Endoscopic vacuum therapy for the management of esophageal perforations: a narrative review

Introduction

Background

Esophageal perforations are uncommon, with a reported incidence of approximately 3 per 100,000 patients. Recent trends indicate a rising frequency, largely attributable to the expanding use of diagnostic and therapeutic endoscopic procedures (1,2). Esophageal perforation may result from a variety of etiologies, with iatrogenic injury during endoscopic intervention being the leading cause, followed by foreign body ingestion, spontaneous rupture (Boerhaave’s syndrome), and external trauma (1). Patients with esophageal perforations present with chest pain, odynophagia, dysphagia and respiratory distress and are diagnosed by imaging studies and endoscopy (1). These injuries may result in significant complications, ranging from local infections to thoracic abscesses and sepsis (3), and thus, require immediate medical intervention.

Traditionally, esophageal perforations have been successfully managed surgically, although at the expense of high morbidity and complication rates. However, with the advancements in minimally invasive techniques, endoscopic approaches have become increasingly preferred. Endoscopic interventions using stent placement and clip closure have been shown to be effective therapeutic options (4). Nevertheless, both surgical and endoscopic approaches typically require additional supportive interventions, including broad-spectrum antibiotics, drainage, irrigation, and nutritional support to optimize patient outcomes (5,6). Endoscopic vacuum therapy (EVT) has demonstrated promising results in minimizing the risks associated with endoscopic and surgical procedures while still achieving superior treatment efficacy and outcomes.

Rationale and knowledge gap

EVT was originally utilized for the management of persistent external infected wounds, most notably intrathoracic anastomotic leaks (2,7), and has since rapidly expanded to include a wide range of gastrointestinal indications. EVT was initially reported for the treatment of anastomotic leakage after rectal surgery. The first reported clinical application in the upper gastrointestinal tract was in 2007 for the management of a gastric leak, and later, in 2008, the first case series for the management of an esophageal wall defect was published. EVT has since been employed for various gastrointestinal conditions including perforations of the upper and lower gastrointestinal tract, post-operative leaks, and Boerhaave syndrome (7,8). In some cases, EVT has been utilized as a preventative tool post-operatively for high-risk anastomoses (9). However, long-term data on the utilization and efficacy of EVT are limited. In addition, there are no standardized guidelines for the application of EVT in esophageal perforations, particularly regarding technical parameters such as sponge size and negative pressure settings. Furthermore, the available evidence is largely limited to retrospective studies, case series, and a few meta-analyses, with little to no data from randomized controlled trials. To date, limited evidence directly compares EVT with alternative strategies such as stenting or surgery.

Objective

This paper aims to provide an overview of the role of EVT in the management of esophageal perforations, with a focus on its efficacy and clinical applications. By outlining its therapeutic advantages, this review seeks to support the integration of EVT into clinical practice, with the potential to reduce reliance on additional interventions, mitigate complications associated with conventional management strategies, and ultimately improve patient outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-25-45/rc).

Methods

We searched original research papers, literature reviews, retrospective studies, case series and meta-analyses available on PubMed and Google Scholar from April 2006 up until July 2025, discussing EVT for the repair of esophageal perforations and Boerhaave syndrome. We used the following terms: “Endoscopic vacuum therapy” AND “Boerhaave syndrome” OR “esophageal perforations”, as well as “self-expandable metallic stents” OR “endoscopic esophageal stenting” AND “Boerhaave syndrome” OR “esophageal perforations”, which respectively yielded 703 and 683 results. Retrospective studies, case series and meta-analyses were predominantly used to compare outcomes between EVT and alternative strategies. We included articles involving adult patients with esophageal leaks, perforations, or Boerhaave syndrome who underwent EVT. Only articles published in English were considered. Studies reporting EVT use in the lower gastrointestinal tract were excluded. The summary of the search strategy is provided in Table 1.

Mechanism of action of EVT

EVT utilizes an open-pore suction device that applies negative pressure to site of the perforation, thereby promoting faster wound healing and effective defect closure through a dual therapeutic mechanism. This technique is implemented by attaching an open-pore sponge to a nasogastric tube (NGT), which is connected externally to a vacuum pump that generates continuous negative pressure. When positioned at the site of the luminal defect, the sponge facilitates effective drainage, removal of debris, and promotion of granulation tissue formation, thereby enhancing wound healing (10). This therapeutic effect is attributed to several mechanisms, including improved microcirculation and oxygenation that enhance nutrient delivery via neoangiogenesis, promotion of granulation tissue formation, modulation of cytokine activity, drainage of infected fluid, and approximation of wound edges (5,7,11). Following device removal, granulation tissue may form nodules, a phenomenon termed ‘micro-deformation’, which is influenced by both the porosity of the material and the level of negative pressure applied. Macro-porous, low-density sponges and polyurethane (PU)-based drains are most commonly used, owing to their superior debriding capacity and ability to induce micro-deformation. Low-density macro-porous sponges also act as a size barrier, allowing sponge ingrowth into the granulation tissue (7,9). More recently, open-pore film drains, originally designed for open abdominal wounds, have been introduced as an adjunct to PU foams, providing a double-layered, highly permeable film that enables more efficient fluid drainage than PU sponges alone (7,12-14).

Indications for EVT

EVT is primarily indicated for the management of leaks and perforations. While it was primarily used for esophageal injuries, its application has expanded to include leaks following bariatric surgery, duodenal defect repair, upper gastrointestinal surgeries, and colorectal anastomotic leaks (7,13,15,16). More recently, a novel indication has been described for refractory non-variceal upper gastrointestinal bleeding (17). EVT has also been explored in the prophylactic setting for high-risk esophageal anastomoses, where it may limit mediastinal contamination and contain minor leaks, with reported leakage rates ranging from 0–7.5% (5,18,19). When necessary, EVT can be used in conjunction with other modalities, such as stent placement, to optimize clinical outcomes. Clinical experience suggests that EVT is most effective in cavities that are undrained, contained, non-loculated, and less than 8 cm in diameter (Figure 1). Treatment success appears largely independent of patient age, timing of initiation, or anatomical site of the defect (6). While most reported cases involve adults, emerging data in pediatric populations are promising, with success rates of up to 88% for esophageal injuries (2). For small cavities, EVT may still be effective, although endoscopic dilation is sometimes required to facilitate sponge placement and ensure adequate function (2).

Figure 1 An 87-year-old female was admitted following intractable vomiting. Cross-sectional imaging was concerning for Boerhaave syndrome with a 3 cm mediastinal cavity. (A) Endoscopic evaluation demonstrating full-thickness esophageal perforation. (B) Contaminated mediastinal cavity with food debris. (C) Irrigation and removal of food debris using an endoscopic forceps. (D) Endoscopic vacuum therapy with intracavitary sponge placement. (E) Healing of the mediastinal cavity following two sponge exchanges. (F) Complete healing of the esophageal perforation and resumption of normal diet.

Absolute contraindications include situations in which continuous negative pressure cannot be maintained, such as in respiratory or gastro-enteric/colonic fistulas, as this would render the technique ineffective (2,7,9). Its use is also limited in the proximal esophagus and hypopharynx, where achieving an airtight seal is technically challenging (7). Chronic or multiloculated cavities filled with food debris may not always be suitable for this technique. Additional limitations include inability to access the transmural gastrointestinal defect, proximity to a major blood vessel, and large open cavities where the sponge cannot maintain adequate contact with the wound surface, due to increased risks of hemorrhage or fistula formation (2,9). In this review, we will focus primarily on EVT for the management of esophageal perforations and leaks.

Technique

The extent of dehiscence and degree of mediastinal contamination are first assessed using cross-sectional imaging and endoscopic evaluation, which guide both the therapeutic approach and the appropriate size of the PU sponge (Figure 2). The procedure is performed under general anesthesia using a standard upper endoscope with a 2.8-mm channel and a 12- to 16-Fr NGT. Prior to sponge placement, the contaminated cavity is irrigated with water and pus and debris are removed. The PU sponge is then trimmed according to the size of the luminal cavity and extent of dehiscence, and a central tunnel is created in the sponge to accommodate the NGT. The NGT is then introduced trans-nasally and brought out through the mouth. The NGT is modified so that the sponge covers all the suction pores. A nonabsorbable monofilament is then used to secure the sponge to the NGT. A second suture is placed through the sponge and NGT to create an air knot that is used to grasp the EVT and secure it in position. The assembled EVT system is advanced under endoscopic guidance using forceps and the sponge is placed either intracavitary or intraluminally covering the area of dehiscence. For large cavities more than 2 cm in size, we recommend intracavitary sponge placement, where intraluminal placement is typically used for smaller cavities. In cases with limited accessibility, a guidewire may be placed through the NGT and advanced into the cavity endoscopically or fluoroscopically, followed by NGT advancement over the guidewire. Continuous negative pressure at −100 to −175 mmHg (medium to high intensity) is typically applied. The sponge is typically exchanged every 5 days, with intervals ranging from 2 to 8 days, and therapy is continued until complete closure of the defect is achieved. Nutritional support with either total parenteral nutrition or jejunal tube feeding is generally required during the treatment course (5,6,20).

Figure 2 Steps and material required to perform endoscopic vacuum therapy. (A,B) Material required to perform endoscopic vacuum therapy including a polyurethane sponge, a nasogastric tube, a needle holder, and a nonabsorbable monofilament suture. (C) The sponge is trimmed according to the size of the luminal cavity and a central tunnel is created in the sponge to accommodate the nasogastric tube. The nasogastric tube is modified so that the sponge covers all the suction pores. A nonabsorbable monofilament is then used to secure the sponge to the nasogastric tube. A second suture is placed through the sponge and nasogastric tube to create an air knot used to grasp the endoscopic vacuum therapy and secure it in position. (D) The nasogastric tube/sponge is connected to the negative pressure wound therapy tubing.

Efficacy

The management of esophageal perforations has evolved considerably, shifting from conventional surgical approaches toward minimally invasive strategies such as endoscopic stenting and EVT. To facilitate objective comparison of these modalities, studies have applied the quality indicator MTL30, which encompasses mortality, transfer, and length of hospital stay (21). A multicenter retrospective study conducted between 2012 and 2016 evaluating different treatment strategies for Boerhaave syndrome demonstrated an 80% success rate with EVT, significantly outperforming surgery (57.1%) and endoscopic stenting (26.7%) (P=0.004). Although both the need for adjuvant therapy [pleural drainage or video-assisted thoracoscopic surgery (VATS)] and mortality were lower with EVT compared to surgery or stenting, these differences were not statistically significant (P=0.16 and P=0.17, respectively) (22). As a retrospective study, it is subject to lack of randomization and potential heterogeneity across centers, which may influence the generalizability of these findings. The centers may have used different EVT sponge sizes, exchange frequencies, and negative pressure settings. Treatment duration has also been favorably impacted by EVT. A systematic review and meta-analysis of five studies, including 274 patients, demonstrated a 14.22-day reduction in treatment duration compared with self-expanding stents (SEMS), without prolonging hospital stay, still achieving a reduction in mortality (by 12%) (23). A retrospective cohort study comparing EVT and SEMS for traumatic perforations (foreign body, stab, and gunshot injuries) found shorter treatment duration with EVT (P<0.05), but longer hospital stays (P=0.02) (24). Differences in perforation etiology across studies may explain these variable effects on hospital stay, as traumatic perforations may require additional care for injuries, longer ICU stays, or delayed EVT placement. Several studies demonstrated comparable success rates between EVT and SEMS (25,26), while others favored EVT, as shown above. EVT has been associated with reductions in both mortality and complication rates. While one cohort showed lower mortality with EVT (28.6%) versus SEMS (67.25%), the difference was not statistically significant (P=0.3) (24). Other studies showed a 12% decrease in mortality with EVT (23). Another retrospective study reported higher success rates and significantly fewer strictures with EVT compared to SEMS (P<0.05), though no differences in hospital stay or mortality were observed (27). Similarly, a 2016 observational study reported 100% success with EVT versus 63.6% with SEMS, with shorter treatment duration (19.5 vs. 27 days) and lower complication rates. Median hospital stay was also shorter with EVT (37.1 vs. 87.3 days) (28). A 2014 retrospective series applying EVT for a mean of 12.1 days in 14 patients achieved complete healing in 86%. Two patients (14.2%) died of mediastinitis and sepsis prior to completion, while two developed esophageal stenosis on follow-up, successfully managed with dilation (29). The variable outcomes in mortality, hospital stay, treatment durations and complications may be due to the studies being mostly single-center and retrospective, which may limit extrapolation to broader patient populations. A meta-analysis covering the period from 2010 to 2013 reported a 90% success rate and no complications related to the interventions. However, there was one recorded death during dilation of a stenosis due to the formation of an aorto-esophageal fistula following complete healing (30).

EVT has also been evaluated in the setting of postsurgical anastomotic leaks. A 2023 systematic review and meta-analysis including patients with anastomotic leaks following gastroesophageal cancer surgery demonstrated lower in-hospital mortality with endoscopic therapies versus surgery, while clinical success, need for surgical re-intervention, and length of stay showed no significant differences. Specifically, EVT achieved higher closure rates and lower complication rates compared with SEMS (stenosis and severe bleeding: 65% vs. 75%), although migration occurred more frequently with EVT (80% vs. 41%). The rates of perforation, fistulization, and reintervention were similar for both approaches (31). Overall, multiple studies confirm higher success rates, shorter treatment duration, and fewer complications with EVT (23,32-34).

Preventive applications of EVT have also been explored. A quality improvement study applying EVT prophylactically postoperatively (mean treatment duration of 7 days) reported an 86.6% success rate (21). Furthermore, a prospective case series of 11 patients undergoing circumferential esophageal endoscopic submucosal dissection (ESD) demonstrated that prophylactic EVT successfully prevented stricture formation, with a mean treatment duration of 3.5 days (35).

Altogether, the evidence supports EVT as a less invasive yet highly effective alternative to surgery, with advantages in efficacy, hospital stay, and complication rates. Comparisons with stenting remain heterogeneous across studies, underscoring the need for further investigation. Nevertheless, EVT offers a valuable therapeutic option, particularly in patients for whom stenting is not feasible or adjunctive therapeutic approaches such as percutaneous drainage are not desired.

Failure of EVT and adverse events

Despite its therapeutic advantages, EVT is associated with certain drawbacks, including delayed resumption of oral intake compared with stent placement, patient discomfort related to the indwelling NGT, and the need for repeated sponge exchanges (36).

Clinical failures have been reported in specific scenarios, such as chronic fibrosed tracts following sleeve gastrectomy (>3 months), large esophageal tears with extensive cavities, chronic mediastinal contamination associated with esophageal perforations, and multiloculated anastomotic leaks after gastrectomy (6). A 2022 meta-analysis evaluating EVT for colorectal leaks identified treatment failure in 110 of 676 cases, attributable to nonresponse (11.8%), death from unrelated comorbidities (1.5%), technical complications, bleeding, fistula formation, and noncompliance or severe pain (<1%) (37). Similarly, a multicenter retrospective cohort study reported EVT failure in 3 of 27 patients, including two deaths (embolic stroke and pulmonary embolism) and one persistent defect requiring esophagectomy (3). Adverse events associated with EVT include bleeding, stenosis, strictures, and fistula formation (5,38,39). Device-related complications such as tube dislocation or blockage have also been described (22).

Treatment considerations

Close monitoring of key clinical indicators is essential throughout the course of EVT. During the first week, clearance of the cavity from enteric contamination is observed with decreasing EVT drainage. By the second week, sepsis control can be evaluated through trends in inflammatory markers, while in later stages, healing is assessed by progressive granulation tissue formation and reduction in cavity size (6).

Postoperative care is critical to ensure complete healing. Under general anesthesia, sponge exchanges are typically performed every 3 to 4 days for 2 to 3 weeks on average, or until complete closure is achieved. Regular exchange allows adjustment of sponge dimensions as the cavity contracts, prevents tissue ingrowth, facilitates detection of sponge migration, and enables direct reassessment of the wound. Adjunctive antibiotic therapy supports maintenance of an aseptic environment. Nutritional support is mandatory, with total parenteral nutrition often preferred over enteral feeding, as it can be continued during sponge exchanges, although this approach carries a higher risk of infection. Confirmation of defect closure can be obtained with a contrast esophagram study, although it is not mandatory. In cases of clinical deterioration or stagnation of progress, sponge migration or EVT failure should be investigated (5).

Future innovations

The development of a dedicated, purpose-built device for EVT would represent a significant advancement over current improvised or hospital-assembled systems. A standardized, all-in-one platform could improve procedural consistency, enhance safety, and increase overall efficiency.

One dedicated platform, the Eso-SPONGE system (B. Braun Melsungen AG, Melsungen, Germany), was introduced in July 2014. It has since demonstrated promising outcomes. Eso-SPONGE was evaluated in a prospective multicenter Spanish registry of 102 patients with upper gastrointestinal defects, achieving an 82% closure rate and a low rate of EVT-related adverse events (5.9%) (38,40). While not currently available in the United States, it is likely to be incorporated into clinical practice in the near future. Furthermore, integration of EVT with stenting techniques has the potential to provide a more comprehensive therapeutic strategy for esophageal perforations by combining wound approximation, defect closure, and active drainage to optimize healing outcomes. Several of these devices have been introduced in recent years, but have not become widely available. For that matter, the first commercially available device to combine EVT and stenting was the VACStent (Fulda, Germany), introduced in 2019, which offers a practical hybrid approach. A study published in 2025 showed 100% technical success and 70% clinical success using the VACStent for esophageal perforations and anastomotic leaks (41). However, the clinical success of VACStent compared to EVT or SEMS alone remains to be established. Additionally, issues such as oral feeding during treatment and mechanical limitations, including incomplete stent expansion, require further investigation, though the device appears promising and warrants continued study (42).

Looking ahead, rapid advances in digital health and artificial intelligence (AI) may further transform EVT. AI-driven technologies could enable real-time monitoring of pressure dynamics, automated adjustment of negative pressure settings, and decision-support systems to guide clinical management. Such innovations hold promise for enhancing precision, standardizing practice, and ultimately improving patient outcomes.

Strengths and limitations of the review

This review provides a comprehensive evaluation of the available literature on the use of EVT in esophageal perforations and leaks, integrating both clinical and technical perspectives. By addressing mechanisms of action, technical approaches, indications, contraindications, adverse effects, and treatment considerations, it offers practical relevance for both surgical teams and endoscopists involved in the management of esophageal perforations and leaks. In addition, it highlights the comparative efficacy of EVT and more traditional modalities, such as surgery and endoscopic stenting, to aid clinicians in tailoring treatment strategies to individual cases. The summarized evidence is primarily derived from retrospective studies, case series, and meta-analyses, thereby ensuring a broad foundation despite the scarcity of randomized clinical trials.

This review is subject to several limitations. As a narrative review, study selection may be influenced by selection bias. Moreover, the lack of randomized controlled trials restricts the overall strength of the conclusions, while heterogeneity in patient populations, treatment protocols, and follow-up strategies across studies limits comparability of reported outcomes. Finally, given the rapidly evolving nature of EVT techniques, devices, and indications, some of the data presented may become outdated as the field continues to advance.

Conclusions

EVT has emerged as a valuable modality for the management of esophageal perforations and other gastrointestinal emergencies, demonstrating advantages over traditional surgical and endoscopic approaches. Its less invasive nature, higher healing rates, reduced complication profile, shorter hospital stays, and decreased need for additional interventions underscore its therapeutic potential. Nonetheless, the current evidence is largely derived from retrospective studies with considerable heterogeneity in techniques, outcome definitions, and patient populations. While available data strongly support the expanding role of EVT in clinical practice, further prospective and randomized studies are needed to establish standardized protocols, refine patient selection, and clarify long-term outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-25-45/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-45/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-45/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work and in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images.

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