER.

Aims & Methods

This single-center retrospective study included cases of perforation among patients who underwent ER for duodenal tumors at our institution between April 2013 and October 2024. The study endpoint was the clinical course after perforation, including the hospitalization period after ER for duodenal tumors. Perforation was defined as the presence of extraluminal gas on computed tomography (CT) scan. Delayed perforation was defined as a perforation that was not endoscopically recognized during the procedure but was diagnosed postoperatively. In contrast, intraoperative perforation was defined as a case in which a perforation was endoscopically identified during the endoscopic procedure. Long hospitalization was defined as a hospital stay of 20 days or longer.

Results

Of the 1,475 cases with duodenal tumors underwent ER during the study period, intraoperative perforation occurred in 8 cases (0.5%) and delayed perforation in 10 cases (0.7%). The median age of patients with perforation was 62 (range: 47–80) years, and 50% (9 patients) were male. The 18 cases included 6 cases of endoscopic papillectomy (EP), 7 cases of endoscopic mucosal resection (EMR), 2 cases of endoscopic submucosal dissection, and 3 cases of endoscopic submucosal resection with a ligation device. Among the cases of intraoperative perforations, long hospitalization, 61 days of conservative treatment, was required in one case who developed a large perforation during scope insertion of single‑balloon enteroscopy for duodenal adenoma resection. The remaining 7 cases achieved successful endoscopic closure intraoperatively and hospitalization periods were within 17 days. Of the 10 delayed perforation cases, 2 occurred after EP and 8 after EMR for non-ampullary tumors. The median time from the end of endoscopic resection to the diagnosis of perforation was 24 hours (4–46 hours). The median hospitalization period of the cases with delayed perforations was 32 days (9–81 days), and significantly longer than that of intraoperative perforation (13 days) (p<0.05). Long hospitalization was required in 8 cases (80%) of delayed perforation. None of the delayed perforation cases required surgical intervention, and endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) was performed in 7 cases (70%). Ascites was observed on CT scan at the time of diagnosis of delayed perforation in 7 of the 8 patients who required long hospitalization. One case without ascites at the diagnosis of delayed perforation still required long hospitalization, possibly due to the 10-hour delay from the diagnosis to ENBPD. On the other hand, two cases who did not need long hospitalization showed no ascites at the diagnosis of delayed perforation.

Conclusion

Compared to intraoperative perforation, delayed perforation was associated with significantly prolonged hospitalization, particularly in cases with ascites. Early detection of ascites and prompt initiation of ENBPD may help mitigate the clinical burden. Establishing an emergent backup system for ENBPD is essential for the safe management of delayed perforation after duodenal ER.