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Successful endoscopic management of a large esophageal defect due to Boerhaave syndrome with endoscopic vacuum therapy using vacuum sponge and vacuum stent

Open AccessPublished:January 21, 2023DOI:https://doi.org/10.1016/j.vgie.2022.12.001

      Video

      (mp4, (128.8 MB)

      Successful endoscopic management of a large esophageal defect due to Boerhaave syndrome with endoscopic vacuum therapy using EsoSponge and VACStent.

      Abbreviation:

      EVT (endoscopic vacuum therapy)

      Introduction

      Endoscopic vacuum therapy (EVT) is an efficient new treatment option for the management of upper GI transmural defects.
      • Tavares G.
      • Tustumi F.
      • Tristao L.S.
      • et al.
      Endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy: a systematic review and meta-analysis.
      • Scognamiglio P.
      • Reeh M.
      • Karstens K.
      • et al.
      Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis.
      • do Monte Junior E.S.
      • de Moura D.T.H.
      • Ribeiro I.B.
      • et al.
      Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis.
      • Schniewind B.
      • Schafmayer C.
      • Voehrs G.
      • et al.
      Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study.
      Using an endoscopically placed sponge, we applied negative pressure, resulting in drainage of exudate, stimulation of perfusion, and secondary wound healing.
      • de Moura D.T.H.
      • de Moura B.
      • Manfredi M.A.
      • et al.
      Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects.
      In our center, EVT in the upper GI tract has become standard treatment for esophageal leaks since 2018, using the EsoSponge (B. Braun, Melsungen, Germany).
      Recently, the VACStent (MICRO-TECH Europe GmbH, Düsseldorf, Germany) was introduced, which consists of a covered stent surrounded by a sponge (Fig. 1). The VACStent combines sealing of the defect with the benefits of negative pressure therapy, which also keeps the VACStent in place and the lumen open. The VACStent seems to be a promising, safe, and feasible treatment option.
      • Chon S.H.
      • Scherdel J.
      • Rieck I.
      • et al.
      A new hybrid stent using endoscopic vacuum therapy in treating esophageal leaks: a prospective single-center experience of its safety and feasibility with mid-term follow-up.
      Figure thumbnail gr1
      Figure 1VACStent with fully covered nitinol stent (length 72 mm, diameter 30-14-30 mm), polyurethane sponge (length 50 mm), and blue suction catheter. Image courtesy of Esophageal Research Team AUMC.

      Case

      A 63-year-old man was admitted with acute chest pain after vomiting. A CT scan showed a defect of 4 cm in length in the distal esophagus, with a cavity extending proximally into the mediastinum. In close consultation with the surgical department, it was decided to perform an endoscopy, and a large contaminated cavity was seen (Fig. 2). After cleaning the cavity, a multidisciplinary decision was made to place an EsoSponge intraluminally to cover the defect, since placing an EsoSponge into the cavity was unsuccessful because of the sharp angle upward. A feeding tube was placed alongside the EsoSponge for enteral feeding.
      Figure thumbnail gr2
      Figure 2Esophageal perforation (A) and adjacent cavity (B) during first endoscopy.
      During EVT, a negative pressure of 75 to 125 mm Hg was applied, and the EsoSponge was exchanged every 3 to 7 days. After initial clinical improvement, little healing tendency of the defect was observed with endoscopy and CT imaging, and the decrease of infectious parameters was stagnant. Therefore, after 37 days of EVT, it was decided to perform surgical decortication and placement of a muscle flap into the cavity (Fig. 3).
      Figure thumbnail gr3
      Figure 3Defect after surgical placement of muscle flap into the cavity.
      Subsequently, intraluminal EVT with EsoSponge was continued to optimize granulation of the defect. However, after 23 days, infectious parameters increased and a CT scan showed expansion of the paraesophageal collection. Furthermore, endoscopic improvement was stagnant. Therefore, it was decided to place a VACStent.

      Procedure and Treatment Course

      The procedure was performed with the patient under deep propofol sedation using a diagnostic endoscope (GIF-EZ1500; Olympus, Tokyo, Japan). First, the EsoSponge was removed, revealing the remaining defect with air bubbles at the proximal site (Fig. 4).
      Figure thumbnail gr4
      Figure 4Remaining defect after endoscopic vacuum therapy with 7 sponge exchanges; feeding tube is still in situ.
      Second, a stiff 0.035-inch guidewire (600375-5 Classic; MICRO-TECH Europe GmbH) was placed into the duodenum. The VACStent was advanced over the guidewire. After reintroduction of the endoscope, the VACStent was positioned over the defect under endoscopic visualization, and the VACStent was deployed (Figs. 5 and 6; Video 1, available online at www.giejournal.org). Subsequently, the suction catheter was guided through the nose and connected to a vacuum pump (ActiV.A.C.; 3M Health Care, St. Paul, Minn, USA). Lastly, 125 mm Hg negative pressure was applied and decreased to 75 mm Hg negative pressure the next day.
      Figure thumbnail gr5
      Figure 5Positioning of VACStent over defect.
      Figure thumbnail gr6
      Figure 6VACStent after intraluminal deployment.
      From the second day after VACStent placement, oral intake was extended to a soft diet without problems. After 7 days, the VACStent was removed using a tapered hood distal attachment cap (DH-28GR Hood; FUJIFILM Corporation, Tokyo, Japan) to carefully separate the stent from the mucosa (Fig. 7). Subsequently, the stent was removed with a grasping forceps.
      Figure thumbnail gr7
      Figure 7Separation of uncovered part of stent (A) and sponge (B) of the VACStent from the mucosa with a tapered hood distal attachment cap.
      The defect had become smaller, infectious parameters had decreased, and the patient was clinically stable. However, the suspicion of a persisting defect remained because of some air bubbles, and another VACStent was placed. Upon removal after 1 week, the defect appeared to be closed (Fig. 8), which was confirmed by a CT scan with oral contrast. Three days after VACStent removal and after 2.5 months of hospitalization, the patient was discharged. At 3 months’ follow-up, the patient was doing well and had a normal oral intake.

      Disclosures

      Dr Pouw is a consultant for MicroTech Endoscopy and Medtronic, is a paid speaker for Pentax Medical, and is on an advisory board for EsoCap. All other authors disclosed no financial relationships.

      Supplementary data

      References

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