Novel treatment options for perforations of the upper gastrointestinal tract: endoscopic vacuum therapy and over-the-scope clips

Abstract

Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.

Keywords: Endoscopic vacuum therapy; Endoscopy; Fistula; Over-the-scope clip; Perforation; Upper gastrointestinal.

Figure 1

Sponge mounted on a gastric tube for endoscopic vacuum therapy (A), and over-the-scope clip mounted on a gastroscope (B). A suture loop at the tip of the sponge facilitates endoscopic handling (A).

Figure 2

Dehiscence of an esophagogastric stapler anastomosis with esophago-bronchial fistula in a 65-year old woman: endoscopic vacuum therapy and over-the-scope clip application. A: Anastomotic dehiscence (after extraction of a covered stent); B: Mediastinal cavity; C: Endoscopic vacuum therapy. Gastric tube with sponge placed in the defect (center), additional tube placed in the duodenum for enteral nutrition; D: Persistent fistula (below) after endoscopic vacuum therapy; E: Over-the-scope clip (OTSC) closure of the fistula; F: Eleven months after OTSC closure.