Endoscopic Vacuum Therapy for Anastomotic Insufficiencies and Perforations of the Esophagus
Although mortality after oesophageal resections has significantly decreased in recent decades, the treatment of transmural oesophageal defects due to anastomotic insufficiencies and perforations remains a challenge (1, 2). The rates reported in the literature for the frequency of insufficiencies after oesophageal resections vary considerably, ranging between one and 30 percent. Insufficiency rates for cervical anastomoses range between one and 25 percent (3 – 7), for intrathoracic anastomoses under ten percent (8 – 12), and after gastrectomy with resection of the distal oesophagus around ten percent (13).
Oesophageal perforations are primarily iatrogenic and attributable to the increasing performance of endoscopic procedures such as interventional resection techniques and dilatations (14 – 16).
Lethal outcomes in anastomotic insufficiencies and perforations are predominantly due to the development of mediastinitis with a septic clinical picture (17). Prognostically decisive is the early initiation of adequate therapy. If it begins more than 24 hours after the development of the leakage, mortality rises to over 20 percent. A meta-analysis from 2013 reports an average perforation-related mortality of nearly 12 percent (18).
Treatment Strategies for Oesophageal Leaks
All treatment measures aim to close the oesophageal defect and drain the extraluminal septic focus (19, 20). A purely conservative approach—systemic antibiotics, parenteral nutrition, and tube drainage—is possible in selected cases (21).
Defect closure can be performed surgically (suture, re-fashioning of the anastomosis, discontinuity resection) or endoscopically by the implantation of self-expanding metal or plastic stents (20, 22), by clip closure (23), or fibrin glue (24, 25). Most commonly, defect bridging is achieved by stents (26).
Drainage of the extraluminal septic focus is achieved through external, percutaneously guided drains, which are either placed during surgical revision or by interventional radiology (27).
A new therapeutic option for oesophageal leaks is endoscopic vacuum therapy (28), whose successful intracorporeal application has been practised for years in the treatment of anastomotic insufficiencies of the rectum (29). Endoscopic sponge placement allows the implantation of a polyurethane sponge drainage under vision at any position accessible by colonoscopy or gastroscopy (30, 31). Sponge placement can be performed either purely intraluminally for defect sealing or intracavitary through the defect into an extraluminal wound cavity (32).
Results of Endoscopic Vacuum Therapy for Oesophageal Leaks
Since 2007, the application of endoscopic vacuum therapy for leaks in the upper GI tract has been described. Excluding case series with fewer than five patients, current literature includes a total of 88 patients treated with the vacuum method for an esophageal defect.
The success rate among the various research groups ranged from 84.4 to 100 percent with a mortality of ten to 16.7 percent. The average therapy duration was reported as 12.1 to 24.4 days. On average, 3.9 to 9.8 changes of the sponge system were required (33 – 38).
Noteworthy therapy-associated complications such as bleeding due to vascular erosions and the formation of an esophagobronchial fistula have been rarely described to date (34, 39).
In two retrospective studies, the treatment outcomes of surgical revision, stent, and vacuum therapy for esophageal anastomotic insufficiency were compared (34, 40). Both studies demonstrated the superiority of vacuum therapy over stent implantation. The healing rate of endoscopic vacuum therapy was 84.4 percent compared to 53.8 percent for endoscopic stent implantation. In one of the studies, mortality after surgical revision or stent placement and vacuum therapy was compared. In the group treated with surgical revision or a stent, 50 and 42 percent respectively died during the hospital stay, whereas only 12 percent of patients treated with endoscopic vacuum therapy died.
The current state of evidence suggests that endoscopic vacuum therapy is an effective, simple, and minimally invasive method for treating esophageal leaks.