Endoluminal Therapy Research Articles

Smart Polyurethane Endosponges for Endoluminal Vacuum Therapy: Integration of a Bacteria Sensor

The development of smart biomedical devices as efficient tools in early diagnosis and therapy monitoring has recently witnessed unprecedented growth, becoming an emerging field in biomedical engineering. Sponges for endoluminal vacuum therapy, which are intended for transmitting negative pressure as trigger for tissue regeneration and for draining infections in anastomotic leakages, are massively used implants with very complex geometry and high risk of infection. In this work, commercial polyurethane (PU) sponges have been converted into smart biomedical devices by incorporating an electrochemical sensor to monitor the growth of bacteria. Such innovative approach, which allows to track the tissue healing process avoiding further infection development, has been performed applying a three-step process: 1) activation of PU using low pressure oxygen plasma; 2) incorporation of conducting polymer (CP) nanoparticles (NPs) at the surface of the activated PU by chemical oxidative polymerization; and 3) formation of a homogeneous electroactive coating using the CP NPs obtained in 2), as growth nuclei in an electrochemical polymerization. The functionalized PU sponge is able to monitor the bacteria growth in the surrounding media by detecting the concentration of nicotinamide adenine dinucleotide (NADH) from respiration reactions in the cytosol (i.e. bacteria do not have mitochondria). Conversely, respiration in normal eukaryotic cells takes place in the mitochondria, whose double membrane is not permeable to NADH. The sensing performance of the CP-coated PU sponges (limit of detection: 0.06mM; sensitivity: 1.21mA/cm2) has been determined in the lab using NADH solutions, while a proof of concept have been conducted using Escherichia coli bacteria cultures.

Endoluminal vacuum therapy using a fenestrated surgical drain for management of anastomotic leak following esophagectomy

Endoluminal vacuum therapy using a fenestrated surgical drain for management of anastomotic leak following esophagectomy

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy.

After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg. EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.

Esophagogastric anastomotic leakage and anastomotic fistula: what can we do when endoluminal vacuum therapy fails?

Anastomotic leak and anastomotic fistula after esophagectomy are frequent and detrimental complications after esophagectomy. Endoluminal vacuum therapy has been used as alternative treatment for these type of complications refractory to use of lumen-apposing metal stents and other endoscopic modalities. In this report, we describe successful endoscopic closure of anastomotic leak and anastomotic fistula with fibrin sealant as adjuvant therapy after vacuum therapy failed to completely treat these complications.

Refractory esophageal–mediastinal fistula successfully treated with endoluminal vacuum therapy and enteral nutrition using a double-lumen elemental diet tube: a case report

BackgroundAortic–esophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) has a high fatality rate and is difficult to treat. Endoluminal vacuum therapy (EVT) has recently appeared and proven to be a useful method for anastomotic leakage.Case presentationA 76-year-old man underwent aortic arch replacement for a stent graft infection after TEVAR. Persistent mediastinitis and pyothorax were observed after aortic arch replacement, and further examination revealed an esophageal–mediastinal fistula (EMF). Over-the-scope clip (OTSC®) closure was performed to treat EMF but achieved no cure. Then, the patient was referred to our hospital. First, we removed the OTSC® that interfered with the treatment using the remOVE System® and started EVT using a double-lumen elemental diet tube (W–EDT®). The vacuum sponge was affixed to the vacuum side of W–EDT®, and enteral nutrition administered through W–EDT was combined with EVT. EMF was cured 11 days after EVT, and the patient was able to feed himself.ConclusionThe combination of EVT and enteral nutrition feeding using W–EDT® is a successful novel procedure to treat refractory EMF.

EGS P03 Outcomes from 450 Endoluminal Vacuum Therapy (EVT) Procedures in the Management of Upper Gastrointestinal Leaks and Perforations

Abstract Background Anastomotic leaks and perforations of the upper gastrointestinal (UGI) tract are life-threatening conditions which result in significant rates of morbidity. There is no consensus with respect to how these challenging cases should be optimally managed. Endoluminal vacuum therapy (EVT) is a novel approach for the management of leaks and perforations in the UGI tract. Proponents highlight the benefits of its use particularly in cases where major invasive surgery or re-operation would otherwise usually be required. We present the outcomes from nearly 450 EVT related procedures during the last 5 years. Methods A retrospective analysis of all UGI leaks and perforations managed with EVT between September 2018 and June 2023 was undertaken. This included patients who had undergone cancer resections (oesophagectomy and gastrectomy), bariatric surgery (both within and out with our centre) and those presenting with benign disease (e.g. oesophageal perforation and iatrogenic injury). The setting was a regional tertiary oesophago-gastric and bariatric centre in the North-West of England serving a population of over 3.5 million people. Demographic data, patient and disease factors, nutrition-related data, and outcomes related to EVT were collected. Descriptive and statistical analysis was undertaken. Results 59 patients (43 males; median age 61) underwent 446 EVT related procedures during the study period, of which 52 (88%) were alive at discharge. Median LOS was 43 days. 66% (39/59) cases related to post-operative leak (resection 28, bariatric surgery 11) vs 11/59 spontaneous and 8/59 iatrogenic perforations. Median number of procedures was 6 (IQR 3-11) over a median of 21 days (IQR 11-41). Successful healing was achieved in 86% (51/59) cases. There was no difference in success rate between pathologies (p=0.88), however, iatrogenic perforations required fewer EVT procedures before healing (p=0.00). No adverse events were directly attributable to EVT. Conclusions UGI leaks and perforations represent a heterogeneous group which pose a significant management challenge. Our study suggests that EVT is a safe and effective approach in managing a broad range of different UGI leaks and perforations. EVT opens the possibility of active treatment for patients unsuitable for more invasive surgical intervention. Further study is required to standardise nomenclature, indications and follow-up. Comparisons to other management approaches are required to further explore the benefits for patients, taking into consideration clinical efficacy, impacts on quality of life and cost-effectiveness.

AHP P03 Challenges in the nutritional management of patients undergoing Endoluminal Vacuum therapy (EVT) for upper gastrointestinal (UGI) leaks and perforations

Abstract Background The management of upper gastrointestinal (UGI) leaks and perforations is complex and challenging. Patients often have multiple comorbidities, have undergone major surgical interventions with protracted pathways, and are associated with compromised nutritional states. Endoluminal Vacuum therapy (EVT) is a novel approach to managing UGI leaks that aims to avoid unnecessary major surgical intervention. Optimising nutrition for this cohort is of paramount importance, however, this may be challenging to achieve due to repeated interventions and interruptions in nutritional support. This study aimed to objectively measure and describe some of these challenges and explore areas of development to optimise outcomes for patients. Methods A retrospective analysis of all leaks and perforations managed with EVT between September 2018 and June 2023 was undertaken. This included patients who had undergone cancer resections (oesophagectomy and gastrectomy), bariatric surgery and those presenting with benign disease (e.g. oesophageal perforation and iatrogenic injury). The setting was a regional tertiary oesophago-gastric and bariatric centre in the North-West of England serving a population of 3.5 million people. A comprehensive dataset relating to the nutritional status of patients preoperatively and the change in nutritional parameters was collected and analysed. Results 59 patients (43 males; median age 61) were included; 88% were discharged from hospital. Median weight on admission and last EVT was 88.5kg (IQR 51-131kg) and 76.9kg. 31% had &amp;gt;10% pre-admission weight loss (IQR 2.4-30%). Median weight loss to last EVT was 7.1% (IQR +16.5 to -18.1%) vs. 9.4% (IQR +2 to -23%) for overall stay. Initial feeding routes were 46% (27/59) jejunostomy, 41% (24/59) parenteral nutrition (PN), 12% (7/59) PN/jejunostomy, and 2% (1/59) naso-gastric. Median weight loss during admission was less (9%) in the jejunostomy cohort versus the other feeding groups (PN 12.4%, PN/jejunostomy 13.9%, nasogastric 9.2%). Conclusions Meeting the nutritional needs in this complex, co-morbid and often nutritionally deplete group is a challenging task. Management algorithms were heterogenous and lacked consistency. An accurate understanding of nutritional requirements was difficult due to a combination of a lack of clinically validated guidelines and little consensus regarding which data points should be used to measure nutritional provision. These issues must be addressed to accurately ascertain the role of nutritional optimisation in this cohort, and to be able to identify modifiable factors and areas of development that may improve patient outcomes.

EGS P17 Expanding the technical armamentarium to treat complex oesophageal perforations with Endoluminal Vacuum Therapy

Abstract Background Endoluminal vacuum therapy (EVT) is increasingly the default treatment modality for oesophageal leaks. If the leak cavity is large or has a dependent element, placement of the endoluminal vacuum device within the leak cavity facilitates healing. However, accessing the leak cavity can be challenging when the oesophageal defect communicating with the leak cavity is small, and it is tempting to default to luminal EVT. This can lead to a EVT failure. We present a case where luminal EVT in the presence of an established leak cavity with a narrow inlet resulted in stagnation of therapy requiring an alternative technical approach. Methods An 80-year-old high-risk female with Boerhaave's syndrome presented with a 4cm esophageal defect and a large mediastinal leak cavity. An ad-hoc endovacuum therapy (EVT) device, consisting of V.A.C granufoam (KCI) attached to a 14Fr nasogastric (NG) tube, was placed in the leak cavity at -125mmHg pressure. The EVT device was replaced every 3-8 days. After 101 days, luminal EVT was adopted due to cavity narrowing. Partial closure of the esophageal defect was achieved, but a persistent mediastinal abscess communicated through a residual pinhole defect. Additional luminal EVT and image-guided drainage couldn't resolve the persistent esophageal fistula, confirmed by contrast-enhanced CT. Results Endoluminal access to the leak cavity was re-established by dilating the fistula using a TTS 12mm radial expansion wire-guided balloon catheter enabling re-establishment of intra-cavity EVT. Having regained access, further intra-cavity EVT using an ad-hoc EVT device fashioned from black granufoam (KCI) sutured to a 10Fr or 12Fr ng tube with 125mmHg negative pressure was applied. The EVT device was changed every 3-6 days. After further 25 days of EVT complete healing was observed. Conclusions Whilst intraluminal EVT has a role in oesophageal leaks associated with small leak cavities which have no dependent element, larger leak cavities require intra-cavity EVT. If access to the leak cavity is challenging due to the small size of the oesophageal defect, endoscopic measures to facilitate endoluminal access to the leak cavity such as dilation of the defect can be safely employed to enable delivery of intra-cavity EVT. This should be considered when endoluminal access to the leak cavity is prevented due to the small size of the defect obviating the need for other more invasive interventions such as surgery.

EGS P02 Lessons learnt from 450 Endoluminal vacuum therapy (EVT) procedures in the treatment of upper gastrointestinal perforations and leaks

Abstract Background Endoluminal vacuum therapy (EVT[BA1] ) is a novel, yet relatively well established tool in the management of upper gastrointestinal (UGI) leaks and perforations. Despite a growing body of evidence supporting its use, management strategies and techniques used in the context of EVT are yet to be standardised. Furthermore, the uptake of EVT in the UK is limited to a small number of centres. This project aimed to summarise the key lessons learnt from our initial experience of 450 EVT procedures, to inform others about how this technique can be integrated into regular clinical practice. Methods This study draws on experiential reflections and analysis of a prospective database of 450 EVT procedures in 59 patients in our unit from October 2018 – June 2023. This included patients who had undergone oesophago-gastric (OG) cancer resections, bariatric surgery (index procedures both in the UK and abroad) and those presenting with benign disease (oesophageal perforation and iatrogenic injury). The setting was a regional tertiary OG and bariatric centre in the North West of England serving a cancer and benign population of 3.5 million people and a larger undetermined population for bariatric emergencies. Results 51/59 (86%) patients were successfully managed with 446 EVT procedures. Patient, system and technical factors were identified which when addressed, facilitated expeditious healing of leaks, and enabled active management patients unfit for more invasive interventions. Factors included understanding the indications for using and stopping EVT, control of sepsis, and optimisation of nutrition and glycaemic control. Technical factors included sponge placement, managing foreign material (e.g. redundant sutures and drains) and approaches to managing necrosis. System factors included supporting a training programme, the necessity of a comprehensive team approach and the financial and governance challenges with adopting a novel intervention. Conclusions EVT is as an effective technique in the management of complex UGI leaks and perforations. There are multiple patient, financial, logistical, governance and systems factors that present as challenges to the implementation of this technique into routine practice. An integrated team-based approach is key to adoption of EVT by other centres into their routine practice.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience.

Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length ofICU and total hospital stays were 11.5 and 22.5days, respectively. There was no 30-day mortality. The incidence of esophageal ALs at our center is similar to that ofother high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

Efficacy of endoluminal vacuum therapy for the treatment of a rectal leak after endoscopic submucosal dissection

Efficacy of endoluminal vacuum therapy for the treatment of a rectal leak after endoscopic submucosal dissection

Indigenously modified endoluminal vacuum-assisted closure therapy for post-operative gastrointestinal leaks: Successful case series

Treatment of gastrointestinal perforations and postoperative anastomotic leaks remains a challenge. Endoluminal Vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years

332. NO NEED FOR A SPONGE! ENDOLUMINAL VACUUM THERAPY WITH A SIMPLE FENESTRATED SURGICAL DRAIN FOR MANAGEMENT OF BENIGN OESOPHAGEAL PERFORATIONS

Abstract Background Conventional endoluminal vacuum therapy (EVT) uses a sponge and can be an effective technique for management of benign esophageal perforations. We describe a unique method of positioning a simple fenestrated surgical drain with applied vacuum suction at or through the site of perforation. We aimed to see whether this was a safe and effective management approach for benign esophageal perforations whilst reducing the frequency and need for general anaesthetic (GA) based endoscopic exchanges. Methods A retrospective case-series was performed on consecutive patients with benign esophageal perforations from 2019 to 2023 at a tertiary hospital in the United Kingdom. Included patients had undergone initial management of benign esophageal perforation with EVT and fenestrated surgical drain. The drain was either placed in an intraluminal or intracavitary position depending on the size of perforation. Primary outcome assessed was complete epithelialisation of the fistulous orifice with EVT. Secondary outcomes included: 90-day mortality, Length of Stay (LOS), re-operation, complications, percentage of EVT procedures under GA, duration of EVT and interval between endoscopic exchanges. Results Seven patients met inclusion criteria (median age: 66 (23–79) years). In four instances aetiology of perforation was iatrogenic from gastroscopic procedures with remaining cases due to Boerhaave’s syndrome, foreign body ingestion and benign ulceration. Six patients achieved full healing of perforation with EVT, with one patient requiring oesophageal stenting. There was 0%, 90-day mortality and two patients underwent re-operation for thoracic drainage procedures. Median LOS was 22 days and mean duration of EVT was 14 days. Patients underwent on average 2.6 gastroscopies during admission, 75% of which were performed without GA. The mean interval between EVT repositioning/exchange was 8 days. Conclusion EVT with a surgical drain achieved complete healing in all but one case of benign esophageal perforation. In contrast to EVT with sponge it can be performed without GA and with a longer duration between drain exchanges and gastroscopies. Additionally, as the same drain can be used for the duration of therapy it may reduce material cost. Further studies should perform prospective and direct comparisons with alternative EVT strategies for benign esophageal perforations.

392. PLANNING IS THE KEY—ESOPHAGECTOMY WITH COLONIC INTERPOSITION FOLLOWING: WHIPPLE’S, LEFT LOWER LOBECTOMY, RIGHT PLEURECTOMY AND COLONIC SURGERY

Abstract Link to Video: https://www.dropbox.com/s/wpr3s097g50oadl/Colonic%20interposition%20%28ISDE%20SUBMISSION%29.mp4?dl=0. Description of Video: We report our learnings from a complex surgical case of Ivor Lewis esophagectomy with colonic conduit in a patient who had undergone multiple previous abdominal and thoracic operations. This seventy-two-year-old man was found to have an esophageal adenocarcinoma (T4N0M0) in the distal esophagus with a significant surgical background: Whipple’s procedure for pancreatic cancer; Left lower lobectomy for lung cancer; Right pneumonectomy for recurrent pneumothoraces and a defunctioning stoma for chemotherapy associated anal fistula. To our knowledge, no such case of colonic interposition for esophagectomy has been reported in the literature for a patient with such extensive surgical history. This presented significant surgical and anaesthetic challenges which are explored in the video. Principally the need for extensive planning to anticipate risk and modify procedural steps to account for these accordingly. For example, the operation began with a right thoracotomy, given the possibility that dense adhesions from previous surgery could obstruct safe dissection and subsequently the procedure could be aborted before any critical steps were made. Additionally, we consider the importance of involving other surgical specialities to aid with safe dissection and delineation of anatomy. Each of the key operative steps are described and paired with real-time video footage. Post-operatively we describe how the risk of anastomotic leak given a high-risk anastomosis may be reduced through pre-emptive Endoluminal Vacuum therapy. We also discuss the importance of recognising and managing feculent aspiration pneumonia which is common following this surgery. Discussion of this case and our operative approach would serve to highlight how surgery remains a feasible option for patients despite complex anatomy and surgical history; provided risks are anticipated and appropriately managed.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery.

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks. A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed. The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43years and a median follow-up of 24months. The mean preoperative body mass index was 45.1kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45days after the index surgery. Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

Endoluminal wound vacuum therapy for gastrointestinal leaks: current state and future directions

Endoluminal wound vacuum therapy for gastrointestinal leaks: current state and future directions

Successful endoscopic management of a large esophageal defect due to Boerhaave syndrome with endoscopic vacuum therapy using vacuum sponge and vacuum stent

Video 1Successful endoscopic management of a large esophageal defect due to Boerhaave syndrome with endoscopic vacuum therapy using EsoSponge and VACStent.

Preemptive endoluminal vacuum therapy with the VACStent-A pilot study to reduce anastomotic leakage after Ivor Lewis hybrid esophagectomy.

Endoscopic treatment by vacuum therapy (EVT) or covered stents has emerged as an improved treatment option for upper gastrointestinal wall defects and is regarded as an improved treatment option for anastomotic leakage (AL) after esophagectomy. However, endoluminal EVT devices may lead to obstruction of the GI tract; and a high rate of migration and missing functional drainage has been shown for covered stents. The recently developed VACStent, a combination of a fully covered stent within a polyurethane sponge cylinder may overcome these issues allowing EVT while stent passage is still open. Initial clinical applications have demonstrated efficacy, practicability and safety in the treatment of esophageal leaks (AL). In this pilot study, 9 patients with high-risk anastomosis after neoadjuvant therapy undergoing hybrid esophagectomy received the VACStent in a preemptive setting for the assessment of the reduction of the AL rate, postoperative morbidity and mortality. Technical success of the application of the VACStent® was achieved in all interventions. One patient experienced anastomotic leakage 10 days after esophagectomy and was successfully treated with two consecutive VACStents and a VAC Sponge. In summary, mortality in-hospital was 0% and anastomotic healing was uneventful without septic episodes. No severe device-related adverse events (SADE) nor significant local bleeding or erosion could be observed. Oral intake of liquids or food was documented in all patients. The device handling was regarded uncomplicated. The preemptive application of the VACStent offers a promising new option for improved clinical treatment avoiding of critical situations in hybrid esophagectomy, which should be validated in a large clinical study.

Experience with endoluminal vacuum therapy in the management of esophageal anastomotic leakage in newborns with esophageal atresia: A case series

Background: The management of dehiscence of esophageal anastomosis is challenging and requires a multidisciplinary approach. Endoluminal vacuum therapy (EVT) has shown promising results. Case Presentation: Herein we present the data of two cases with esophageal atresia who developed esophageal anastomotic leakage, during 2021-2022, and who underwent EVT. The first case had 60% dehiscence of the anastomosis, anastomotic leak repair was performed followed by esophageal EVT placement. In the second case, the dehiscence was limited to 10%, and only esophageal EVT was provided. Within four and six days of EVT, upper gastrointestinal endoscopy and fluoroscopy were performed which showed tissue proliferation in situ and the absence of contrast leakage. Both patients were able to resume oral tolerance on the 4th day. Conclusion: Esophageal EVT has shown promising results in the management of esophageal anastomotic leakage in newborns with esophageal atresia.

Endoscopic management of esophageal perforations and tears

: Esophageal perforation is a life-threatening condition burdened by high morbidity and mortality. The esophageal perforation can occur spontaneously (such as Boerhaave syndrome) or can be an iatrogenic complication. The diagnostic approach may be difficult as the clinical presentations is often non-specific. However, a proper and early diagnosis is crucial to reduce the mortality rate. Once the diagnosis is obtained, the therapeutic management differs among the different clinical scenarios. In some cases, a wait and watch approach is preferred, in other cases a more aggressive treatment is required. Although surgery was considered the standard of care, nowadays endoscopy is emerging as the first line treatment in esophageal perforations non-responsive to medical treatments. The endoscopic techniques available are the application of through-the-scope clips (TTSCs), over-the-scope clips, esophageal stents, endoscopic suturing techniques, endoluminal vacuum therapy (EVT), and locoregional application of regenerative medicine. The choice of the specific endoscopic technique depends on the injury length, the perforation site, and the presence of fluid collections. The complexity of the diagnostic and therapeutic approach to esophageal perforation imposes a multidisciplinary approach in order to choose the proper treatment in each singular case. The aim of this study is to assess the role of endoscopy in the management of esophageal injuries and to describe the endoscopic techniques nowadays available.