Use of the endoscopic vacuum therapy technique for the treatment of esophageal fistulas: an integrative review and clinical case series study

Esophageal fistula is a rare disease with a mortality rate of up to 31% of cases and with multifactorial causes. The most common etiologies of esophageal perforation are associated with iatrogenic, foreign body ingestion, as well as cases of lesions of neoplastic origin. Consisting of an innovative therapy with efficiency not yet evaluated in clinical studies, the present study sought to report a series of cases of patients with esophageal fistulas undergoing treatment with endoscopic vacuum therapy (VTE) assisted by the service team of a tertiary public hospital. from the state of Ceará in order to contribute with evidence that reinforces the role of VTE in the closure of esophageal perforations of different etiologies. In addition, in order to contextualize the importance of the cases presented, we carried out an integrative review in order to list the main clinical findings on the use of VTE available in the world scientific literature. There was a need for continuous development of new clinical studies that seek to improve and validate the use of VTE for the safe and effective treatment of esophageal fistulas, emphasizing that treatment with VTE can maximize the therapeutic response, bringing a greater and better clinical patient satisfaction.


Introduction
Esophageal perforation or fistula is a rare, potentially fatal problem, with a mortality rate of up to 31% of cases and with multifactorial causes. The most common etiologies of esophageal perforation are associated with iatrogenic, spontaneous and foreign body ingestion, as well as cases of lesions of neoplastic origin. Esophageal fistula presentation is usually associated with very evident clinical symptoms, such as nausea, vomiting and epigastric pain, requiring a high index of clinical suspicion to result in timely diagnosis and treatment [1][2].
Several therapeutic modalities are available to treat esophageal perforation, including primary surgical repair, surgical resection of the defect, endoscopic stents, and endoscopic suturing. Additionally, as an emerging and promising alternative for endoluminal closure, it is seen that the use of endoscopic endoluminal vacuum therapy (VTE) treats the defect through mechanisms of control of the source of leakage, formation of granulation tissue, stimulating the reperfusion and debridement of necrotic tissue as sponges are removed or replaced [3][4].
Technically, VTE consists of a surgical procedure that uses a polyurethane sponge drain positioned in the esophageal lumen or inside the fistulous cavity with its connection connected to a continuous negative pressure vacuum system. However, it can also be performed using a low-cost modified drainage system, using a nasogastric tube with gauze coated with perforated sterile plastic [5].
Consisting of an innovative therapy with efficiency not yet evaluated in clinical studies, the present study sought to report a series of cases of patients with esophageal fistulas undergoing treatment with endoscopic vacuum therapy assisted by the service team of a tertiary public hospital in the state of Ceará in order to contribute with evidence that reinforces the role of VTE in the closure of esophageal perforations of different etiologies. In addition, in order to contextualize the importance of the cases presented, we carried out an integrative review in order to list the main clinical findings on the use of VTE available in the world scientific literature.

Methodology
In addition to the clinical description of the case reports, an Integrative Review (IR) study was carried out, restricting theoreticalmethodological, quantitative or qualitative research, which investigated clinical, surgical, epidemiological and therapeutic data of patients, regardless of gender and age, submitted to VTE treatment for the treatment of esophageal fistulas published from 2017 to 2022 (maximum 5 years), regardless of language.
The scientific survey was based on the use of a search filter for references related to case reports (Case Reports). Primary studies that did not assess the clinical aspects, and their derivations, of the use of VTE were excluded, such as experimental studies, clinical trials or publication of scientific productions of congress abstracts, academic manuscripts, such as monographs, dissertations and theses, and, finally, technical documents.
For the purposes of IR consolidation, we sought to answer two main questions, namely (1) does the scientific text present clinical data on patients diagnosed with esophageal fistula? (2) does the text consistently discuss the importance of using VTE for clinical reversal of esophageal fistula?. It is noteworthy that the survey of scientific articles, as well as the obtaining of information, was carried out by two professionals, independently.
In a second stage, the establishment of inclusion and exclusion criteria was recommended, always focusing on the research question established at the time of identification of the theme. For this, as for the search strategy, Pubmed was used, which includes MEDLINE, as an informational resource. From this, studies that fit the expressions "endoscopic vacuum therapy" and "esophagus", in their versions in English or Portuguese, were included for later verification of the title, abstract or subject of the manuscript. November 2021 to January 2022.
Studies in which the assessment of VTE therapy was a secondary outcome or an analyzed variable, without being the main focus of the research, were excluded. In the third stage, the identification of pre-selected and selected studies was carried out, based on a careful reading of the titles, abstracts and keywords of all complete publications located by the search strategy used.
Then, the categorization of the selected studies followed, in order to summarize and document the information extracted from the scientific articles found in the previous phases. Finally, the presentation of the review and the synthesis of knowledge followed, favoring the obtaining of information that would allow readers to assess the pertinence of the procedures used in the preparation of the review.                        layers of visceral organs [13].
As a surgical procedure, it was rapidly close esophageal fistulas [13].
Cwalinski and colleagues [14] reported that esophagogastric leakage is Mallory-Weiss bleeding that did not respond to endoscopic treatment [14]. Successful closure of the anastomotic fistula was achieved after 5 weeks and 15 replacement sessions in total [15].
During the VEC treatment period, nutrition was provided by enteral nutrition with a jejunostomy, which was placed during index surgery.
These studies reinforce that the use of VEC as a multidisciplinary endoscopic and surgical approach is a successful therapy for the management of suture dehiscence with esophageal anastomotic leaks after thoracic surgery or esophageal perforations [15].
Finally, we verified the study by Stašek et al. [16] who described that post-esophagectomy leakage occurs in It is noteworthy that the main clinical diagnoses reported in the present study that led to the occurrence of esophageal fistulas were mainly associated with advanced stages of digestive system neoplasms, such as esophageal squamous cell carcinoma and advanced stomach adenocarcinoma, similar to the cases clinicians presented. It should be noted that an interesting case of fistulas caused by esophageal ulcers due to the presence of a foreign body was presented, which, to our knowledge, is considered a case rarely described in the literature. Regardless of the diagnosis that caused the fistula, the clinical reports presented here reinforce the importance and efficiency of VTEmediated treatment.
Finally, there is a need for continuous development of new clinical studies that seek to improve and validate the use of VTE for the safe and effective treatment of esophageal fistulas, emphasizing that, based on the findings presented in this study, the treatment with VTE was able to maximize the therapeutic response, bringing greater and better clinical satisfaction to the patient.