Published online Jun 28, 2014. doi: 10.3748/wjg.v20.i24.7767
Revised: February 23, 2014
Accepted: March 12, 2014
Published online: June 28, 2014
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
Core tip: The novel technique of endoscopic vacuum therapy has recently been developed for the closure of upper gastrointestinal (GI) perforations. A sponge is connected to a gastric tube, and then endoscopically placed into the perforation or cavity. The first case series demonstrate excellent healing rates with very low procedure-related morbidity; it appears likely that this technique will become the new standard for upper GI perforations. A second novel endoscopic option is the over-the-scope clip (OTSC) which allows full thickness closure of smaller defects and fistulas. Both endoscopic vacuum therapy and OTSC are valuable contributions to endoscopic therapy of upper GI perforations.