Clin Endosc.  2021 Nov;54(6):787-797. 10.5946/ce.2021.240.

Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks

• Livingstone I
• Pollock L
• Sgromo B
• Mastoridis S

• KMID: 2522697
• DOI: http://doi.org/10.5946/ce.2021.240

Abstract

Esophageal wall defects, including perforations and postoperative leaks, are associated with high morbidity and mortality and pose a significant management challenge. In light of the high morbidity of surgical management or revision, in recent years, endoscopic vacuum therapy (EVT) has emerged as a novel alternative treatment strategy. EVT involves transoral endoscopic placement of a polyurethane sponge connected to an externalized nasogastric tube to provide continuous negative pressure with the intention of promoting defect healing, facilitating cavity drainage, and ameliorating sepsis. In the last decade, EVT has become increasingly adopted in the management of a diverse spectrum of esophageal defects. Its popularity has been attributed in part to the growing body of evidence suggesting superior outcomes and defect closure rates in excess of 80%. This growing body of evidence, coupled with the ongoing evolution of the technology and techniques of deployment, suggests that the utilization of EVT has become increasingly widespread. Here, we aimed to review the current status of the field, addressing the mechanism of action, indications, technique methodology, efficacy, safety, and practical considerations of EVT implementation. We also sought to highlight future directions for the use of EVT in esophageal wall defects.

Keyword

Endoscopic vacuum therapy; Esophagus; Leak; Perforation

Figure

• 

  Fig. 1. (A) Eso-SPONGE® kit contents. A.Overtube with an inner diameter of 13 mm to allow passage of endoscope. B. Sponge pusher. C. Eso-SPONGE® unit. D. Y connecting piece. (B) Endoscopic vacuum therapy of anastomotic leak. A. Anastomotic suture line. B. Intraluminal sponge. C. Tubing.

Reference

1. Kuehn F, Schiffmann L, Janisch F, et al. Surgical endoscopic vacuum therapy for defects of the upper gastrointestinal tract. J Gastrointest Surg. 2016; 20:237–243.

2. Markar SR, Mackenzie H, Wiggins T, et al. Management and outcomes of esophageal perforation: a national study of 2,564 patients in England. Am J Gastroenterol. 2015; 110:1559–1566.

3. Neumann PA, Mennigen R, Palmes D, Senninger N, Vowinkel T, Laukoetter MG. Pre-emptive endoscopic vacuum therapy for treatment of anastomotic ischemia after esophageal resections. Endoscopy. 2017; 49:498–503.

4. Dasari BVM, Neely D, Kennedy A, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg. 2014; 259:852–860.

5. Wedemeyer J, Schneider A, Manns MP, Jackobs S. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks. Gastrointest Endosc. 2008; 67:708–711.

6. Loske G. Endoscopic negative pressure therapy of the upper gastrointestinal tract. Chirurg. 2019; 90:1–6.

7. Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta J. Vacuum-assisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg. 2006; 117:121S–126S.

8. Erba P, Ogawa R, Ackermann M, et al. Angiogenesis in wounds treated by microdeformational wound therapy. Ann Surg. 2011; 253:402–409.

9. Borgquist O, Ingemansson R, Malmsjö M. The influence of low and high pressure levels during negative-pressure wound therapy on wound contraction and fluid evacuation. Plast Reconstr Surg. 2011; 127:551–559.

10. de Moura DTH, de Moura BFBH, Manfredi MA, et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc. 2019; 11:329–344.

11. Leeds SG, Mencio M, Ontiveros E, Ward MA. Endoluminal vacuum therapy: how I do it. J Gastrointest Surg. 2019; 23:1037–1043.

12. Ahrens M, Schulte T, Egberts J, et al. Drainage of esophageal leakage using endoscopic vacuum therapy: a prospective pilot study. Endoscopy. 2010; 42:693–698.

13. Loske G, Schorsch T, Müller C. Endoscopic vacuum sponge therapy for esophageal defects. Surg Endosc. 2010; 24:2531–2535.

14. Wedemeyer J, Brangewitz M, Kubicka S, et al. Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system. Gastrointest Endosc. 2010; 71:382–386.

15. Weidenhagen R, Hartl WH, Gruetzner KU, Eichhorn ME, Spelsberg F, Jauch KW. Anastomotic leakage after esophageal resection: new treatment options by endoluminal vacuum therapy. Ann Thorac Surg. 2010; 90:1674–1681.

16. Schorsch T, Müller C, Loske G. Endoscopic vacuum therapy of perforations and anastomotic insufficiency of the esophagus. Chirurg. 2014; 85:1081–1093.

17. Bludau M, Hölscher AH, Herbold T, et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted closure system (E-VAC). Surg Endosc. 2014; 28:896–901.

18. Heits N, Stapel L, Reichert B, et al. Endoscopic endoluminal vacuum therapy in esophageal perforation. Ann Thorac Surg. 2014; 97:1029–1035.

19. Loske G, Schorsch T, Dahm C, Martens E, Müller C. Iatrogenic perforation of esophagus successfully treated with endoscopic vacuum therapy (EVT). Endosc Int Open. 2015; 3:E547–E551.

20. Laukoetter MG, Mennigen R, Neumann PA, et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc. 2017; 31:2687–2696.

21. Bludau M, Fuchs HF, Herbold T, et al. Results of endoscopic vacuum-assisted closure device for treatment of upper GI leaks. Surg Endosc. 2018; 32:1906–1914.

22. Fraga JC, Nunes DL, Andreolio C, et al. Endoscopic vacuum sponge therapy for an infant with an esophageal leak. J Thorac Cardiovasc Surg. 2018; 156:e193–e195.

23. Mencio MA, Ontiveros E, Burdick JS, Leeds SG. Use of a novel technique to manage gastrointestinal leaks with endoluminal negative pressure: a single institution experience. Surg Endosc. 2018; 32:3349–3356.

24. Noh SM, Ahn JY, Lee JH, et al. Endoscopic vacuum-assisted closure therapy in patients with anastomotic leakage after esophagectomy: a single-center experience. Gastroenterol Res Pract. 2018; 2018:1697968.

25. Ooi G, Burton P, Packiyanathan A, et al. Indications and efficacy of endoscopic vacuum-assisted closure therapy for upper gastrointestinal perforations. ANZ J Surg. 2018; 88:E257–E263.

26. Pournaras DJ, Hardwick RH, Safranek PM, et al. Endoluminal vacuum therapy (E-Vac): a treatment option in oesophagogastric surgery. World J Surg. 2018; 42:2507–2511.

27. Still S, Mencio M, Ontiveros E, Burdick J, Leeds SG. Primary and rescue endoluminal vacuum therapy in the management of esophageal perforations and leaks. Ann Thorac Cardiovasc Surg. 2018; 24:173–179.

28. Cwaliński J, Hermann J, Kasprzyk M, Banasiewicz T. Endoscopic vacuum assisted closure of esophagogastric anastomosis dehiscence: a case report. World J Gastrointest Endosc. 2020; 12:42–48.

29. Hayami M, Klevebro F, Tsekrekos A, et al. Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center’s early experience. Dis Esophagus. 2021; 34:doaa122.

30. Mastoridis S, Chana P, Singh M, et al. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. Minim Invasive Ther Allied Technol. 2020; 1–9.

31. Manfredi MA, Clark SJ, Staffa SJ, et al. Endoscopic esophageal vacuum therapy: a novel therapy for esophageal perforations in pediatric patients. J Pediatr Gastroenterol Nutr. 2018; 67:706–712.

32. Brangewitz M, Voigtländer T, Helfritz FA, et al. Endoscopic closure of esophageal intrathoracic leaks: stent versus endoscopic vacuum-assisted closure, a retrospective analysis. Endoscopy. 2013; 45:433–438.

33. Tavares G, Tustumi F, Tristão LS, Bernardo WM. Endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy: a systematic review and meta-analysis. Dis Esophagus. 2021; 34:doaa132.

34. Rausa E, Asti E, Aiolfi A, Bianco F, Bonitta G, Bonavina L. Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis. Dis Esophagus. 2018; 31:doy060.

35. Newton NJ, Sharrock A, Rickard R, Mughal M. Systematic review of the use of endo-luminal topical negative pressure in oesophageal leaks and perforations. Dis Esophagus. 2017; 30:1–5.

36. Schniewind B, Schafmayer C, Voehrs G, et al. Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study. Surg Endosc. 2013; 27:3883–3890.

37. Berlth F, Bludau M, Plum PS, et al. Self-expanding metal stents versus endoscopic vacuum therapy in anastomotic leak treatment after oncologic gastroesophageal surgery. J Gastrointest Surg. 2019; 23:67–75.

38. Heits N, Bernsmeier A, Reichert B, et al. Long-term quality of life after endovac-therapy in anastomotic leakages after esophagectomy. J Thorac Dis. 2018; 10:228–240.

39. Dhayat SA, Schacht R, Mennigen R, et al. Long-term quality of life assessment after successful endoscopic vacuum therapy of defects in the upper gastrointestinal tract quality of life after EVT. J Gastrointest Surg. 2019; 23:280–287.

40. Ward MA, Hassan T, Burdick JS, Leeds SG. Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost. Surg Endosc. 2019; 33:3970–3975.