Abstract
Purpose of Review
Esophageal perforations are associated with high morbidity and mortality. As opposed to surgical repair, endoscopic closure techniques have emerged over the years as a more minimally invasive approach for management. Our goal is to discuss different modalities for closure.
Recent Findings
Through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), and esophageal stent placement are well known options for closure. We will also discuss the more recent technique of endoscopic suturing for closure of larger defects as well as prevention of esophageal stent migration. For mediastinal collections associated with perforations, a more novel endoluminal vacuum therapy (EVT) for drainage may be an option.
Summary
Overall, there are several different endoscopic options that can tailored to the specific features of an esophageal perforation. This review will discuss various techniques with which a gastroenterologist or thoracic surgeon should be familiar.
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References
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Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardiovasc Surg. 2010;58(8):476–80. https://doi.org/10.1055/s-0030-1250347.
Chirica M, Champault A, Dray X, Sulpice L, Munoz-Bongrand N, Sarfati E, et al. Esophageal perforations. J Visc Surg. 2010;147(3):e117–28. https://doi.org/10.1016/j.jviscsurg.2010.08.003.
Gonzalez JM, Benezech A, Barthet M. Complications of submucosal endoscopy. Best Pract Res Clin Gastroenterol. 2016;30(5):783–91. https://doi.org/10.1016/j.bpg.2016.10.015.
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475–83. https://doi.org/10.1016/j.athoracsur.2003.08.037.
Feldman M, Friedman LS, Sleisenger MH. Sleisenger & Fordtrans gastrointestinal and liver disease: pathophysiology, diagnosis, management. 10th ed. Philadelphia: Saunders Elsevier; 2010.
Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986;42(3):235–9.
Hayashi I, Yonezawa TM, Kuwabara TKI. The study on staunch clip for the treatment by endoscopy. Gastrointest Endosc. 1975;17:92–101.
Watkins JR, Farivar AS. Endoluminal therapies for esophageal perforations and leaks. Thorac Surg Clin. 2018;28(4):541–54. https://doi.org/10.1016/j.thorsurg.2018.07.002.
Saxena P, Khashab MA. Endoscopic management of esophageal perforations: who, when, and how? Curr Treat Options Gastroenterol. 2017;15(1):35–45. https://doi.org/10.1007/s11938-017-0117-3.
Stavropoulos SN, Modayil R, Friedel D. Closing perforations and postperforation management in endoscopy: esophagus and stomach. Gastrointest Endosc Clin N Am. 2015;25(1):29–45. https://doi.org/10.1016/j.giec.2014.09.008.
Haito-Chavez Y, Law JK, Kratt T, Arezzo A, Verra M, Morino M, et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc. 2014;80(4):610–22. https://doi.org/10.1016/j.gie.2014.03.049.
Hagel AF, Naegel A, Lindner AS, Kessler H, Matzel K, Dauth W, et al. Over-the-scope clip application yields a high rate of closure in gastrointestinal perforations and may reduce emergency surgery. J Gastrointest Surg. 2012;16(11):2132–8. https://doi.org/10.1007/s11605-012-1983-6.
Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut. 2018;67(7):1280–9. https://doi.org/10.1136/gutjnl-2016-313677.
Shin EJ, Ko CW, Magno P, Giday SA, Clarke JO, Buscaglia JM, et al. Comparative study of endoscopic clips: duration of attachment at the site of clip application. Gastrointest Endosc. 2007;66(4):757–61. https://doi.org/10.1016/j.gie.2007.03.1049.
Voermans RP, Le Moine O, von Renteln D, Ponchon T, Giovannini M, Bruno M, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603–8. https://doi.org/10.1016/j.cgh.2012.02.005.
Dasari BV, Neely D, Kennedy A, Spence G, Rice P, Mackle E, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg. 2014;259(5):852–60. https://doi.org/10.1097/SLA.0000000000000564.
DaVee T, Irani S, Leggett CL, Berzosa Corella M, Grooteman KV, Wong Kee Song LM, et al. Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents. Surg Endosc. 2016;30(6):2332–41. https://doi.org/10.1007/s00464-015-4475-4.
Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg. 2006;81(2):467–72. https://doi.org/10.1016/j.athoracsur.2005.08.047.
Sharma P. Kozarek R; Practice parameters committee of American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol. 2010;105(2):258–73; quiz 274. https://doi.org/10.1038/ajg.2009.684.
Wright A, Chang A, Bedi AO, Wamsteker EJ, Elta G, Kwon RS, et al. Endoscopic suture fixation is associated with reduced migration of esophageal fully covered self-expandable metal stents (FCSEMS). Surg Endosc. 2017;31(9):3489–94. https://doi.org/10.1007/s00464-016-5374-z.
Ngamruengphong S, Sharaiha RZ, Sethi A, Siddiqui AA, DiMaio CJ, Gonzalez S, et al. Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy. 2016;48(9):808. https://doi.org/10.1055/s-0042-113997.
Martins BC, Retes FA, Medrado BF, de Lima MS, Pennacchi CM, Kawaguti FS, et al. Endoscopic management and prevention of migrated esophageal stents. World J Gastrointest Endosc. 2014;6(2):49–54. https://doi.org/10.4253/wjge.v6.i2.49.
Freeman RK, Ascioti AJ, Giannini T, Mahidhara RJ. Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak. Ann Thorac Surg. 2012;94(3):959–64; discussion 964-5. https://doi.org/10.1016/j.athoracsur.2012.05.047.
Henderson JB, Sorser SA, Atia AN, Catalano MF. Repair of esophageal perforations using a novel endoscopic suturing system. Gastrointest Endosc. 2014;80(3):535–7. https://doi.org/10.1016/j.gie.2014.03.032.
•• Sharaiha RZ, Kumta NA, DeFilippis EM, Dimaio CJ, Gonzalez S, Gonda T, et al. A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review. J Clin Gastroenterol. 2016;50(5):388–92. https://doi.org/10.1097/MCG.0000000000000336. This retrospective study showed high technical success rates for endoscopic suturing of luminal perforations.
Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc. 2008;22(8):1818–25. https://doi.org/10.1007/s00464-007-9706-x.
•• Laukoetter MG, Mennigen R, Neumann PA, Dhayat S, Horst G, Palmes D, et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc. 2017;31(6):2687–96. https://doi.org/10.1007/s00464-016-5265-3. Prospective study showing high healing rates of esophageal leakage with EVT.
Bludau M, Hölscher AH, Herbold T, Leers JM, Gutschow C, Fuchs H, et al. Management of upper intestinal leaks using an endoscopic vacuum-assisted closure system (E-VAC). Surg Endosc. 2014;28(3):896–901. https://doi.org/10.1007/s00464-013-3244-5.
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Shelly Gurwara and Steven Clayton declare no conflict of interest.
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Gurwara, S., Clayton, S. Esophageal Perforations: An Endoscopic Approach to Management. Curr Gastroenterol Rep 21, 57 (2019). https://doi.org/10.1007/s11894-019-0730-5
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DOI: https://doi.org/10.1007/s11894-019-0730-5