Evidence - Eso-SPONGE® – Endoluminal vacuum treatment in staple line failure and perforations of the upper GI tract - general and visceral surgery

Endoscopic vacuum therapy of esophageal staple line failure and perforation

While mortality rates following esophageal resection have decreased significantly in recent decades, management of transmural esophageal defects in staple failure and perforation continues to be a challenge (1, 2). The incidence rates reported in the literature for leakage following esophageal resection vary considerably, ranging from 1% to 30%. The leakage rates for cervical anastomoses range from 1% to 25% (3 - 7), for intrathoracic anastomoses less than 10% (8 - 12) and following gastrectomy with resection of the distal esophagus around 10% (13).

The etiology of esophageal perforations is primarily iatrogenic and can be attributed to the increasing performance of endoscopic procedures such as interventional resections and dilations (14 - 16).

Fatal courses in staple line failures and perforations are predominantly due to the development of mediastinitis with clinical sepsis (17). Early initiation of appropriate treatment is crucial for the prognosis. If treatment is delayed for more than 24 hours after leakage onset, the mortality rate is more than 20%. In a meta-analysis from 2013, the mean perforation-related mortality rate was nearly 12% (18).

Treatment strategies in esophageal leakage

All treatment measures aim to close the esophageal defect and drain the extraluminal septic focus (19, 20). A strictly non-surgical approach—systemic antibiotics, parenteral nutrition, and tube drainage—is possible in selected cases (21).

The defect may be closed surgically (suture, refashioning the anastomosis, resection with closure of the esophageal stump) or endoscopically by insertion of self-expanding metal or plastic stents (20, 22), by clip closure (23), or by fibrin sealant (24, 25). Defects were most often bridged by stents (26).

The extraluminal septic focus is drained by external percutaneous drains placed either during revision surgery or by interventional radiology (27).

Endoscopic vacuum therapy is a novel therapeutic option in esophageal leaks (28). It has already been employed successfully for many years as an intracorporeal modality in the treatment of rectal staple line failure (29). Endoscopic sponge placement allows placement of a polyurethane sponge drain under vision at any position accessible by colonoscopy or gastroscopy (30, 31). Sponge placement can be strictly intraluminal for defect sealing or intracavitary through the defect into an extraluminal wound cavity (32).

Outcome in endoscopic vacuum therapy of esophageal leaks

Endoscopic vacuum therapy in upper GI tract leakage was first reported in 2007. Disregarding case series of less than five patients, the current literature lists a total of 88 patients who underwent the vacuum procedure to repair esophageal defects.

The success rate for the different study groups ranged from 84.4% to 100% with a mortality of 10% to 16.7%. The mean duration of treatment was reported as 12.1–24.4 days. The mean number of sponge system replacements required was 3.9–9.8 (33–38).

To date, there have only been rare reports of any notable treatment-associated complications, such as bleeding due to vascular erosion and formation of esophagobronchial fistulas (34, 39).

Two retrospective studies compared the therapeutic outcomes of surgical revision, stenting, and vacuum treatment in esophageal staple line failure (34, 40). Both studies found vacuum therapy to be superior to stenting. For example, the healing rate for endoscopic vacuum therapy was 84.4% versus 53.8% in endoscopic stenting. One of the studies compared the mortality following revision surgery or stenting versus vacuum therapy. In the group treated by revision surgery or stenting, 50% and 42%, respectively, died during their hospital stay, compared with only 12% of patients treated by endoscopic vacuum therapy.

The current study findings suggest that endoscopic vacuum therapy is an effective, simple, and minimally invasive modality in the treatment of esophageal leakage.

Subjective Functional Outcome After Oesophagectomy With and Without Anastomotic Leak

Data Collection on the Treatment of Gastrointestinal Leakage by the Use of Combination of Covered Nitinol Stent and Negative Pressure Wound Treatment

Evaluation of Effectiveness and Safety of Autologous BioMatrix OBSiDiAN to Enhance a Stapled Circular Esophagogastric Anastomosis After Ivor Lewis Esophagectomy in a Multicentre Randomized Controlled Trial.

Assessment of Graft Perfusion and Oxygenation for Improved Outcome in Esophageal Cancer Surgery

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