In Reply

The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation by Dr. med. Arthur Schmidt, Prof. Dr. med. Karl-Hermann Fuchs, Prof. Dr. med. Karel Caca, Dr. med. Armin Küllmer, and Prof. Dr. med. Alexander Meining in issue 8/2016

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).

DOI: 10.3238/arztebl.2016.0539b

Dr. med. Arthur Schmidt
Prof. Dr. med. Karel Caca
Klinik für Innere Medizin, Gastroenterologie,
Hämato-Onkologie, Diabetologie und Infektiologie
Klinikum Ludwigsburg

Conflict of interest statement
Dr. Schmidt has received lecture fees and study support (third-party funding) from Ovesco Endoscopy.

Prof. Caca has received lecture fees from Olympus, Cook, Boston Scientific, Ovesco, and G-Surg. He has received study support (third-party funding) from Ovesco und G-Surg.

References

1. Mennigen R, Senninger N, Laukoetter MG: Novel treatment options for perforations of the upper gastrointestinal tract: endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20: 7767–76

2. Schmidt A, Fuchs KH, Caca K, Küllmer A, Meining A: The endoscopic treatment of iatrogenic gastrointestinal perforation. Dtsch Arztebl Int 2016; 113: 121–8

3. Paspatis GA, Dumonceau J, Barthet M, et al.: Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Positions Statement. Endoscopy 2014; 693–711

4. Schmidt A, Riecken B, Damm M, et al.: Endoscopic removal of over-the-scope clips using a novel cutting device: a retrospective case series. Endoscopy 2014; 762–6