"Effects of the lavage through fistula in treatment of spontaneous esophageal rupture by combined thoracoscopic and gastroscopic management"

Reviewed by

Reza Lankarani

M.D

--------------------------------

World Journal of Emergency Surgery

Published: 07 June 2025

https://doi.org/10.1186/s13017-025-00630-6

--------------------------------

This retrospective study (2014-2024, n = 24) evaluates a novel lavage-drainage technique for spontaneous esophageal rupture (SER/Boehhaave's syndrome).

Patients undergoing VATS debridement/drainage were divided into:

1. Lavage-Drainage Group (n = 11): Gastroscopically guided placement of a nasogastric tube through the esophageal fistula for continuous irrigation (iodinated saline) + standard thoracic/mediastinal drainage.

2. Drainage Group (n = 13): Standard VATS debridement/drainage alone.

No Difference: Operative time, ICU/hospital stay, mechanical ventilation duration.

The authors conclude that fistula lavage enhances drainage efficiency, reduces inflammation, and improves SER prognosis but requires cost optimization.

--------------------------------

Comparison to Recent Literature:

VATS as Standard: Confirms VATS as the preferred minimally invasive approach for stable SER patients, aligning with consensus (Elliott et al., Surg Endosc 2019; Haverman et al., Surg Endosc 2011).

Beyond Basic VATS Drainage: Addresses limitations of simple VATS drainage (tube blockage, inadequate clearance) highlighted by Yu et al. (J Int Med Res 2018). The lavage technique offers a solution similar in spirit to "two-tube" methods but with direct fistula access.

Lavage Concept Supported: Hanajima et al. (J Thorac Dis 2021) also reported success with VATS-guided lavage/drainage (lower mortality, shorter hospital stay in historical controls), providing external validation for the lavage concept, though without the gastroscopic fistula cannulation.

--------------------------------

Conclusion & Significance:

Huang et al. present a promising technical advancement in managing SER. The combined thoracoscopic-gastroscopic lavage-drainage technique demonstrates potential for reducing mortality and severe complications compared to standard VATS drainage alone, particularly in delayed presentations. Its strength lies in directly addressing a key failure mode of traditional drainage (tube blockage) through enhanced debridement and controlled fistula management.

However, the small, retrospective, single-center nature of the study is a major limitation. The observed benefits, while clinically compelling, require confirmation in larger, prospective, multi-center studies with longer follow-up and detailed cost-effectiveness analyses. This technique represents a valuable addition to the "damage control" armamentarium for SER but should be considered within the context of available expertise and resources due to its complexity and higher initial cost.

--------------------------------

Reza Lankarani

M.D