An 86-year-old male patient with a history of arterial hypertension was admitted to the emergency room with acute diarrhea, cough, dyspnea, and fever that started 5 days before admission. Blood analysis revealed a hemoglobin level of 14.3

Background Upper gastrointestinal fistulas, leaks, and perforations represent a high cost burden to health systems worldwide, with high morbidity and mortality rates for affected patients. Management of these transmural defects remains therapeutically challenging. Objectives The aim of this study is to perform a systematic review and meta‐analysis to investigate the efficacy and safety of self‐expanding metal stents (SEMS) versus endoscopic vacuum therapy (EVT) for treatment of upper gastrointestinal transmural defects. Methods Searches were performed on MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events. Results Five studies with a total of 274 patients were included. There was a 21% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.21, CI 0.10–0.32; P = 0.0003). EVT demonstrated a 12% reduction in mortality compared to stenting (RD 0.12, CI 0.03–0.21; P = 0.006) and an average reduction of 14.22 days in duration of treatment (CI 8.38–20.07; P < 0.00001). There was a 24% reduction in adverse events (RD 0.24, CI 0.13–0.35; P = 0.0001. There were no statistical differences between the studied therapies regarding the length of hospital stay. Conclusion Endoscopic vacuum therapy proves to be superior in successful defect closure, mortality, adverse events and duration of treatment.

Modified endoscopic vacuum therapy in the management of a duodenal transmural defect E-Videos ▶ Fig. 1 Photographs showing: a the modified endoscopic vacuum therapy (EVT) device; b the items required to make the modified EVT device. ▶ Fig. 2 Endoscopic image showing evidence of an ischemic ulcer in the duodenum with a contained perforation. Video 1 Video showing how to make the modified endoscopic vacuum therapy device and its use, with subsequent exchanges performed, in the management of a patient with a duodenal transmural defect.

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Video Video 1 Cost-effective modified endoscopic vacuum therapy for GI transmural defects. Step-by-step process of manufacturing and potential advantages. Cut half gauze to the ideal size to cover only the fenestrated portion of the nasogastric tube (NGT). Wrap the gauze around the fenestrated portion of the NGT. The assistance of another person is important in this process. Cut the antimicrobial incise drape to match the size of the fenestrated portion of the NGT. Note that the incise drape is a very strong adhesive; therefore, 3 people are usually required to assemble it properly. Next, the suture is used to fix the gauze and drape to the NGT. Perform fixation of the modified sponge in 3 places. The first knot is in the proximal portion, just below the last fenestra of the NGT, as a marker of where the vacuum system starts. The second knot is at the distal end, to avoid migration of the modified sponge. The third knot is in the middle of the modified sponge, which is essential to serve as a guide during endoscopic placement. For example, in cases of defects without collection in which the sponge will be placed in an intraluminal position, it is ideal to place the vacuum system in the middle of the defect; in cases of intracavitary placement, it will work as a guide to how much of the modified sponge will be inside the collection. Finally, use a needle to make innumerable punctures in the modified sponge system to obtain adequate aspiration. An 18G needle is recommended because, in addition to having an adequate diameter, it is very sharp, which facilitates perforation of the modified sponge system. After creation of the modified endoscopic vacuum therapy, the functionality test is performed. Turn on the wall suction system, connect the distal end of the NGT to the tube of the canister connected on the wall, and place the NGT inside a bowl with a liquid solution. The aspiration of a large amount of liquid indicates proper functioning of the modified endoscopic vacuum therapy system. The device is then ready to be positioned endoscopically in the patient. After proper positioning, connect the NGT to the suction tube to avoid migration of the device upon removal of the scope. In addition to the cost-effective device as described, in our practice we also use wall suction to reduce costs associated with the use of the vacuum machine. Use the antimicrobial incise drape to seal the connection between the NGT and the suction tube to avoid leakage within the connection. Last, owing to instability of the negative wall pressure, a 20F intravenous catheter is connected to the tube to maintain a negative pressure between –75 and –150 mmHg, as confirmed by laboratory studies performed by our group.