The expanding role of endoscopic vacuum therapy

Endoscopic vacuum therapy (EVT) is an established technique for the treatment of gastrointestinal wall defects and particularly anastomotic leaks after oesophageal and rectal surgery. The increasing expertise in combination with the introduction of new, commercially available devices, has led to an expansion of the indications in the last decade. EVT is a good alternative for acute perforations and particularly for Boerhaave's syndrome. The induction and acceleration of the healing process under negative pressure was the basis of the preemptive EVT application for high-risk gastrointestinal anastomoses in an attempt to reduce anastomotic leak rate, with the initial results being encouraging. Further uses include stricture prevention after extensive esophageal ESD as well as treatment of diffuse non-variceal upper gastrointestinal bleedings. The current evidence for these new applications ist still low, however the first results are promising and shine a light to the extensive possibilities of EVT as a multi-purpose item in the endoscopist's toolbox.

Endoscopic vacuum therapy (EVT) is an established therapeutic option for the treatment of all kinds of wall defects in the gastrointestinal (GI) tract and particularly anastomotic leaks after esophageal and rectal surgery. After its initial description in the early 2000s, the technique soon gained popularity in central Europe; however, its establishment in the rest of the world would take another decade, partially owing to the lack of commercially available EVT products outside of the European Union, but also to the pragmatic difficulties of planning and performing prospective studies to prove its efficacy. Nevertheless, large retrospective studies have shown impressive outcomes of EVT for the treatment of GI defects, with reported clinical success of over 80% [1]. A comparison of EVT with self-expanding metal stents (SEMSs) showed advantages for the former, with higher success rates, shorter duration of the treatment, and lower morbidity and mortality rates [2].

“Despite the small number of included patients and the heterogeneity of the study population, the findings of this study are promising, offering a useful tool for the treatment of gastrointestinal bleeds that are difficult to treat with other techniques.”

The favorable results of EVT for anastomotic leaks in the esophagus and rectum encouraged endoscopists to explore its applications for different types of defects and other locations. A recent retrospective multicenter study compared EVT with SEMSs and surgical treatment for the treatment of spontaneous esophageal rupture or Boerhaave’s syndrome in a total of 57 patients [3]. Boerhaave’s syndrome is a unique form of acute esophageal perforation, with significantly worse prognosis and high mortality rates. In contrast to iatrogenic perforations, which are usually detected and treated directly, in most cases of Boerhaave’s syndrome, the index endoscopy is performed 12–48 hours after the rupture, thereby allowing a contaminated cavity to form in the mediastinum. In this study, EVT as primary treatment showed a higher rate of clinical success and lower rate of mortality in comparison with the other groups. The authors explained the success rates of EVT as being due to a combination of defect coverage, active drainage of the cavity, and a minimally invasive approach; they argued that EVT should be considered as first-line treatment for Boerhaave’s syndrome.

The development of new EVT devices was crucial for the further expansion of their indications. Open-pore film drains (OFDs), consisting of a double-layered, open-pore film draped around the perforated end of a nasogastric tube, are longer and thinner and are therefore easy to position in distant or not so easily accessible locations. OFDs have been successfully used for the treatment of duodenal defects and chronic fistulas, and the first retrospective clinical studies have shown promising results [4].

A better understanding of the pathophysiologic effects of negative pressure on the tissue led to the first attempts at preemptive EVT in high risk GI anastomoses before any clinical manifestations of a leak were apparent. Neoangiogenesis, local control of inflammation, drainage of erosive secretions including bile and gastric acid, and the induction of granular tissue formation can all facilitate healing of the anastomosis, thereby preventing the occurrence of a leak. The first retrospective data showed encouraging results in reducing anastomotic leaks after esophageal surgery [5], and several ongoing prospective studies are currently exploring the indications and suitability of devices for preemptive EVT in both the upper and lower GI tract.

Apart from transmural defects, EVT also seems to have favorable effects on mucosal healing after extensive endoscopic resections. EVT devices have occasionally been used to promote healing after wide duodenal endoscopic mucosal resection in high risk patients. A recently published prospective study evaluated the application of preemptive EVT after wide-field esophageal endoscopic submucosal dissection (ESD) for early esophageal cancer with epithelial defects of at least 5 cm in length and including more than 75% of the circumference [6]. Patients undergoing this treatment showed significantly reduced rates of esophageal stricture, in comparison with the pre-existing literature. Based on these findings the authors argue that preemptive EVT could be used – alone or in combination with local corticosteroids – for the prevention of strictures after wide-field, and even circumferential, esophageal ESD, thereby offering a potential solution to this serious restriction of extensive endoscopic resections.

The principle of advanced mucosal healing under negative pressure was also demonstrated by Mega et al. in their retrospective study published in this journal, in this case for nonvariceal upper GI bleeding (NVUGIB) [7]. The authors used a modified EVT device, similar to the OFD, initially in critically ill COVID patients with diffuse bleeding from the duodenal mucosa, who were mainly undergoing extracorporeal membrane oxygenation (ECMO) and receiving anticoagulation. The application of negative pressure led to faster healing of the bleeding erosions and small ulcers, and successful management of the bleeding. After these initial cases, the same treatment was then applied for other types of NVUGIB, including gastric and duodenal ulcers, erosive esophagitis, and malignant tumors, with similar results and an overall clinical success rate of 89.5% in a total of 19 patients. Despite the small number of included patients and the heterogeneity of the study population, the findings of this study are promising and may offer us a useful tool for the treatment of GI bleeds that are difficult to treat with other techniques.

There is a clear trend toward the expansion of the indications for EVT, which are no longer restricted to anastomotic leaks. The induction and promotion of tissue healing under negative pressure is now a focus for endoscopists and researchers. The first data showed a benefit for patients with GI bleeding and large mucosal defects; however, the same pathophysiologic mechanisms could be applied to different types of mucosal damage, including chronic inflammatory bowel diseases and post-radiation proctitis. Similarly to a standard endoscopic clip, which can be applied for closure, hemostasis, and other purposes, EVT is a useful and versatile tool that can be applied in a variety of situations and should not be missing from the toolbox of any endoscopist.

Publication History

Article published online:
26 May 2025

• References

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