Endoscopic vacuum therapy for esophageal perforations: is it risk effective for every size of defect?

We have read with great interest the article by Luttikhold et al., which reports results of their initial multicenter experience of endoscopic vacuum therapy (EVT) in the treatment of esophageal perforations, demonstrating an 89 % effectiveness rate [1]. In recent years, EVT has primarily been used for the treatment of post-surgical leaks, as well as for rescue therapy [2] and for prophylactic purposes [3]. This is the first study to assess only esophageal perforations treated by EVT, and did not include anastomotic leaks. However, we have some concerns regarding certain aspects of the report and we believe that addressing these criticisms could guide new research directions.

First, the authors reported that the negative pressure applied varied between centers, ranging from –50 to –125 mmHg; thus, the technique was not standardized in the study. Furthermore, gradients lower than 125 mmHg, which represents the standard target, may have led to an underestimation of the efficacy of the device.

Second, the authors reported that although more than half the patients (14/25 patients, 56 %) had a defect greater than 20 mm, they performed the intraluminal technique in most patients (21/27 patients, 78 %). These data might seem to be contradictory.

Esophageal perforations, particularly iatrogenic ones, differ from post-esophagectomy leaks. They are typically promptly recognized, leaving no time for the leak to remain hidden and lead to the development of collections. Thus, the primary objective of endoscopic therapy is often to close the defect, rather than drain it.

Recently, Jung et al. found that intraluminal EVT (for smaller defects) was associated with treatment failure in esophageal leaks/perforations [4].

EVT could serve as an organ-sparing alternative to surgery for large esophageal perforations. Would it be useful also for smaller defects (<2 cm) that may require intraluminal EVT and could be promptly treated with clips including over-the-scope-clips [5]?

Publication History

Article published online:
27 September 2023

• References

• 1 Luttikhold J, Pattynama LMD, Seewald S. et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023; DOI: 10.1055/a-2042-6707.
• 2 Mandarino FV, Barchi A, Fanti L. et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus 2022; 19: 417-425
• 3 Mandarino FV, Barchi A, Biamonte P. et al. The prophylactic use of endoscopic vacuum therapy for anastomotic dehiscence after rectal anterior resection: is it feasible for redo surgery?. Tech Coloproctol 2022; 26: 319-320
• 4 Jung DH, Huh CW, Min YW. et al. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022; 95: 281-290
• 5 Paspatis GA, Arvanitakis M, Dumonceau JM. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy 2020; 52: 792-810