Endoscopic vacuum therapy for esophageal perforations: size and etiology of the defect need to be considered

We read with interest the article by Luttikhold et al. [11] about the treatment of esophageal perforations with endoscopic vacuum therapy (EVT). The authors described a rate of 70% for successful defect closure with EVT alone and 89% when used in addition to other endoscopic treatments. The majority of the included cases (n=16/27) had an iatrogenic perforation of unclear etiology; we kindly ask the authors to clarify this point and provide more details regarding the “scenario” where EVT might be indicated.

The study also reported that the treatment was started immediately after diagnosis for cases of iatrogenic perforation, obtaining 100% clinical success, confirming the remark: “the earlier, the better.” Other factors involved in a successful treatment were: etiology, size and location of the perforation, presence or absence of a communicating collection, and age and co-morbidities of the patient. For these reasons, in the authors' experience, the Boerhaave syndromes had the worst outcomes: more time required to start the treatment, higher mortality due to the etiology, larger perforation size, and the presence of empyema.

As underlined by Mandarino et al. [22], most of the patients (78%) received an intraluminal sponge alone to treat small (<10mm) and intermediate (10–19mm) perforations without the presence of collections and in non-anastomotic leakage. In these situations, the sponge aspirates mainly saliva and gastric juice; the same result could be achieved with widely available and cheaper gastric tubes. Also, there is a risk of sponge dislodgement resulting in delayed treatment. Furthermore, the use of endoscopic clips (both over-the-scope and through-the-scope clips) is the first-line option for primary closure of small and intermediate esophageal perforations [33].

We agree with the authors that every single patient and situation should be carefully evaluated, and the best-tailored approach should be chosen. We thank the authors for sharing their extensive experience in using EVT.

Publication History

Article published online:
29 May 2024

• References

• 1 Luttikhold J, Pattynama LMD, Seewald S. et al. Endoscopic vacuum therapy for esophageal perforation: a multicenter retrospective cohort study. Endoscopy 2023; 55: 859-864 DOI: 10.1055/a-2042-6707. (PMID: 36828030)
• 2 Mandarino FV, Fanti L, Barchi A. et al. Endoscopic vacuum therapy for esophageal perforations: is it risk effective for every size of defect?. Endoscopy 2023; 55: 971 DOI: 10.1055/a-2070-5524. (PMID: 37757794)
• 3 Paspatis GA, Arvanitakis M, Dumonceau JM. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy 2020; 52: 792-810 DOI: 10.1055/a-1222-3191. (PMID: 32781470)