Endoscopic Vacuum Therapy for the Treatment of Upper Gastrointestinal Transmural Defects

Abstract

Upper gastrointestinal transmural defects are associated with a high morbidity and mortality. Stents are the first-line endoscopic approach, however, their efficacy varies considerably and are associated with important adverse events (AEs). Endoscopic vacuum therapy (EVT) is a new approach to this condition. We performed a single-center retrospective study that evaluated patients with upper gastrointestinal transmural defects that underwent EVT between May 2017 and May 2018. EVT was performed using the Endo and Eso-Sponge system (B. Braun, Melsungen, Germany). Continuous negative pressure of 100 mmHg, generated by an electronic vacuum pump system was applied. Whenever possible the sponge was placed in an intracavitary position. Sponge replacement was performed every 3-7 days. Five patients (3 males) with a median age of 58 years were referred for EVT due to anastomotic leak after distal esophagectomy (n=2), gastrojejunal leak following Roux-en-Y gastric bypass (n=1), gastropleural fistula post-sleeve gastrectomy (n=1) and esophageal-pleural fistula after esophageal diverticulectomy (n=1). In 80% of cases, the size of the cavity was greater than 20 mm and there was an associated cavity in 100%. EVT was used as the first-line endoscopic treatment in 1 patient and in the remainder after stent failure. After a median of 5 procedures (IQR 4-6), complete closure of the defect was seen in 2 patients (40%). In another patient, after almost complete reduction of the cavity, effective closure was achieved after application of an OTSC (Ovesco, TSymbolbingen, Germany). These 3 patients were discharged after a median of 43 days (IQR 39-50) since the beginning of EVT therapy. In the remaining 2 patients, there was a decrease in dimensions of the defect, without closure, with placement of a biodegradable stent in one and need of revision surgery in the other patient. EVT is a promising approach in the treatment of upper gastrointestinal transmural defects, even after stent failure. It appears to be most effective when performed intracavitarily. Despite the need for multiple procedures, it can lead to complete closure of the defect, avoiding the need for surgery.Symbol