Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects

VACStent closure of oesophageal defects by covered stent and endoscopic vacuum therapy: initial use and clinical outcomes

Endoscopic management of transmural oesophageal defects following esophagectomy or spontaneous perforations, such as Boerhaave's syndrome, is often complicated by stent migration and luminal occlusion [1]. The Vacuum-Assisted Closure (VAC) stent, which integrates a covered stent with endoscopic vacuum therapy, aims to address these issues by providing functional drainage and promoting wound healing [2]. This case series presents our initial experience with VACStent therapy in four patients treated between February 2023 and April 2024. Two patients had staple line defects post-esophagectomy, and two had Boerhaave's syndrome. Treatment involved stent placement under general anaesthesia, followed by evaluations and scheduled stent exchanges every 6 days. All patients achieved successful defect closure, with no procedural complications noted. Three patients required one stent application, while one needed two applications. VACStent therapy appears to be a safe and effective treatment for transmural oesophageal defects, potentially establishing a new standard of care.

How to close mucosal incisions?

This article provides an overview of the techniques for closure of the mucosal entry point following advanced procedures in the third space. The outbreak of natural orifice transluminal endoscopic surgery (NOTES) has significantly impacted the treatment of various benign and malignant conditions. Reliable and secure closure of the mucosal entrance is essential for avoiding serious adverse events. Although small defects are typically closed using through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs), challenges may occur with larger or transmural defects. Alternative methods, such as specialised stitches and full-thickness suturing systems, have been developed to address these challenges with promising results. Each method has its own pros and cons, and the choice of closure technique depends on various factors such as anatomical location, endoscopist expertise, costs, and clinical context. By understanding the technical specifications of each closure device, endoscopists can make decisions that enhance patient outcomes and minimise the risk of complications associated with the approximation of defect edges. Continued research is essential to optimise the evolution of newer closure devices and techniques for advancing NOTES.

VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review

Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.

VacStent as an Innovative Approach in the Treatment of Anastomotic Insufficiencies and Leakages in the Gastrointestinal Tract-Review and Outlook

Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to prolonged hospitalization, serious tissue inflammation, and even sepsis, along with the need for recurrent surgery. Current non-surgical treatments such as self-expanding metal stents (SEMSs) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GITM (Möller Medical GmbH, Fulda, Germany), a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GITM application demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal promising and most importantly equally good outcomes while maintaining the possibility for sustained enteral nutrition and reducing the risk of stent migration. The VacStent GITM presents a promising alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and comprehensively establish its role in leak management. Further investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GITM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma.

Multi-modality management of defects in the gastrointestinal tract: Where the endoscope meets the scalpel: Endoscopic vacuum therapy in the upper gastrointestinal tract

BACKGROUND

Transmural defects in the upper gastrointestinal (GI) tract, such as anastomotic leakage and oesophageal perforations, are associated with significant morbidity and mortality risks. Endoscopic vacuum therapy (EVT) is an efficient and safe treatment option for these patients. With the growing use of EVT in the upper GI tract, it is important to share expertise on the topic.

AIM

This review explores the emerging role of endoscopic vacuum therapy (EVT) as treatment for transmural defects in the upper GI tract. An overview of the mechanism and procedures, outcomes in current literature and challenges of implementation and application are discussed.

CONCLUSION

EVT exhibits great efficacy and safety for the treatment of transmural defects in the upper GI tract. Current use of EVT is mostly experience-based, emphasizing the importance of sharing expertise and performing research to unlock its full potential.