In Reply

Endoscopic vacuum therapy (EVT) is an effective approach to the treatment of chronic leakages, and for esophageal anastomotic failures. However, our review article focused on acute iatrogenic perforation after diagnostic or therapeutic endoscopy (2). In this setting, very few data exist with regard to EVT, as most of the available studies included mostly patients with postoperative leakages (3).

The “treatment advantage” mentioned by our correspondents for EVT compared with stenting has not been satisfactorily confirmed for acute perforation: the three studies are retrospective and included primarily postoperative anastomotic failures. The current position paper of the ESGE mentions EVT in the context of treating acute perforation, but it does not provide any concrete recommendations, and neither does it provide an algorithm (3). Usually relevant paraesophageal fluid accumulation does not occur in the acute setting, especially in patients with smaller defects, and therefore effective closure, rather than drainage, is the primary concern: clips (for smaller defects) and coated stents are two established and widely available procedures. The case series of 10 patients mentioned by Loske indicates great effectiveness of EVT for acute perforations too, but the case number seems too low to recommend the procedure generally as first-line therapy. Larger studies are required in this setting. The remaining foreign body in the case of over the scope clips is clinically not problematic since these are intended as long-term implants, and in case of (rare) complications, such as luminal obstruction, they can usually be removed by using a special instrument for cutting (4).