Saurabh Chandan, MD1, Babu P. Mohan, MD2, Shahab R. Khan, MBBS2, Sarah Malik, MD1, Neil Bhogal, MD1, Ojasvini Choudhry Chandan, MD1, Douglas G. Adler, MD, FACG3
1University of Nebraska Medical Center, Omaha, NE; 2University of Arizona / Banner University Medical Center, Tucson, AZ; 3University of Utah School of Medicine, Salt Lake City, UT
Introduction: Treatment of gastroesophageal leaks and perforations after upper gastrointestinal surgery remains clinically challenging. Advanced endoscopic interventions have traditionally included placement of self-expanding metal or plastic stents i.e. endoscopic stent therapy (EST) and endoscopic vacuum-assisted closure therapy (EVAC). The aim of our study was to evaluate the overall clinical efficacy of EVAC when compared to EST in the treatment of gastroesophageal defects.
Methods: Our primary goals were to analyze the pooled rates of clinical success and overall mortality with EVAC therapy in gastroesophageal defects. Using EST as a comparator group, we analyzed clinical outcomes and predictors of clinical success.
Results: 6 cohort studies compared EVAC (109 patients) to EST (197 patients). These included 313 cases of esophageal anastomotic leaks. The pooled odds ratio of clinical success with EVAC was 2.9 (95% CI 1.4-5.8, p=0.003, I 2=13) when compared to EST in the treatment of esophageal leaks secondary to surgical anastomosis. The pooled odds ratio of mortality was 0.43 (95% CI 0.19-0.95, p=0.04, I 2=0). When all studies that evaluated EVAC alone were analyzed (14 studies - 89 perforations and 136 anastomotic leaks), the pooled rate of clinical success was 87.5% (95% CI 81.6-91.7, I 2=0, p=0.001). For studies evaluating EST (12 studies, 349 patients), the pooled rate of clinical success was 75.4% (95% CI 75.6-84.1, p=0.001, I 2=30). EVAC performed significantly better than EST (p=0.004). The pooled mortality rate with EVAC was 9.1% (95% CI 4.5-17.5, p=0.01, I2=0) and with EST was 17.2% (95% CI 11.2-20.2, p=0.001, I 2=38). Based on univariate meta-regression analysis, anastomotic leaks demonstrated statistical significance as a predictive factor of clinical success with EVAC (2-sided p-value 0.05, R2 analog=1), whereas perforation almost reached statistical significance (2-sided p-value 0.06, R2 analog=0). On multivariate meta-regression, neither of the etiologies showed statistical significance as a possible predictor of clinical success. We performed meta-regression analysis on mortality data and found no significant predictive effect of etiology in EVAC and EST groups, except for anastomotic leaks that almost reached statistical significance as a predictor of mortality with EST(2-sided p-value 0.06, R2 analog=1).
Discussion: EST performed favorably when compared to EST in the treatment of gastroesophageal defects with higher clinical success and lesser mortality.
Citation: Saurabh Chandan, MD; Babu P. Mohan, MD; Shahab R. Khan, MBBS; Sarah Malik, MD; Neil Bhogal, MD; Ojasvini Choudhry Chandan, MD; Douglas G. Adler, MD, FACG. P1459 - CLINICAL EFFICACY OF ENDOSCOPIC VACUUM-ASSISTED CLOSURE THERAPY (EVAC) IN GASTROESOPHAGEAL DEFECTS: A SYSTEMATIC REVIEW AND COMPARATIVE META-ANALYSIS WITH ENDOSCOPIC STENT THERAPY (EST). Program No. P1459. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.