Endoscopic Vacuum Therapy for Anastomotic Insufficiencies and Perforations of the Esophagus
Although mortality after esophageal resections has significantly decreased in recent decades, the treatment of transmural esophageal defects due to anastomotic insufficiencies and perforations remains a challenge (1, 2). The literature reports varying rates of insufficiencies after esophageal resections, ranging from one to 30 percent. Insufficiency rates for cervical anastomoses range from one to 25 percent (3 – 7), for intrathoracic anastomoses under ten percent (8 – 12), and after gastrectomy with resection of the distal esophagus around ten percent (13).
Esophageal perforations are primarily iatrogenic and attributed to the increasing performance of endoscopic procedures such as interventional resection techniques and dilations (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 initiated more than 24 hours after the development of the leakage, mortality rises to over 20 percent. A meta-analysis from 2013 indicates an average perforation-related mortality of nearly 12 percent (18).
Treatment Strategies for Esophageal Leaks
All treatment measures aim to close the esophageal 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).
The defect closure can be performed surgically (suture, new 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).
The drainage of the extraluminal septic focus is achieved through external, percutaneously guided drains, which are either placed during surgical revision or interventionally-radiologically (27).
A new therapeutic option for esophageal leaks is endoscopic vacuum therapy (28), whose sufficient intracorporeal application has been practiced for years in the treatment of anastomotic insufficiencies in the rectum (29). The endoscopic sponge placement allows the implantation of a polyurethane sponge drainage under visual control at any position accessible by colonoscopy or gastroscopy (30, 31). The sponge placement can be purely intraluminal for defect sealing or intracavitary through the defect into an extraluminal wound cavity (32).
Results of Endoscopic Vacuum Therapy for Esophageal 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 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 therapy outcomes of surgical revision, stent, and vacuum treatment 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, while only 12 percent of patients treated with endoscopic vacuum therapy died.
The current state of studies suggests that endoscopic vacuum therapy is an effective, simple, and minimally invasive method for treating esophageal leaks.