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Abusuliman M, Jamali T, Zuchelli TE. Advances in gastrointestinal endoscopy: A comprehensive review of innovations in cancer diagnosis and management. World J Gastrointest Endosc 2025; 17:105468. [PMID: 40438719 PMCID: PMC12110152 DOI: 10.4253/wjge.v17.i5.105468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 03/26/2025] [Accepted: 04/15/2025] [Indexed: 05/12/2025] Open
Abstract
The field of gastroenterology has experienced revolutionary advances over the past years, as flexible endoscopes have become widely accessible. In addition to enabling faster, less invasive, and more affordable treatment, flexible endoscopes have greatly improved the detection and endoscopic screening of malignancies and prevented many cancer-related deaths. The development and clinical application of new diagnostic endoscopic technologies, such as magnification endoscopy, narrow-band imaging, endoscopic ultrasound with biopsy, and more recently, artificial intelligence enhanced technologies, have made the recognition and detection of various neoplasms and sub-epithelial tumors more possible. This review demonstrates the latest advancements in endoscopic procedures, techniques, and devices applied in the diagnosis and management of gastrointestinal cancer.
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Affiliation(s)
- Mohammed Abusuliman
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, United States
| | - Taher Jamali
- Department of Gastroenterology, Henry Ford Hospital, Detroit, MI 48202, United States
| | - Tobias E Zuchelli
- Department of Gastroenterology, Henry Ford Hospital, Detroit, MI 48202, United States
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Le TM, Tran VH, Chung KS, Jeon SW. Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review. Clin Endosc 2025; 58:181-190. [PMID: 39511930 PMCID: PMC11983136 DOI: 10.5946/ce.2024.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/30/2024] [Accepted: 08/14/2024] [Indexed: 11/15/2024] Open
Abstract
Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.
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Affiliation(s)
- Tan Minh Le
- Department of Biomedical Science, Graduate School, Kyungpook National University, Daegu, Korea
- BK21 Four Program, Kyungpook National University School of Medicine, Daegu, Korea
| | - Van Huy Tran
- Gastroenterology and Endoscopy Center, University of Medicine and Pharmacy Hospital, Hue University, Hue, Viet Nam
| | - Kyu Sung Chung
- Gastroenterology and Endoscopy Center, University of Medicine and Pharmacy Hospital, Hue University, Hue, Viet Nam
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Wannhoff A, Kouladouros K, Koschny R, Walter B, Zoll Z, Büringer K, Blank S, Schempf U, Caca K, Wichmann D. Endoscopic vacuum therapy for the treatment of Boerhaave syndrome: a multicenter analysis. Gastrointest Endosc 2025; 101:365-374. [PMID: 39218268 DOI: 10.1016/j.gie.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/31/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Boerhaave syndrome, an effort rupture of the esophagus, is a rare but serious condition. Endoscopic vacuum therapy (EVT) is a new therapeutic approach for GI perforation. We aimed to evaluate EVT for treatment of Boerhaave syndrome. METHODS This retrospective study was conducted at 5 tertiary hospitals in southern Germany. All patients treated for Boerhaave syndrome since 2010 were identified and included. Treatment success and outcomes were assessed and compared between the different modes of primary treatment. RESULTS Fifty-seven patients with Boerhaave syndrome were identified (median age, 68 years; n = 16 female). The primary treatment was EVT in 25 cases, surgery in 14, and endoscopic stenting in 15. Primary EVT was successful in 20 (80.0%) of the 25 patients. Two patients were switched to surgical treatment, 1 was switched to esophageal stenting, and 2 patients died. The mortality rate was lower (P = .160) in patients treated primarily with EVT (n = 2 [8.0%]) compared with patients in the non-EVT group (n = 8 [25.0%]). Treatment success was significantly higher (P = .007) for primary EVT (80.0%) than for non-EVT (43.8%). Primary EVT was associated with treatment success in multivariable analysis. CONCLUSIONS EVT showed a high success rate for treatment of Boerhaave syndrome and was associated with treatment success.
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Affiliation(s)
- Andreas Wannhoff
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany.
| | - Konstantinos Kouladouros
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Mannheim, Germany; Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité University Hospital Berlin, Berlin, Germany
| | - Ronald Koschny
- Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Walter
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Zita Zoll
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Karsten Büringer
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
| | - Susanne Blank
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Mannheim, Germany
| | - Ulrike Schempf
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
| | - Karel Caca
- Department of Internal Medicine, Gastroenterology, Haemato-Oncology, Diabetology, and Infectiology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Dörte Wichmann
- Department of Internal Medicine I, Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology and Geriatrics, University Hospital Tübingen, Tübingen, Germany
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Ylli K, AlQahtani J, Hraishawi I, Murphy T. VACStent closure of oesophageal defects by covered stent and endoscopic vacuum therapy: initial use and clinical outcomes. J Surg Case Rep 2025; 2025:rjae804. [PMID: 39717413 PMCID: PMC11663413 DOI: 10.1093/jscr/rjae804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Accepted: 12/05/2024] [Indexed: 12/25/2024] Open
Abstract
Endoscopic management of transmural oesophageal defects following esophagectomy or spontaneous perforations, such as Boerhaave's syndrome, is often complicated by stent migration and luminal occlusion [1]. The Vacuum-Assisted Closure (VAC) stent, which integrates a covered stent with endoscopic vacuum therapy, aims to address these issues by providing functional drainage and promoting wound healing [2]. This case series presents our initial experience with VACStent therapy in four patients treated between February 2023 and April 2024. Two patients had staple line defects post-esophagectomy, and two had Boerhaave's syndrome. Treatment involved stent placement under general anaesthesia, followed by evaluations and scheduled stent exchanges every 6 days. All patients achieved successful defect closure, with no procedural complications noted. Three patients required one stent application, while one needed two applications. VACStent therapy appears to be a safe and effective treatment for transmural oesophageal defects, potentially establishing a new standard of care.
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Affiliation(s)
- Kristali Ylli
- Department of Surgery, Mercy University Hospital, Grenville Place, Cork, T12 WE28, Ireland
| | - Jowhara AlQahtani
- Department of Surgery, Mercy University Hospital, Grenville Place, Cork, T12 WE28, Ireland
| | - Ihab Hraishawi
- Department of Surgery, Mercy University Hospital, Grenville Place, Cork, T12 WE28, Ireland
| | - Thomas Murphy
- Department of Surgery, Mercy University Hospital, Grenville Place, Cork, T12 WE28, Ireland
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Mendes I, Nunes G, Vara-Luiz F, Vaz J, Luz C, Fonseca J, Pinto-Marques P. Endoscopic vacuum therapy of a refractory esophagopleural fistula in a patient with Boerhaave syndrome, using an innovative hybrid stent. Endoscopy 2024; 56:E683-E684. [PMID: 39111754 PMCID: PMC11305858 DOI: 10.1055/a-2363-8977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Affiliation(s)
- Ivo Mendes
- Gastroenterology, Hospital Garcia de Orta EPE, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
| | - Gonçalo Nunes
- Gastroenterology, Hospital Garcia de Orta EPE, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
| | - Francisco Vara-Luiz
- Gastroenterology, Hospital Garcia de Orta EPE, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
| | - João Vaz
- Surgery, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Carlos Luz
- Surgery, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Jorge Fonseca
- Gastroenterology, Hospital Garcia de Orta EPE, Almada, Portugal
- Aging Lab, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
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Papadakos SP, Argyrou A, Katsaros I, Lekakis V, Mpouga G, Vergadis C, Fytili P, Koutsoumpas A, Schizas D. The Impact of EndoVAC in Addressing Post-Esophagectomy Anastomotic Leak in Esophageal Cancer Management. J Clin Med 2024; 13:7113. [PMID: 39685572 PMCID: PMC11642085 DOI: 10.3390/jcm13237113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Revised: 11/10/2024] [Accepted: 11/21/2024] [Indexed: 12/18/2024] Open
Abstract
Anastomotic leakage (AL) remains a major complication after esophagectomy, especially in patients with esophagogastric cancers who have undergone neoadjuvant therapies, which can impair tissue healing. Endoscopic vacuum-assisted closure (EndoVAC) is an innovative approach aimed at managing AL by facilitating wound drainage, reducing infection, and promoting granulation tissue formation, thus supporting effective healing. This review explores the role and effectiveness of EndoVAC in treating AL post-esophagectomy in esophageal cancer patients. We present an overview of its physiological principles, including wound contraction, enhanced tissue perfusion, and optimized microenvironment, which collectively accelerate wound closure. In addition, we examine clinical outcomes from recent studies, which indicate that EndoVAC is associated with improved leak resolution rates and potentially shorter hospital stays compared to traditional methods. Overall, this review highlights EndoVAC as a promising tool for AL management and underscores the need for continued investigation to refine its protocols and broaden its accessibility. By optimizing EndoVACs use, multidisciplinary teams can improve patient outcomes and advance esophageal cancer care.
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Affiliation(s)
- Stavros P. Papadakos
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Alexandra Argyrou
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece
| | - Vasileios Lekakis
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Georgia Mpouga
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | | | - Paraskevi Fytili
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Andreas Koutsoumpas
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece; (S.P.P.); (A.A.); (V.L.); (G.M.); (P.F.); (A.K.)
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 115 27 Athens, Greece
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Conrad H, Sridhar P. What Is New with Cervical Perforations? A Clinical Review Article. Thorac Surg Clin 2024; 34:321-329. [PMID: 39332857 DOI: 10.1016/j.thorsurg.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
Approximately 15% of all esophageal perforations occur within the cervical esophagus. Advances in medical care and surgical technique overtime have led to decreased mortality associated with esophageal perforations. While early recognition, accurate characterization, and adequate drainage, or repair when appropriate, remain the mainstays in the management of cervical perforations, endoscopic innovation has provided a minimally invasive option in the management of this disease and expanded the armamentarium of options available to providers.
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Affiliation(s)
- Hope Conrad
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, 1625 North Campbell Avenue, Tucson, AZ, USA
| | - Praveen Sridhar
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, 1625 North Campbell Avenue, Tucson, AZ, USA.
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Kollmann L, Weich A, Gruber M, Flemming S, Meining A, Germer CT, Lock JF, Seyfried F, Brand M, Reimer S. Additional over-the-scope-clip closure can shorten endoscopic vacuum therapy for postoperative upper gastrointestinal leakage. Endosc Int Open 2024; 12:E1023-E1028. [PMID: 39263560 PMCID: PMC11383616 DOI: 10.1055/a-2387-2054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/07/2024] [Indexed: 09/13/2024] Open
Abstract
Background and study aims Endoscopic vacuum therapy (EVT) has become the most effective therapeutic option for upper gastrointestinal leakage. Despite its efficiency, this treatment can necessitate a long hospitalization. The aim of this study was to evaluate whether additional use of an over-the-scope-clips (OTSC) closure after successful EVT can shorten leakage therapy. Patients and methods All patients treated with EVT for leakages in the upper gastrointestinal tract at our center from 2012 to 2022 were divided into two propensity matched cohorts (EVT+OTSC vs. EVT only). The EVT+OTSC patients received OSTC application at the end of successful EVT directly after removal of the last sponge. The primary endpoint was the time interval from leakage diagnosis until discharge. Secondary endpoints included EVT efficacy, complications, and nutritional status at discharge. Results A total of 84 matched patients were analyzed. EVT efficacy was 100% in both groups. The time interval from leakage until discharge was significantly shorter in the EVT+OTSC vs. EVT group (33 [19-48] vs. 46 days [29-77] P = 0.004). No patient in the EVT+OTSC group required additional procedures for leakage management, whereas five (12%) in the EVT group needed additional stent placement ( P = 0.021). More patients could be discharged on sufficient oral nutrition in the EVT+OTSC group (98% vs. 60%; P < 0.001). Conclusions The addition of OTSCs after successful EVT is safe and has the potential to shorten leakage therapy, enabling earlier discharge along with better functional outcomes.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Alexander Weich
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Maximilian Gruber
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Johann Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital Wurzburg, Wurzburg, Germany
| | - Markus Brand
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
| | - Stanislaus Reimer
- Department of Gastroenterology, University Hospital Wurzburg, Wurzburg, Germany
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Han S, Girotra M, Abdi M, Akshintala VS, Chen D, Chen YI, Das KK, Desilets DJ, Vinsard DG, Leung G, Mishra G, Muthusamy VR, Onyimba FU, Pawa S, Rustagi T, Sakaria S, Shahnavaz N, Law RJ. Endoscopic vacuum therapy. IGIE 2024; 3:333-341. [DOI: 10.1016/j.igie.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
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10
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Jung CFM, Binda C, Tuccillo L, Secco M, Gibiino G, Liverani E, Petraroli C, Coluccio C, Fabbri C. New Endoscopic Devices and Techniques for the Management of Post-Sleeve Gastrectomy Fistula and Gastric Band Migration. J Clin Med 2024; 13:4877. [PMID: 39201020 PMCID: PMC11355382 DOI: 10.3390/jcm13164877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/14/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Post-sleeve gastrectomy fistulas are a rare but possibly severe life-threatening complication. Besides early reoperation and drainage, endoscopy is the main treatment option. According to the clinical setting, endoscopic treatment options comprise stent or clip placement. New endoscopic therapies have recently gained attention, including endoscopic vacuum therapy, VacStent therapy, endoscopic internal drainage with pigtail stents, endoscopic suturing and stem cell injection. In this narrative review, we shed light on recent literature, developments, indications and contraindications of these treatments. Intragastric gastric band migration is a rare complication after gastric band positioning. Reoperation can sometimes be difficult, especially when a gastric band has already migrated far into the stomach. Endoscopic retrieval can be a valid, non-invasive therapeutic solution. We reviewed the current literature on this matter.
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Affiliation(s)
- Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy
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Heiss MM, Lange J, Knievel J, Yohannes A, Hügle U, Dormann AJ, Eisenberger CF. Treatment of anastomotic leak in colorectal surgery by endoluminal vacuum therapy with the VACStent avoiding a stoma - a pilot study. Langenbecks Arch Surg 2024; 409:234. [PMID: 39083099 PMCID: PMC11291571 DOI: 10.1007/s00423-024-03426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/22/2024] [Indexed: 08/03/2024]
Abstract
PURPOSE Anastomotic leak (AL) represents the most relevant and devastating complication in colorectal surgery. Endoscopic vacuum therapy (EVT) using the VACStent is regarded as a significant improvement in the treatment of upper gastrointestinal wall defects. The innovative concept of the VACStent was transferred to the lower GI tract, gaining initial experience by investigating safety and efficacy in 12 patients undergoing colorectal resections. METHODS The pilot study, as part of a German registry, began with 2 patients suffering from AL, who were treated with the VACStent after stoma placement. Subsequently, 6 patients with AL were treated with the VACStent omitting a stoma placement, with a focus on fecal passage and wound healing. Finally, the preemptive anastomotic coverage was investigated in 4 patients with high-risk anastomoses to avoid prophylactic stoma placement. RESULTS In total 26 VACStents were placed without problems. The conditioning and drainage function were maintained, and no clogging problems of the sponge cylinder were observed. No relevant clinical VACStent-associated complications were observed; however, in 2 patients, a dislodgement of a VACStent occurred. The 6 patients with AL but without stoma had a median treatment with 3 VACStents per case with a laytime of 17 days, leading to complete wound healing in all cases. The 4 prophylactic VACStent applications were without complications. CONCLUSION The clinical application of the VACStent in the lower GI tract shows that successful treatment of anastomotic colonic leaks and avoidance of creation of an anus praeter is possible. TRIAL REGISTRATION NUMBER Clinicaltrials.gov NCT04884334, date of registration 2021-05-04, retrospectively registered.
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Affiliation(s)
- Markus M Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Jonas Lange
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Judith Knievel
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Alexander Yohannes
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - Ulrich Hügle
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - Arno J Dormann
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - Claus F Eisenberger
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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de Moura DTH, Hirsch BS, Ribas PHBV, Silveira SQ, Guedes HG, Bestetti AM. Endoscopic vacuum therapy: pitfalls, tips and tricks, insights, and perspectives. Transl Gastroenterol Hepatol 2024; 9:50. [PMID: 39091653 PMCID: PMC11292076 DOI: 10.21037/tgh-23-86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 04/03/2024] [Indexed: 08/04/2024] Open
Abstract
This article provides a comprehensive review of the use of endoscopic vacuum therapy (EVT) in the management of transmural gastrointestinal (GI) defects (TGIDs) and its future perspectives, such as pre-emptive EVT and novel indications, including GI bleeding and large gastroduodenal ulcers management. This review is based on the available literature data and personal experience to demystify the mentioned limitations of EVT as technical difficulties related to the procedure, possible patients' complaints, and institutions' concerns, by sharing several tips and tricks to overcome EVT-related challenges that may discourage endoscopists from using this live-saving technique, and consequently, restricting patients to receive this therapy, which may lead to undesired outcomes. Several factors, such as placement techniques, EVT type selection, management during its use, EVT system exchanges, device removal, type of anesthesia, and how to avoid EVT-related adverse events are described in detail. Additionally, this review discusses good ways to promote effective communication with patients and relatives, surgeons, and multidisciplinary team. EVT possesses a unique mechanism of action including macro/micro deformation, changes in perfusion (stimulating angioneogenesis), exudate control, and bacterial clearance, promoting healing. EVT has an adequate safety profile and higher clinical success rate compared to any other endoscopic therapy for TGID. Additionally, pre-emptive EVT and its novel indications are promising due to its satisfactory effectiveness in initial studies. Therefore, detailing some practical solutions obtained by years of experience may collaborate to widespread EVT adoption, providing less-invasive treatment for several critical conditions to more patients worldwide.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Division, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Bruno Salomão Hirsch
- Deparment of Gastroenteroloy, Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Pedro Henrique Boraschi Vieira Ribas
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Saullo Queiroz Silveira
- Department of Anesthesiology-CMA Anesthesia Group, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
| | - Hugo Gonçalo Guedes
- Gastrointestinal Endoscopy Unit, Instituto D’Or de Pesquisa e Ensino-Hospital DF Star, Brasília, DF, Brazil
| | - Alexandre Moraes Bestetti
- Gastrointestinal Endoscopy Division, Instituto D’Or de Pesquisa e Ensino-Hospital Vila Nova Star, São Paulo, SP, Brazil
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Richter F, Conrad C, Hoffmann J, Reichert B, von Schoenfels W, Schafmayer C, Egberts JH, Becker T, Ellrichmann M. Endoluminal Vacuum Therapy Using a New "Fistula Sponge" in Treating Defects of the Upper Gastrointestinal Tract-A Comparative, Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1105. [PMID: 39064534 PMCID: PMC11279286 DOI: 10.3390/medicina60071105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/17/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT's duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.
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Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Claudio Conrad
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
| | - Julia Hoffmann
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Benedikt Reichert
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Witigo von Schoenfels
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Clemens Schafmayer
- Department of General Surgery, University Hospital Rostock, 18057 Rostock, Germany;
| | | | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Mark Ellrichmann
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
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14
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Triantafyllou T, Lamb P, Skipworth R, Couper G, Deans C. Surgical treatment of Boerhaave syndrome in the past, present and future: updated results of a specialised surgical unit. Ann R Coll Surg Engl 2024; 106:509-514. [PMID: 38563067 PMCID: PMC11214861 DOI: 10.1308/rcsann.2024.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis. METHODS This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade. RESULTS Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011. CONCLUSIONS Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.
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Affiliation(s)
- T Triantafyllou
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - P Lamb
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - R Skipworth
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - G Couper
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
| | - C Deans
- Department of Surgery, Royal Infirmary of Edinburgh, Scotland, NHS Lothian, UK
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15
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Dell’Anna G, Fanti L, Fanizza J, Barà R, Barchi A, Fasulo E, Elmore U, Rosati R, Annese V, Laterza L, Fuccio L, Azzolini F, Danese S, Mandarino FV. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med 2024; 13:3805. [PMID: 38999371 PMCID: PMC11242239 DOI: 10.3390/jcm13133805] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
| | - Lorella Fanti
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Ugo Elmore
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy;
| | - Riccardo Rosati
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
- Gastrointestinal Surgery Unit, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy;
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Liboria Laterza
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (L.L.); (L.F.)
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (L.L.); (L.F.)
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (L.F.); (J.F.); (R.B.); (A.B.); (E.F.); (F.A.); (S.D.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy;
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16
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Yohannes A, Knievel J, Lange J, Dormann AJ, Hügle U, Eisenberger CF, Heiss MM. VacStent as an Innovative Approach in the Treatment of Anastomotic Insufficiencies and Leakages in the Gastrointestinal Tract-Review and Outlook. Life (Basel) 2024; 14:821. [PMID: 39063574 PMCID: PMC11277949 DOI: 10.3390/life14070821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to prolonged hospitalization, serious tissue inflammation, and even sepsis, along with the need for recurrent surgery. Current non-surgical treatments such as self-expanding metal stents (SEMSs) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GITM (Möller Medical GmbH, Fulda, Germany), a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GITM application demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal promising and most importantly equally good outcomes while maintaining the possibility for sustained enteral nutrition and reducing the risk of stent migration. The VacStent GITM presents a promising alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and comprehensively establish its role in leak management. Further investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GITM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma.
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Affiliation(s)
- Alexander Yohannes
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Judith Knievel
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Jonas Lange
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Arno J. Dormann
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
| | - Ulrich Hügle
- Center for Interdisciplinary Visceral Medicine, Department of Gastroenterology, Gastrointestinal Oncology, Gastrointestinal Infections and Nutritional Medicine, Cologne-Holweide and Merheim Medical Centers, 51109 Cologne, Germany; (A.Y.); (A.J.D.); (U.H.)
| | - Claus F. Eisenberger
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
| | - Markus M. Heiss
- Center for Interdisciplinary Visceral Medicine, Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, 51109 Cologne, Germany; (J.K.); (J.L.); (C.F.E.)
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17
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Kouladouros K. Applications of endoscopic vacuum therapy in the lower gastrointestinal tract: Tips and tricks and a review of the literature. Best Pract Res Clin Gastroenterol 2024; 70:101927. [PMID: 39053980 DOI: 10.1016/j.bpg.2024.101927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/29/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
Endoscopic vacuum therapy (EVT) is an established technique for the treatment of rectal wall defects and especially anastomotic leaks. A wide range of EVT devices, both handmade and commercially available, allow for their successful placement even in small defects and difficult localizations. Reported success rates range between 85 and 97 %, while periintervenional morbidity is low and major adverse events are very rare. EVT has proven its effectiveness in the lower gastrointestinal tract and is now considered first line treatment for pelvic anastomotic leaks. This narrative review summarizes the current literature on EVT in the lower gastrointestinal tract, focusing on its indications, technical aspects and results, and offers tips and tricks for its clinical applications.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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18
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Mandarino FV, Sinagra E, Barchi A, Danese S. The Triple-S Advantage of Endoscopic Management in Gastrointestinal Surgery Complications: Safe, Successful, and Savings-Driven. Life (Basel) 2024; 14:122. [PMID: 38255737 PMCID: PMC10820887 DOI: 10.3390/life14010122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Despite advances in gastrointestinal (GI) surgery, post-operative complications are not entirely avoidable [...].
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (S.D.)
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy;
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (S.D.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (S.D.)
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19
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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20
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Luttikhold J, Pattynama LMD, Seewald S, Groth S, Morell BK, Gutschow CA, Ida S, Nilsson M, Eshuis WJ, Pouw RE. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023; 55:859-864. [PMID: 36828030 PMCID: PMC10465237 DOI: 10.1055/a-2042-6707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/24/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND : Endoscopic vacuum therapy (EVT) is a novel treatment for esophageal perforations. This study aimed to describe initial experience with EVT of esophageal perforations due to iatrogenic cause, Boerhaave syndrome, or other perforations not related to prior upper gastrointestinal surgery. METHODS : Data from patients treated with EVT for esophageal perforation at five hospitals in three European countries, between January 2018 and October 2021, were retrospectively collected. The primary end point was successful defect closure by EVT, with or without the use of other endoscopic treatment modalities. Secondary end points included mortality and adverse events. RESULTS : 27 patients were included (median age 71 years). The success rate was 89 % (24/27, 95 %CI 77-100). EVT failed in three patients: two deceased during EVT (septic embolic stroke, pulmonary embolism) and one underwent esophagectomy due to a persisting defect. Two adverse events occurred: one iatrogenic defect expansion during sponge exchange and one hemorrhage during sponge removal. Median treatment duration was 12 days (interquartile range [IQR] 6-16) with 1 sponge exchange (IQR 1-3). CONCLUSION : EVT is a promising organ-preserving treatment for esophageal perforations, with a success rate of 89 %. More experience with the technique and indications will likely improve success rates.
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Affiliation(s)
- Joanna Luttikhold
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Lisanne M. D. Pattynama
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Zürich, Switzerland
| | - Stefan Groth
- Centre of Gastroenterology, Klinik Hirslanden, Zürich, Switzerland
| | - Bernhard K. Morell
- Department of Gastroenterology and Hepatology, Universitätsspital, Zürich, Switzerland
- Department of Gastroenterology and Hepatology, Stadtspital Zürich, Zürich, Switzerland
| | - Christian A. Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Satoshi Ida
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, and Department of Upper Abdominal Diseases, Stockholm, Sweden
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E. Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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21
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Monino L, Moreels TG. Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks: How to Deal with the Challenges (with Video). Life (Basel) 2023; 13:1412. [PMID: 37374194 DOI: 10.3390/life13061412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/19/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Anastomotic leaks after gastrointestinal surgery have an important impact on surgical outcomes because of the high morbidity and mortality rates. Multiple treatment options exist requiring an individualized patient-tailored treatment plan after multidisciplinary discussion. Endoscopic vacuum therapy (EVT) is a novel treatment option that is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. EVT has a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient. To the unexperienced, the EVT technique may be prone to several hurdles which may deter endoscopists from using it and depriving patients from a potentially life-saving therapeutic option. The current review highlights the possible difficulties of the EVT procedure and aims to provide some practical solutions to facilitate its use in daily clinical practice. Personal tips and tricks are shared to overcome the pre-, intra- and post-procedural hurdles. An instructive video of the procedure helps to illustrate the technique of EVT.
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Affiliation(s)
- Laurent Monino
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
| | - Tom G Moreels
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
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22
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Lange J, Knievel J, Wichmann D, Kähler G, Wiedbrauck F, Hellmich T, Kandler M, Bernhardt J, Scholz D, Beyna T, Hausmann J, Wedi E, Ellrichmann M, Hügle U, Dormann AJ, Eisenberger CF, Heiss MM. Clinical implantation of 92 VACStents in the upper gastrointestinal tract of 50 patients-applicability and safety analysis of an innovative endoscopic concept. Front Surg 2023; 10:1182094. [PMID: 37215348 PMCID: PMC10198570 DOI: 10.3389/fsurg.2023.1182094] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Endoscopic vacuum therapy (EVT) has emerged as a promising treatment option for upper gastrointestinal wall defects, offering benefits such as evacuation of secretions and removal of wound debris by suction, and reduction and healing of wound cavities to improve clinical outcomes. In contrast, covered stents have a high rate of migration and lack functional drainage, while endoluminal EVT devices obstruct the GI tract. The VACStent is a novel device that combines the benefits of EVT and stent placement. Its design features a fully covered Nitinol-stent within a polyurethane sponge cylinder, enabling EVT while maintaining stent patency. Methods This study analyzes the pooled data from three different prospective study cohorts to assess the safe practicality of VACStent placement, complete leak coverage, and effective suction-treatment of esophageal leaks. By pooling the data, the study aims to provide a broader base for analysis. Results In total, trans-nasal derivation of the catheter, suction and drainage of secretion via vacuum pump were performed without any adversity. In the pooled study cohort of 92 VACStent applications, the mean stent indwelling time was 5.2 days (range 2-8 days) without any dislocation of the device. Removal of the VACStent was done without complication, in one case the sponge was lost but subsequently fully preserved. Minor local erosions and bleeding and one subsequent hemostasis were recorded unfrequently during withdrawal of the device (5.4%, 5/92) but no perforation or pressure ulcer. Despite a high heterogeneity regarding primary disease and pretreatments a cure rate of 76% (38/50 patients) could be achieved. Discussion In summary, insertion and release procedure was regarded as easy and simple with a low potential of dislocation. The VACStent was well tolerated by the patient while keeping the drainage function of the sponge achieving directly a wound closure by continuous suction and improving the healing process. The implantation of the VACStent provides a promising new procedure for improved clinical treatment in various indications of the upper gastrointestinal wall, which should be validated in larger clinical studies.Clinical Trial Registration: Identifier [DRKS00016048 and NCT04884334].
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Affiliation(s)
- J. Lange
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - J. Knievel
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - D. Wichmann
- Department for Visceral, General and Transplant Surgery, Tübingen University Hospital, Tübingen, Germany
| | - G. Kähler
- Multispecialty Endoscopy Center, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany
| | - F. Wiedbrauck
- Department of Gastroenterology, AKH Celle, Celle, Germany
| | - T. Hellmich
- Department of Gastroenterology, Städtisches Klinikum Dresden, Dresden, Germany
| | - M. Kandler
- Department of Gastroenterology, Städtisches Klinikum Dresden, Dresden, Germany
| | - J. Bernhardt
- Department of Surgery, Klinikum Suedstadt Rostock, Rostock, Germany
| | - D. Scholz
- Department of Gastroenterology and Metabolism, Ameos Klinikum Am Bürgerpark, Bremerhaven, Germany
| | - T. Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - J. Hausmann
- Department of Gastroenterology/Internal Medicine, St. Vinzenz-Hospital Hanau, Hanau, Germany
| | - E. Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - M. Ellrichmann
- Department of Interdisciplinary Endoscopy, Medical Department 1, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - U. Hügle
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - A. J. Dormann
- Department of Gastroenterology, Cologne-Holweide and Merheim Medical Center, Cologne, Germany
| | - C. F. Eisenberger
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - M. M. Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
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Rosianu CG, Hoara P, Achim F, Birla R, Bolocan A, Mohssen A, Copca N, Constantinoiu S. The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review. Life (Basel) 2023; 13:life13040966. [PMID: 37109495 PMCID: PMC10144597 DOI: 10.3390/life13040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.
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Affiliation(s)
- Cristian Gelu Rosianu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Petre Hoara
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Florin Achim
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Rodica Birla
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Alexandra Bolocan
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ahmed Mohssen
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Narcis Copca
- Second Department of Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
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Lange J, Eisenberger CF, Knievel J, Linderer A, Heiss MM. Preemptive endoluminal vacuum therapy with the VACStent—A pilot study to reduce anastomotic leakage after Ivor Lewis hybrid esophagectomy. Front Surg 2023; 10:1133083. [PMID: 37066006 PMCID: PMC10097441 DOI: 10.3389/fsurg.2023.1133083] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionEndoscopic 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).MethodsIn 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.ResultsTechnical 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.DiscussionThe 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.
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Pattynama LMD, Eshuis WJ, van Berge Henegouwen MI, Bergman JJGHM, Pouw RE. Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects. Front Surg 2023; 10:1145984. [PMID: 36923375 PMCID: PMC10010284 DOI: 10.3389/fsurg.2023.1145984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Introduction Endoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent. Patients and methods This prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events. Results In total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed. Conclusion The vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.
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Affiliation(s)
- Lisanne M. D. Pattynama
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands
| | - Jacques J. G. H. M. Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Roos E. Pouw
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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The VACStent trial: combined treatment of esophageal leaks by covered stent and endoscopic vacuum therapy. Surg Endosc 2023; 37:3657-3668. [PMID: 36639580 PMCID: PMC10156910 DOI: 10.1007/s00464-023-09861-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic treatment of esophageal leaks, mostly by covered stents or endoscopic vacuum therapy (EVT), has largely improved the clinical outcome in the last decade. However, both techniques suffer from significant limitations. Covered stents are hampered by a high rate of migration and missing functional drainage, whereas endoluminal EVT devices are limited by obstruction of the GI tract. The new design of the VACStent makes it a fully covered stent within a polyurethane sponge cylinder, allowing EVT while stent passage is still open. Initial clinical applications have demonstrated the fundamental concept of the VACStent. METHOD A prospective multicenter open-label study was performed with the primary endpoint safe practicality, complete leak coverage, and effective suction-treatment of esophageal leaks. Secondary endpoints were prevention of septic conditions, successful leak healing, and complications, in particular stent-migration, local erosions and bleeding. RESULTS Fifteen patients with different, mostly postoperative anastomotic leaks were enrolled in three centers. A total of 41 VACStents were implanted. The mean number of VACStents per patient was 2.7, with a mean duration of VACStent treatment of 15 days. The primary endpoint was met in all VACStent applications (41/41 implants), resulting in a leak healing rate of 80% (12/15 patients). Septic episodes were prevented in 93% (14/15 patients) and there was no mortality. There were no severe device-related adverse events (SADE) nor significant local bleeding or erosion. Minor stent-dislocation and migration, respectively, was observed in 7%. Oral intake of liquids or food was documented in 87% (13/15 patients). One anastomotic stenosis was seen during follow-up. CONCLUSIONS VACStent treatment is a safe and effective treatment in esophageal leaks which can be covered by the sponge cylinder. Its application was described as easy and resembling that of conventional GI stents, with an impressive clinical success rate comparable to EVT outcomes. The VACStent offers a new option for clinical treatment of critical situations in esophageal perforations and anastomotic sutureline failures.
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Binda C, Jung CFM, Fabbri S, Giuffrida P, Sbrancia M, Coluccio C, Gibiino G, Fabbri C. Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:136. [PMID: 36676760 PMCID: PMC9864982 DOI: 10.3390/medicina59010136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Paolo Giuffrida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90127 Palermo, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli—Cesena Hospitals, AUSL Romagna, 47121 Forlì Cesena, Italy
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Schäfer C. Don't be afraid of black holes: Vacuum sponge and vacuum stent treatment of leaks in the upper GI tract-a case series and mini-review. Front Surg 2023; 10:1168541. [PMID: 37206354 PMCID: PMC10191254 DOI: 10.3389/fsurg.2023.1168541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/04/2023] [Indexed: 05/21/2023] Open
Abstract
The treatment of leaks in the upper gastrointestinal tract has been revolutionized by the advent of covered self-expanding metal stents (cSEMS), endoscopic vacuum therapy (EVT), and recently, vacuum stent therapy (VST). In this retrospective study, we report the experiences with EVT and VST at our institution. Patients and methods Twenty-two patients (15 male, 7 female) with leaks in the esophagus, at the esophago-gastric junction or anastomotic leaks underwent EVT by placing a sponge connected to a negative pressure pump into or near the leak. VST was applied in three patients. Results EVT led to closure of the leak in 18 of 22 Patients (82%). In 9 patients (41%), EVT was followed by application of a cSEMS. One patient (5%) died during the hospital stay due to an aorto-esophageal fistula near the leak, four others (18%) due to underlying disease. The stricture rate was 3/22 (14%). All three patients in whom VST was applied had closure of the leak and recovered. Reviewing the literature, we identified sixteen retrospective series of ten or more patients (n = 610) with an overall closure rate for EVT of 84%. In eight additional retrospective observations, a comparison between the efficacy of EVT and cSEMS therapy was performed that revealed a success rate of 89% and 69%, respectively (difference not significant, chi-square test). For VST, two small series show that closure is possible in the majority of patients. Conclusion EVT and VST are valuable options in the treatment of leaks in the upper gastrointestinal tract.
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Drefs M, Schardey J, von Ehrlich-Treuenstätt V, Wirth U, Burian M, Zimmermann P, Werner J, Kühn F. Endoscopic Treatment Options for Gastrointestinal Leaks. Visc Med 2022; 38:311-321. [PMID: 37970585 PMCID: PMC10642546 DOI: 10.1159/000526759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients. Methods We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
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Gutschow CA, Schlag C, Vetter D. Endoscopic vacuum therapy in the upper gastrointestinal tract: when and how to use it. Langenbecks Arch Surg 2022; 407:957-964. [PMID: 35041047 PMCID: PMC9151563 DOI: 10.1007/s00423-022-02436-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) has emerged as a novel treatment option for upper gastrointestinal wall defects. The basic principle of action of EVT entails evacuation of secretions, removal of wound debris, and containment of the defect. Furthermore, there is increasing evidence that EVT reduces interstitial edema, increases oxygen saturation, and promotes tissue granulation and microcirculation. Various devices, such as macroporous polyurethane sponge systems or open-pore film drains, have been developed for specific indications. Depending on the individual situation, EVT devices can be placed in- or outside the intestinal lumen, as a stand-alone procedure, or in combination with surgical, radiological, and other endoscopic interventions. PURPOSE The aim of this narrative review is to describe the current spectrum of EVT in the upper gastrointestinal tract and to assess and summarize the related scientific literature. CONCLUSIONS There is growing evidence that the efficacy of EVT for upper GI leakages exceeds that of other interventional treatment modalities such as self-expanding metal stents, clips, or simple drainages. Owing to the promising results and the excellent risk profile, EVT has become the therapy of choice for perforations and anastomotic leakages of the upper gastrointestinal tract in many centers of expertise. In addition, recent clinical research suggests that preemptive use of EVT after high-risk upper gastrointestinal resections may play an important role in reducing postoperative morbidity.
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Affiliation(s)
- Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14040980. [PMID: 35205730 PMCID: PMC8870330 DOI: 10.3390/cancers14040980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments. Abstract Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.
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Postoperative Leckagen im Gastrointestinaltrakt – Diagnostik und Therapie. DER GASTROENTEROLOGE 2022; 17:47-56. [PMID: 35035584 PMCID: PMC8744584 DOI: 10.1007/s11377-021-00584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
Postoperative Leckagen nach Ösophagus‑, Magen- oder Kolon- bzw. Rektumchirurgie stellen schwerwiegende chirurgische Komplikationen mit einer hohen Morbidität und Mortalität dar. Leckagen werden zumeist durch eine Kombination aus klinischer Beobachtung, Infektionsparametern sowie endoskopischen und schnittbildgebenden Verfahren diagnostiziert. Die Therapie ist bei intraperitonealen Leckagen chirurgisch, bei retroperitonealen bzw. mediastinalen Leckagen in einem interdisziplinären Setting überwiegend interventionell endoskopisch. Hier stehen der Defektverschluss durch die Abdichtung mittels selbstexpandierender gecoverter Stents mit gleichzeitiger externer extraluminaler Drainage sowie der Defektverschluss mit simultaner innerer Drainage und endoskopischer Unterdrucktherapie als vorrangige Methoden zur Verfügung.
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