Endoscopy 2023; 55(01): 101
DOI: 10.1055/a-1901-8750
Letter to the editor

Reply to Danese et al.

Carlo Felix Maria Jung
 1   Department of Gastroenterology and Digestive Endoscopy, Forli-Cesena Hospitals, AUSL Romagna, Italy
 2   Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
,
Rachel Hallit
 3   Department of Gastroenterology and Gastrointestinal Oncology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
,
Annegret Müller-Dornieden
 4   Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
,
Mélanie Calmels
 5   Department of Digestive Surgery, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
,
Diane Goere
 5   Department of Digestive Surgery, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
,
Ulriikka Chaput
 6   Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
,
Marine Camus
 6   Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
,
Jean Michel Gonzalez
 7   Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
,
 7   Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
,
Jérémie Jacques
 8   Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
,
Romain Legros
 8   Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
,
Thierry Barrioz
 9   Department of Gastroenterology, Poitiers University Hospital, Poitiers, France
,
Fabian Kück
10   Department of Medical Statistics, University Medical Center, University of Göttingen, Göttingen, Germany
,
Ali Seif Amir Hosseini
11   Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
,
Michael Ghadimi
 4   Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
,
Steffen Kunsch
 2   Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
12   Department of Gastroenterology, Internal Medicine and Geriatrics, Rems-Murr Hospital, Winnenden, Germany
,
Volker Ellenrieder
 2   Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
,
Edris Wedi
 2   Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
13   Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Klinikum Offenbach, Offenbach, Germany
,
Maximilien Barret
 3   Department of Gastroenterology and Gastrointestinal Oncology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
› Author Affiliations

We thank Prof. Danese and colleagues for their comments on our article [1]. As noted, bias pertaining to the surgical and endoscopic expertise of each center is indeed a concern and multicenter studies could help in attenuating this bias. Here, the treatment choices were down to the poor availability of endoscopic vacuum therapy (EVT) in France, coupled with the experience in endoscopic internal drainage (EID), as opposed to the high expertise in EVT in Germany.

As co-morbidity and leak sizes were well balanced in both groups, the anatomic site of the leaks (intrathoracic vs. intra-abdominal) and prior chemoradiotherapy could explain the inferior treatment success observed in the EVT group. Indeed, the EVT cohort had more patients with intrathoracic leaks (70.4 % vs. 60.0 %) and more patients treated with neoadjuvant chemoradiotherapy (40.7 % vs. 8.0 %).

The characteristics of the negative pressure used in EVT are still a point of debate. No studies comparing the different pressure levels have been published in humans. Our own experience has shown comparable results between low negative pressure and −125 mmHg EVT [2]. Low negative-pressure EVT most likely works by deviating the biologic fluids (bile, gastric and pancreatic juice) away from the anastomotic site. Recently, Loske et al. confirmed the crucial role of gastroesophageal reflux in the development of anastomotic leaks by showing the efficacy of pre-emptive active drainage of reflux in patients with Ivor Lewis esophagectomy [3].

As stressed by Danese et al., for leaks of > 20 mm, EID may not be the best option, because the double-pigtail stents can migrate through the anastomotic dehiscence: initial EVT or a self-expandable metal stent (SEMS) is therefore advisable in this situation [4].

We cannot but agree on the need for large prospective multicenter studies on the endoscopic treatments for anastomotic leaks in order to determine the respective efficacy of different negative pressures in EVT, and the optimal treatment sequences.



Publication History

Article published online:
20 December 2022

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