Eugene Kligman, MD1, J. Andy Tau, MD2, Jose Luis Aranez, MD3, Robert J. Sealock, MD3, Gyanprakash Ketwaroo, MD, MPH3, Wasif Abidi, MD, PhD3; 1Baylor College of Medicine, Wheeling, IL; 2Austin Gastroenterology, Austin, TX; 3Baylor College of Medicine, Houston, TX
Introduction: Endoscopic interventions have been successful in the closure of gastrointestinal perforations and post-operative leaks, issues that have traditionally been addressed surgically. Mechanical endoscopic closure has been reported with clips, stents, suturing, and fibrin glue. Endoscopic vacuum therapy (EVT) offers an alternate mechanism of closure via negative pressure that results in defect reduction, aspiration of infected fluid, and promotion of granulation tissue. We present our experience with EVT as it relates to spontaneous, iatrogenic, and post-operative upper GI tract perforations, leaks, and fistulas. Methods: We retrospectively reviewed patients presenting with upper GI tract perforation, post-operative leak, or fistula that underwent EVT at one of five hospitals between 6/2018–5/2020. Data collected includes age, ethnicity, gender, BMI, Charlson comorbidity index, indication, defect size and location, duration of antibiotics, prior endoscopic therapies, time to EVT from diagnosis, sponge placement (intraluminal vs intracavitary), NG tube size, total days with EVT, number/interval of EV exchanges, and adjunctive endoscopic therapies. Technical success, degree of closure, hospital length of stay (LOS), and duration of follow up were analyzed. Student t-test and chi-squared analyses were performed. Results: 15 patients underwent EVT with a technical success rate of 100%. There was an 80% closure rate with 9 patients achieving complete closure and 3 patients achieving partial closure. Two of three failures were patients with external fistulas compared to the 12 successes which were patients with post-operative leaks, perforations, and one enclosed fistula with a concomitant cutaneous wound vacuum (p< 0.02). There was a higher success rate with intraluminal compared to intracavitary placement of EVT (p< 0.006). The average LOS was shorter in those with successful EVT (p< 0.05). Discussion: EVT is effective for closure of complex upper gastrointestinal defects, potentially obviating the need for surgical intervention and reducing the LOS. It appears less effective for external fistulas, likely because a complete vacuum seal is difficult to accomplish. Many patients (56%) required adjunctive endoscopic therapy such as double pigtail stents, over the scope clips, and percutaneous drains to achieve complete closure, suggesting that the optimal strategy is likely a tailored one. Larger studies are needed to make firm conclusions regarding optimal patient selection and methodologies for EVT.
Endoscopic and Technical Variables
Disclosures: Eugene Kligman indicated no relevant financial relationships. J. Andy Tau: Wilson-Cook – Consultant, Speaker's Bureau. Jose Luis Aranez indicated no relevant financial relationships. Robert Sealock indicated no relevant financial relationships. Gyanprakash Ketwaroo indicated no relevant financial relationships. Wasif Abidi: Apollo Endosurgery – Consultant. GI Dynamics – Grant/Research Support.