The present paper describes two different cases of esophageal fistulas, with different origin and frequency, successfully managed by E-Vac therapy.
Regarding Case n°1, postoperative esophageal anastomotic leak is a severe condition that negatively impacts postoperative outcomes10. The incidence ranges between 0 to 35%3 after esophagectomy and 2.7% to 12.3% after total gastrectomy with up to 60% mortality11.
As regards Case n°2, only few bronchogenic cysts communicating with the esophagus have been reported in the available literature14. Only one case of bronchogenic cyst complicated with post-operative esophageal perforation was reported15.
The management of esophageal fistula, regardless the cause, requires a multidisciplinary approach between surgeons, gastroenterologists, radiologists and intensive care physicians. The key point of treatment is the control of sepsis, achieved by containing the ongoing leakage from the esophagus, draining the pleural, mediastinal or abdominal cavities and giving appropriate antibiotic therapy. Nutritional support is mandatory, preferably with the enteral way or via parenteral nutritional when the former is not available12. Surgical closure of the esophageal defect is generally complex and scarcely effective. On the other hand, during the last decades, numerous endoscopic techniques have been developed, the real cornerstone of which being the endoscopic stent implantation13, with a demonstrated clinical success rate of over 80%. In 2008, Weidenhagen et al.22 reported on Endo-VAC treatment of anastomotic leakages after rectal resections. Only a few years later, Loske et al. started to transfer this treatment in patients with leakages in the upper gastrointestinal tract23.
In the last decade, the E-VAC therapy for the treatment upper GI defects has become a valid endoscopic alternative. This has been demonstrated in published case series of more than 200 patients, in numerous German endoscopic centers24.
In 2017, Kuehn et al.25 published a Medline analysis of 11 case series with over 210 patients with upper GI tract defects treated with E-VAC. In this review, success rate was 90 and 96% respectively for anastomotic leakages and esophageal perforations. Currently, there are no prospective randomized clinical trials available comparing endoscopic stenting, E-VAC therapy and surgical revisions in upper GI leakages or perforations.
Our initial practice in E-VAC therapy for treatment of esophageal postoperative fistula confirms some technical rules:
- Crucial for E-vac placement is the dimension of the esophageal defect: it should be crossed with a standard diagnostic endoscope. In case of small wall defects, widening of the insufficiency hole is required to put the sponge into the leak cavity (Fig 2-4).
- Granulation tissue often ingrowths in to the sponge, leading to more difficult removal. More frequent changes of the device reduce the risk of bleeding and the complexity of the sponge extraction. We always changed the sponge within 72 hours without problems.
- Enteral feeding should be the mainstay of nutrition support (by nasojejunal feeding tube, PEG or surgical jejunostomy); parenteral nutrition should be established as a bridge strategy.