Endoscopic Vacuum Therapy for Spontaneous and Iatrogenic Esophageal Perforations: A Retrospective Study

Introduction: Esophageal perforations are associated with high morbidity/mortality. Treatment of this life-threatening condition remains challenging with no consensus on the appropriate management. Endoscopic vacuum therapy represents a novel therapeutic option. This retrospective study aimed to evaluate the feasibility, effectiveness, and safety of endoscopic vacuum therapy for esophageal perforations. Methods: Twenty-seven consecutive patients with esophageal perforations were treated in our hospital, of which 7 underwent surgery (surgical repair, n=4; diversion, n=3), 1 underwent endoscopic stenting, and 19 were treated with endoscopic vacuum therapy. Results: Overall, 21 patients were treated with endoscopic vacuum therapy, including two patients following the failure of primary surgical approach. The median number of endoscopic vacuum therapy procedures per patient was 2, with a median duration of therapy of 10 days. A minor complication related to endoscopic vacuum therapy occurred in one patient (n=1/21; 4.8%), and successful closure of esophageal perforations with endoscopic vacuum therapy was achieved in 90.5% (n=19/21). Overall successful treatment of all perforations could be achieved in 77.8% of the patients (n=21/27); of the remaining six patients, five underwent a diversion, whereas one died during endoscopic vacuum therapy. The overall in-hospital mortality rate was 7.4% (n=2/27). Conclusion: Endoscopic vacuum therapy is a safe and effective approach for spontaneous and iatrogenic esophageal perforations, offers high closure rates, and can potentially reduce perforationrelated mortality. Chengcheng Christine Zhang1*, Henrik Nienhüser2, Christian Rupp1, Ronald Koschny1, Thomas Schmidt2, Beat P Müller-Stich2, Thilo Hackert2, Peter Sauer1, Markus W Büchler2 and Anja Schaible2 1Department of Gastroenterology, Heidelberg University Hospital, Germany 2Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany Introduction Esophageal perforations are life-threatening with substantial morbidity and mortality rates [13]. The mortality rate is 10% to 25% when therapy is initiated within 24h of perforation and increases to 50% upon delayed treatment [1,2,4-7]. Early diagnosis and management are essential for preventing enteric leakage complications [1,8,9]. Esophageal perforation treatment remains challenging, with no consensus on appropriate management. While conservative procedures are suitable for small tears [1,10,11], surgery serves as main modality, including thoracic cavity drainage, primary repair, and esophageal resections [2,7,12]. Treatment choice depends on several factors (e.g., defect genesis, time to therapy, perforation site, patients’ physical condition, systemic inflammatory signs, and extent of contamination) [1,2]. Endoscopic management of esophageal perforations has recently emerged as a beneficial therapeutic strategy [7,13-17]. Several studies could show the effectiveness of endoscopic placement of Self-Expanding Metal Stents (SEMS) for esophageal perforations and anastomotic leakages [13,18-22]. The reported mortality rates of stent therapy are 0% to 33% and successful healing rates widely vary 13% to 84% [7,20,23-27]. Nonetheless, common stent therapy complications include stent dislocation with consequent inadequacy of defect closure, stent in growth with possible difficulties in subsequent stent removal, and local esophageal necrosis due to stent pressure [13,28]. Furthermore, esophageal stenting is often combined with simultaneous external drainage, as wound cavity debridement cannot be performed [9]. Endoscopic Vacuum Therapy (EVT) has recently emerged as a novel therapeutic option for Chengcheng Christine Zhang, et al., Clinics in Surgery Gastroenterological Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2021 | Volume 6 | Article 3103 2 gastrointestinal leakages [29-32]. Although in contrast to stent placement, EVT requires multiple endoscopic procedures, it still has several advantages over stent therapy: Negative-pressure therapy reduces and prevents extraluminal contamination and promotes perfusion and granulation of the defect; EVT combines defect closure and effective internal drainage [33,34]. But evidence of EVT application in the upper GI tract is scarce and mostly based on small study cohorts, including heterogeneous esophageal defects of different etiologies [18,31,32,35-38]. Only a few studies based on small case series or case reports have evaluated EVT effects on esophageal perforations and reported success rates of 90% to 100% [39-42]. We aimed to evaluate the feasibility, effectiveness, and safety of EVT for spontaneous and iatrogenic esophageal perforations concerning success rate and associated mortality and morbidity. Methods Study design and population This study was conducted at the Interdisciplinary Endoscopy Center of Heidelberg University Hospital. Data from all patients during the study period (March 2014 to March 2020) were prospectively collected and retrospectively analyzed. Written informed consent was obtained from all patients or their legally authorized representative. Unlike other retrospective studies on EVT, only patients with iatrogenic or spontaneous esophageal perforations were included. A perforation was diagnosed either by endoscopy or computed tomography scan with detected extravasation of contrast or air into the mediastinal, pleural, or peritoneal cavity. Other etiologies of esophageal perforations that were not of spontaneous or iatrogenic genesis were excluded. Data on demographic and clinical patient characteristics were retrieved. Endpoints The primary endpoint was the successful closure rate with EVT, defined as endoscopically verified resolution of the perforation and presence of surface epithelium on the former defect. EVT failure was defined as persistent defect/fistula after EVT, change in treatment strategy, and death before confirmation of healing. Secondary endpoints were EVT duration, number/frequency of sponge changes, procedure-related complications of EVT, duration of Intensive Care Unit (ICU)/Intermediate Care Unit (IMC) hospitalization, overall hospitalization length, and in-hospital mortality. EVT EVT was performed as previously reported by Wedemeyer et al. [30,43]. If the perforation size was sufficiently large, a sponge was inserted into the abscess cavity. With diminishing defect size, the sponge was placed from its initial intracavitary position to an intraluminal position. In cases of small defects, the sponge was placed into the esophageal lumen covering the defect. The intracavitary sponge was exchanged after 3 days, whereas the sponge placed in an intraluminal position was exchanged after 5 to 7 days. Endoscopic procedures were performed under either conscious sedation or general anesthesia, depending on each patient’s medical condition. The decision for additional drainage was based on a computed tomography scan report and the patients’ clinical course. Statistical analysis Descriptive statistics were calculated for all parameters. Results are expressed as mean ± standard deviation or median and interquartile range for continuous variables and as counts and percentages for categorical variables. Statistical analyses were performed using SPSS, version 27.0 (IBM Corp., Armonk, N.Y., USA). Results Overall patient characteristics Twenty-seven patients (16 men, median age: 64 years) presented with esophageal perforations to our institution (Table 1). Of these, 16 (59.3%) had iatrogenic perforation and 11 (40.7%) had Boerhaave syndrome. The mean size of endoscopically detected perforation was 32 mm ± 38 mm (median, 20 mm; range, 5 mm to 200 mm). One patient received SEMS as first-line therapy (3.7%), 19 patients received EVT as initial therapy (n=19/27; 70.4%), and seven patients were primarily operated on (n=7/27; 25.9%). No significant difference in age, sex, and underlying disease were observed between patients primarily treated with EVT and other patients. The mean perforation size in patients treated with EVT was 23 mm ± 15 mm (median, 20 mm; range, 5 mm to 60 mm), whereas, in patients primarily treated by surgery, it was 51 mm ± 69 mm (median, 20 mm; range, 10 mm to 200 mm). Of the seven patients treated by surgery, four (57.1%) underwent surgical repair and three (42.9%) esophageal diversion, respectively. Therapy was changed in four patients: two underwent esophageal diversion after unsuccessful EVT/SEMS therapy, and two others, who were initially treated by surgical repair but showed persistent defects, received successful EVT later. Characteristics of the EVT collective Twenty-one patients (13 men; median age, 65 years) were treated with EVT (Table 1). Detailed demographics of the overall EVT collective are summarized in Table 2. Feasibility of EVT Overall EVT data are presented in Table 3. Perforations were endoscopically diagnosed mostly on the same day or within 24 h after the perforation event (mean, 0.9 day; median, 1 day; range, 0 to 4 days). Therapy initiation was delayed in three patients >24 h after the initial event (Table 4). The first patient had spontaneous esophageal perforation after repeated vomiting and was transferred from another hospital to our clinic four days after the initial event. The second patient had odynophagia and elevated inflammatory markers and was diagnosed with an iatrogenic perforation four days after a microlaryngoscopic intervention. The third patient was diagnosed with Boerhaave syndrome and transferred from another hospital to our clinic three days after the initial event because of progressive clinical worsening and sepsis. Endoscopy was immediately performed after patient transfer and revealed a large (>60 mm) perforation. Treatment was immediately commenced after diagnosed perforation in all patients. EVT was used as first-line therapy in 19 patients, whereas two patients underwent primary surgical cl