Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Göttingen, Germany.
Department of General-, Visceral- and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany.
Digestion. 2021;102(3):469-479. doi: 10.1159/000506101. Epub 2020 Feb 11.
Management of esophageal anastomotic leaks (AL) and esophageal perforations (EP) remains difficult and often requires an interdisciplinary treatment modality. For primary endoscopic management, self-expanding metallic stent (SEMS) placement is often considered first-line therapy. Recently, endoscopic vacuum therapy (EVT) has emerged as an alternative or adjunct for management of these conditions. So far, data for EVT in the upper gastrointestinal-tract is restricted to single centre, non-randomized trials. No studies on optimal negative pressure application during EVT exist. The aim of our study is to describe our centre's experience with low negative pressure (LNP) EVT for these indications over the past 5-years.
Between January 2014 and December 2018, 30 patients were endoscopically treated for AL (n = 23) or EP (n = 7). All patients were primarily treated with EVT and LNP between -20 and -50 mm Hg. Additional endoscopic treatment was added when EVT failed. Procedural and peri-procedural data, as well as clinical outcomes including morbidity and mortality, were analysed.
Clinical successful endoscopic treatment of EP and AL was achieved in 83.3% (n = 25/30), with 73.3% success using EVT alone (n = 22/30). Mean treatment duration until leak closure was 16.1 days (range 2-58 days). Additional treatment modalities for complete leak resolution was necessary in 10% (n = 3/30), including SEMS placement and fibrin glue injection. Mean hospital stay for patients with EP was shorter with 33.7 days compared to AL with 54.4 days (p = 0.08). Estimated preoperative 10-year overall survival (Charlson comorbidity score) was 39.4% in patients with AL and 59.9% in patients with EP (p = 0.26). A mean of 5.1 EVT changes (range 1-12) was needed in EP and 3.6 changes (range 1-13) in AL to achieve complete closure, switch to other treatment modality, or reach endoscopic failure (p = 0.38).
LNP EVT enables effective minimally - invasive endoluminal leak closure from anastomotic esophageal leaks and EP in high-morbid patients. In this study, EVT was combined with other endoscopic treatment options such as SEMS placement or fibrin glue injection in order to achieve leak or perforation closure in the vast majority of patients (83.3%). Low aspiration pressures led to slower but still sufficient clinical results.
食管吻合口瘘（AL）和食管穿孔（EP）的处理仍然具有挑战性，通常需要采用多学科治疗方法。对于原发性内镜治疗，自膨式金属支架（SEMS）置入通常被认为是一线治疗方法。最近，内镜真空治疗（EVT）已成为这些疾病治疗的另一种选择或辅助手段。到目前为止，上消化道 EVT 的数据仅限于单中心、非随机试验。关于 EVT 期间最佳负压应用尚无研究。本研究旨在描述过去 5 年来，我们中心使用低负压（LNP）EVT 治疗这些疾病的经验。
2014 年 1 月至 2018 年 12 月，30 例患者因 AL（n = 23）或 EP（n = 7）接受内镜治疗。所有患者均采用 EVT 和 LNP 治疗，负压范围为-20 至-50 mmHg。当 EVT 失败时，会添加其他内镜治疗。分析了治疗过程中的程序和围手术期数据以及包括发病率和死亡率在内的临床结果。
83.3%（n = 25/30）的 EP 和 AL 患者经内镜治疗后获得临床成功，单独使用 EVT 治疗的成功率为 73.3%（n = 22/30）。从漏口关闭的平均治疗时间为 16.1 天（范围 2-58 天）。10%（n = 3/30）的患者需要额外的治疗方法来完全解决漏口，包括 SEMS 放置和纤维蛋白胶注射。EP 患者的平均住院时间为 33.7 天，AL 患者为 54.4 天（p = 0.08）。AL 患者的术前 10 年总体生存率（Charlson 合并症评分）为 39.4%，EP 患者为 59.9%（p = 0.26）。EP 患者平均需要进行 5.1 次 EVT 更换（范围 1-12），AL 患者需要进行 3.6 次更换（范围 1-13），以实现完全闭合、切换到其他治疗方法或达到内镜治疗失败（p = 0.38）。
LNP EVT 可在高合并症患者中有效进行微创性内镜吻合口食管漏和 EP 漏口闭合。在本研究中，EVT 与 SEMS 放置或纤维蛋白胶注射等其他内镜治疗选择联合使用，以在绝大多数患者（83.3%）中实现漏口或穿孔闭合。低抽吸压力导致治疗时间延长，但仍获得了足够的临床效果。
