EGS SO29 - Therapeutic Endoluminal Vacuum Therapy (EVT) as first line management for oesophageal and selected gastric and duodenal perforations

Abstract Background Upper gastro-intestinal (GI) perforations and leaks affect roughly 2,800 patients annually in the UK. They can occur spontaneously, as a complication of medical intervention, or be due to trauma. Mortality rates are around 20%, rising to 50% if diagnosis and treatment is delayed. Around a third of cases fall into the delayed category. Traditionally, management of this group of patients involved surgery with long hospital stays and poor outcomes. Our Unit has adopted EVT as first line management for these cases, using an ad-hoc Endoluminal Vacuum Device (EVD), which has significantly improved patient outcomes compared to traditional treatment strategies. Method The primary aim of this study was to assess the successful perforation/ leak healing rate, the overall mortality rate, and the complication rate of EVT. A retrospective analysis of a prospectively collated database for all patients who received EVT between May 2011 to November 2023 was performed. Patients who had oesophageal, gastric or duodenal perforations were included. The ad-hoc EVD was constructed using an open pore sponge (granufoam, KCI) sutured to the end of a nasogastric (NG) tube. This was inserted endoscopically into the site of perforation and with negative pressure (125mmHg) applied using a negative pressure vacuum pump. Results 104 patients received EVT, with a median age of 65years (range 23-92years), and median ASA of 3 (range 1-5) at presentation. Eighty-five cases were oesophageal, 15 gastric and 4 duodenal. Post-operative leaks accounted for 42 cases, 26 were iatrogenic, 30 spontaneous, and 6 traumatic. Leak resolution was achieved in 94 patients (90.4%). Twelve (11.5%) patients died; 7 (6.7%) deaths were due to treatment failure. Seven (6.7%) patients had a significant bleeding event during EVT of which 4 (3.8%) were directly related to the leak because of undrained sepsis. One patient had an oesophageal mucosal injury during EVD removal. Conclusion EVT is a safe and effective treatment for upper GI tract leaks regardless of their cause. It achieves a significant reduction in mortality compared to traditional treatments, especially in patients with delayed presentation. Adequate drainage of surrounding sepsis is essential to ensure therapy success and avoid bleeding complications. Given the improvement in patient outcomes that EVT delivers, it should be considered for first line management in patients with delayed diagnosis and presentation of oesophageal perforation, following anastomotic leak after resectional surgery, as well as in select patients with gastric and duodenal perforations.