Comments on „Tube-in-tube endoscopic vacuum therapy for the closure of upper gastrointestinal fistulas, leaks, and perforations”

We read with great interest the article by de Lima et al. on the application of endoscopic vacuum therapy (EVT) to upper gastrointestinal perforations [1]. We have experienced and previously published the technique in the same setting (for postoperative esophageal leaks) [2] and for chronic duodenal leaks [3], and would like to discuss a few points on the basis of our expertise. First, the timing of the treatment is not clearly defined. This is crucial to discuss the clinical results of the treatment because, as we have already underlined in our papers, a delayed referral for endoscopic treatment worsens the definitive clinical outcome. Second, a single double-channel tube is sufficient to obtain the same suction as two Levine tubes as the presence of the second channel guarantees continuous aspiration from the main channel because of the constant air passage through it. Finally, the authors decided that, if a surgical drain was in situ, the suction tube was placed using this route. This percutaneous variant can however reduce the clinical success rate because it increases the pressure gradient between the intraluminal pressure and the pressure in the para-anastomotic abscess cavity, allowing the intraluminal content to flow from the leak through the creation of a stable enterocutaneous pathway. In contrast, suction to the intraluminal site has all the advantages described in the article and may facilitate the formation of granulation tissue from the extraluminal side to the enteral wall. Furthermore, the nose-to-collection suction drain can be gradually retrieved from the nose to guide the internal fistula gradually to the enteral lumen during the EVT period of 15–19 days. In conclusion, we agree that EVT using suction tubes (not only polyurethane sponges) is feasible and especially useful when using nose-to-collection tubes. Conflict of interests