Management of esophageal perforations in infants by endoscopic vacuum therapy: a single center case series

Abstract

Background Endoscopic vacuum therapy (EVT) has become a standard treatment method for esophageal perforations in adults. However, experience with EVT in infants is scarce. In this retrospective case series, we report on four very young infants who were successfully treated with EVT for esophageal perforations of different etiology. Methods Four infants were diagnosed with esophageal perforations on day 7, 32, 35 and 159 of life, respectively. The youngest one was prematurely born in the 31st week of pregnancy weighing 980 g only. Three infants had perforations due to foreign body insertion (nasogastric tube or pulling through of percutaneous endoscopic gastrostomy (PEG) tube through the esophagus). One child had an anastomotic dehiscence after Foker’s surgery for atresia. In three children EVT was applied as first-line therapy for perforation, in one child EVT was a rescue therapy due to persisting leakage after surgical closure involving thoracotomy. Depending on the esophageal diameter, either an open-pore drainage film or polyurethane sponge was attached to a single-lumen 8 Fr suction catheter, endoscopically (or fluoroscopically by wire-guidance) placed into the esophagus (intraluminal EVT) and supplied with continuous negative pressure (ranging between 75 and 150 mmHg). The EVT system was exchanged twice per week. Results Complete closure of the perforation/leakage could be achieved in all four infants (100%) after 22 days of continuous EVT (median value; range 7–39) and 4.5 EVT exchanges (median value; range 1–12). No serious adverse events occurred. Conclusions EVT is an effective and safe addition to our therapeutic armamentarium in the management of esophageal perforations irrespective of its etiology. Here we prove the feasibility of EVT even in very young infants. The use of an extra thin vacuum open-pore drainage film is helpful to cope with the small esophageal diameter. EVT settings and exchange rates similar to those known from adult treatment were used.

Pulling instead of pushing: A case report of gastrostomy‐assisted pull technique as an alternative method for endoluminal sponge placement in EVAC therapy

“…A preexisting gastrostomy site was re‐accessed to allow for a novel approach for endoluminal sponge placement in E‐VAC therapy by gastrostomy‐assisted pull technique. Although primary closure remains standard of care for esophageal perforation, others include medical management, drainage, and many cases can be successfully treated with endoscopic intervention with stent placement 5–7 . EVAC demonstrated greater success in healing surgical anastomotic perforations over stenting and has been used for gastrointestinal leaks, fistulas, and perforations within pediatric patients 5 .…”

“…EVAC demonstrated greater success in healing surgical anastomotic perforations over stenting and has been used for gastrointestinal leaks, fistulas, and perforations within pediatric patients 5 . EVT functions by connecting a polyurethane sponge or porous film to a suction catheter that is either intraluminally placed via endoscopy, or via intracavitary placement by insertion into the perforation site to cover the region of perforation 7 . This creates negative pressure therapy at the perforation site, causing a collapse of surrounding tissue forming the seal, which stimulates granulation of the wound to promote closure 7 .…”

Experience with endoluminal vacuum therapy in the management of esophageal anastomotic leakage in newborns with esophageal atresia: A case series

“…During EVT, the patients remained NPO, and parenteral nutrition was provided until the absence of leaks is verified. Fasting is considered in these patients because oral nutrition would contaminate both the perforation site and the sponge, rendering EVT ineffective [7,8].…”

“…The pressure ranges between 75 and 150 mmHg. A pressure of 75 mmHg is considered low intensity, 125 mmHg of medium intensity, and 150 mmHg as high intensity in pediatric patients [7]; in neonates, we apply 75-100 mmHg, and chest drainage is maintained (Fig. 1).…”

Vacuum-Assisted Closure Treats Refractory Esophageal Leak in a Pediatric Patient

“…Kaczmarek et al [ 10 ] specifically looked at infants at 7-159 days of life and found that in all four of their cases, EVAC led to complete EP closure after 22 days and an average of 4.5 EVAC exchanges. Fraga et al looked at an eight-month-old male with esophageal perforation after a video-assisted thoracoscopic lobectomy for a right lower lobe congenital malformation [ 11 ].…”