Discussion
EVT failure, perforations, esophageal perforations, necrotic, gastrointestinal tract, infection, ill, Boerhaave syndrome
ANASTOMOTIC LEAKS, NECROTIC, INFECTION, COLLAPSE, ADVERSE EVENT, ESOPHAGEAL PERFORATION, CAVITY, LEAKAGE, BOERHAAVE SYNDROME
This study describes the initial experiences with EVT for esophageal perforations, including Boerhaave syndrome and iatrogenic causes in five centers in the Netherlands, Switzerland, and Sweden. The rate of successful defect closure by EVT, with or without the use of other endoscopic treatment modalities, was 89 %, suggesting that EVT is an effective organ-sparing therapeutic option for these perforations, allowing invasive surgery to be avoided in the vast majority of patients. All-cause mortality and adverse event rates were low (11 % and 7 %, respectively).
These results correspond with previous studies on EVT in the upper GI tract, with success rates ranging from 60 % to 100 %, and an overall mortality rate of 0 % to 10 %
As demonstrated in the current study, the success rate increased when EVT was combined with other treatment modalities. In this cohort, five patients were additionally treated with an intraluminal stent or surgical intracavitary placement of a muscle flap. Three patients received a stent over a small remaining defect, at the endoscopist’s discretion. It is likely that these defects would have also closed with EVT alone, as good clinical and endoscopic recovery was seen with EVT.
Although initial stent placement often causes a necrotic cavity to be sealed off, warranting additional percutaneous drainage, it may be a valid option if the defect is clean and shows good healing tendency after initial EVT, as it allows for the rest of the defect to heal while sealing the defect. Stent treatment allows the possibility of oral intake and requires fewer endoscopies compared with EVT with sponge exchanges. Future studies should focus on the optimal timing for combining EVT and stenting. In this respect, the recently released VACStent (MICRO-TECH Europe GmbH, Düsseldorf, Germany) may also be interesting. This device combines the sealing effect of a stent with the benefits of negative pressure wound therapy at the site of the defect, while keeping the stent in place with the vacuum and allowing for oral intake
In addition, one patient had a stiff pleura, causing inadequate expansion of the lung and collapse of the cavity with EVT alone. Therefore, this patient underwent surgical decortication with placement of a muscle flap into the pleural cavity. Given that EVT only works if the cavity collapses adequately, this could have been an exclusion criteria for EVT. However, this operation, in combination with endoscopic management, still has benefits when compared with an esophagectomy, as continuity of the gastrointestinal tract can be preserved. The optimal timing for such a surgical intervention has yet to be determined. One of the advantages of performing this surgery after initial EVT, is that the area in which the operation takes place is relatively clean and the patient is in a better clinical condition than at the start of the treatment, optimizing healing and reducing the risk of infection. Furthermore, thoracoscopic decontamination of the mediastinum could improve the healing process if significant decontamination is present.
Until recently, surgical treatment provided the best chance of cure for esophageal perforations. For example, Harikrishnan et al. (2020) described a retrospective overview of treatments for Boerhaave syndrome in a tertiary care center between 2008 and 2019
Comparison of successful and unsuccessful groups may allow factors contributing to treatment failure to be identified and the best indications for EVT to be determined. However, given the relatively small and heterogeneous cohort in the current study, multivariable analysis on factors associated with successful or unsuccessful EVT could not be performed. Data did show that patients with a higher Perforation Severity Score were more likely to experience EVT failure. Moreover, success rates in patients with Boerhaave syndrome were lower (67 %) compared with patients with an iatrogenic perforation (100 %). This may probably be explained by the larger defect size and longer time to intervention in patients with Boerhaave syndrome, resulting in more leakage into the mediastinum and more systemically ill patients. Despite the lower success rates, EVT seemed to be an efficient and feasible therapy, even for Boerhaave syndrome.
Furthermore, perforations occurring during endoscopic treatment can often be adequately treated by primary closure with clips
This study has several strengths. First, to our knowledge, this is the largest cohort describing the outcomes of EVT for exclusively esophageal perforations, excluding anastomotic leaks. Second, the international multicenter design allowed accumulation of expertise due to participation of multiple experts on EVT.This study also has a number of limitations that need to be acknowledged. First, as this was a retrospective observational study and the EVT protocol differed per center, selection and information bias could have occurred during case and data retrieval. In addition, no comparison was made with a control group treated with other treatment modalities, such as placement of an intraluminal stent. Furthermore, due to the relatively small sample size, assessment of factors associated with EVT failure (e. g. the intracavitary versus intraluminal technique), could not be performed.This paper retrospectively describes an international multicenter patient cohort treated with EVT for esophageal perforations, including those associated with Boerhaave syndrome and iatrogenic causes. Efficacy was established, with a success rate of 89 %. Although EVT for esophageal perforations is a promising technique promoting defect closure, a number of relevant questions remain, mostly regarding appropriate indications and combination with other treatment modalities.