Modified Endoscopic Vacuum Assisted Closure (E-VAC) is a novel minimally invasive technique for treating esophageal pleural fistulas

Abstract

BackgroundSurgical pathologies of the esophagus in the pediatric age are not unusual. However, when they appear, they are not complications-free. These include anastomotic dehiscence or pleural fistulas. Classically they are treated clinically, and this treatment is associated with complications such as mediastinitis, pleural effusion, sepsis, and death. We propose treating esophageal dehiscence using a negative pressure system placed endoscopically. This minimally invasive procedure can be used as definitive treatment or bridging therapy for surgical correction. MethodsThis is a retrospective longitudinal multicenter study from January 2018 to January 2022 in five medical centers, three located in Colombia and two in Mexico. The patients had esophageal dehiscence or pleural fistula diagnosed by contrast leakage in postoperative esophagogram or endoscopy and treated with an endoscopic negative pressure system, with a 30-day follow-up after the diagnosis. We analyze the time of placement, pressure and E-VAC (Endoscopic- Vacuum Assisted Closure) replacements, as well as the efficacy and inherent complications. ResultsWe present nine patients diagnosed with esophageal dehiscence or pleural fistula treated with endoscopic VAC. The oldest was 14-years old and the youngest was 2-day-old. Six patients were diagnosed with esophageal atresia, either type III or type I. The other three patients had gastric volvulus, short esophagus, and embryonic esophageal remnants. The most frequent initial surgical procedures were the correction of esophageal atresia and esophageal-jejunal anastomosis. The esophageal dehiscence or pleural fistula was diagnosed by esophagogram with hydrosoluble contrast. Four patients had E-VAC as initial therapy; the remaining five used it after expectant management failed. Fistula closure took an average of 13 days, with fewer than three VAC changes required. Two of the nine patients presented with subsequent anastomotic stenosis, which was treated with endoscopic dilation using a balloon dilation. ConclusionsUsing the E-VAC system in esophageal and pleural fistulas is effective in all our patients. It also shortens hospitalization and treatment time when performed as the first management line. We recommend using E-VAC at a pressure of 50 - 125 mmHg and preferably of the continuous type. System changes are indicated when there are suction problems, system clogging, or E-VAC migration when relocation is impossible. The other methods described do not use the transparent dressing, so it must be completely changed at each control. Level evidenceIV