Endoscopic vacuum therapy as a salvage treatment of a life-threatening esophageal perforation

The mortality rate of esophageal perforations is 31% [1]. In severe cases, surgery becomes its mainstay management. But what happens when they fail to resolve a life-threatening condition? Endoscopic therapies (stenting, suturing, clipping) become a salvage option showing favorable results [2]; sometimes, though, they are not enough and require exploration of alternatives [3] [4]. We present challenging cases successfully treated with rescue endoscopic vacuum therapy (EVT) ([Video 1]).

Ex vivo demonstration of endoscopic vacuum therapy technique and application of this procedure as a rescue therapy in life-threatening situations.Video 1

A 19-year-old woman required hemostatic clips and a 23 × 115-mm partially covered self-expandable metal stent (SEMS) for distal esophageal mucosal injury closure after repeat peroral endoscopic myotomy. Empyema and mediastinitis refractory to medical treatment developed and chest tube drainage was performed. Eight days after Ivor-Lewis partial esophagectomy ([Fig. 1]), hypoxemia and hemodynamic instability arose, and hydropneumothorax and esophageal contrast leakages were found. Pulmonary collections were percutaneously drained via interventional radiology. EVT treated the 2.5 × 3-cm cavity found by esophagogastroduodenoscopy (EGD). During EVT, a 16 F nasogastric tube (NGT) fixed to a sponge (V.A.C. Granufoam Silver Dressing; Acelity, San Antonio, Texas, USA) was positioned intraluminally perorally with an overtube (Guardus overtube; Steris, Mentor, Ohio, USA) and rat tooth forceps. Subsequently, a 14 F NGT was intranasally fixed distal to the 16 F NGT and proximal to the vacuum device placed at –125 mmHg. EVT was repeated seven times every five days ([Fig. 2]). After computed tomography scan and EGD confirmed leakage closure, the patient was discharged. In the 18-month follow-up, the patient remained asymptomatic, but required stenotic ring dilation.

Fig. 1 Case 1: Anastomotic dehiscence after Ivor-Lewis esophagectomy.

Fig. 2 Case 1: Granulation tissue revealed on follow-up esophagogastroduodenoscopy.

A 75-year-old woman underwent endoscopic ultrasound, confirming a 90-mm pseudocyst. During placement of a lumen-apposing metal stent, cystic bleeding occurred requiring closure with over-the-scope clips. On scope retrieval, a cervical-esophageal tear was seen, needing an 18 × 103-mm SEMS. Acute respiratory distress arose 3 days later, requiring mechanical ventilation. The SEMS was removed and oral contrast leakage confirmed suspicion of esophageal perforation ([Fig. 3]). EVT was performed placing the endo sponge intraluminally with a polypectomy snare (CoinTip snare, Steris). This procedure was performed two times in total, visualizing granulation tissue after session one. ([Fig. 4]). On day 9, complete perforation closure and a normal esophagogram were documented ([Fig. 5]). In the 2-month follow-up, the patient remained asymptomatic.

Fig. 3 Case 2: Esophageal perforation diagnosed during videoendoscopy.

Fig. 4 Case 2: Granulation tissue and closure over previous esophageal perforation.

Fig. 5 Case 2: Normal esophagogram after endoscopic vacuum therapy.

Endoscopy_UCTN_Code_CPL_1AH_2AG

Publication History

Article published online:
14 March 2024

• References

• 1 Watkins JR, Farivar AS. Endoluminal therapies for esophageal perforations and leaks. Thorac Surg Clin 2018; 28: 541-554
• 2 Khaitan PG, Famiglietti A, Watson TJ. The etiology, diagnosis, and management of esophageal perforation. J Gastrointest Surg 2022; 26: 2606-2615
• 3 Jung CFM, Müller-Dornieden A, Gaedcke J. et al. Impact of endoscopic vacuum therapy with low negative pressure for esophageal perforations and postoperative anastomotic esophageal leaks. Digestion 2021; 102: 469-479
• 4 Still S, Mencio M, Ontiveros E. et al. Primary and rescue endoluminal vacuum therapy in the management of esophageal perforations and leaks. Ann Thorac Cardiovasc Surg 2018; 24: 173-179