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CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1811523
News and Views

Endoscopic Vacuum Therapy: A Boon for the Patients with Post-surgical Anastomotic Site Leaks

Aditya Kale
1   Department of Digestive Diseases and Clinical Nutrition, Advanced Centre for Treatment, Research and Education in Cancer, Kharghar and Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
2   Gastrointestinal Disease Management Group, TMH, Mumbai, Maharashtra, India
,
Sukanya Thakur
3   Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
,
Vaneet Jearth
3   Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Abstract

Postoperative leaks remain a significant clinical problem with high morbidity and mortality. Traditionally, image-guided pigtail drain placement for collections, feeding tube placement for nutrition, clips or clip–loop combinations for defect closure, surgical repair with buttressing, excision of esophageal conduit and colonic interposition for esophageal leaks, colostomy, and revision of anastomosis for colorectal leaks are often employed. Recently, endoscopic vacuum therapy has gained popularity due to being a minimally invasive, safe, and effective therapeutic option. In this news and views, we will review studies and literature related to this topic.


 

Keywords

leaks - endoscopic vacuum therapy - complications - perforation

Postoperative anastomotic site leaks continue to pose a significant challenge, regardless of advancements in surgical techniques. The incidence of anastomotic site leaks ranges from 11.4 to 21.2% following esophagectomy and from 2.8 to 8.4% after colorectal resections.[1] [2] Traditionally, percutaneous drainage of collections, surgical repair with buttressing, excision of the esophageal conduit, colonic interposition, clipping for small leaks, and supportive measures such as antibiotics and nutrition via feeding tubes or parenteral nutrition are commonly utilized for post-esophagectomy leaks.[1] Similarly, fecal diversion and stoma are commonly used to treat post-colorectal surgical leaks.[2] Endoscopic vacuum therapy is a minimally invasive, effective, and cost-effective treatment for post-surgical leaks. This technique involves the use of open-pored polyurethane foam, which is connected to a portable vacuum device via a flexible tube and inserted into the cavity under endoscopic guidance.[3] [4] Endoscopic vacuum therapy generates continuous negative pressure at the leak site, enhancing local tissue perfusion and decreasing tissue edema. The continuous aspiration of pus, secretions, and necrotic debris cleanses the wound surface and stimulates granulation tissue formation, facilitating wound healing by secondary intention.[5]

Loske et al conducted a study utilizing endoscopic vacuum sponge therapy for various types of leaks, including anastomotic leaks following esophagectomy or gastrectomy (n = 5), iatrogenic esophageal perforations (n = 2), esophageal wall necrosis (n = 1), Boerhaave syndrome (n = 1), and perforations due to esophageal cancer (n = 1). The therapy involved one to seven sessions of sponge changes at intervals ranging from 2 to 7 days. The average duration of therapy was 12 days. Patients received nutrition via percutaneous gastrostomy or an enteral feeding tube. All but one survived, with healing of defects occurring without stricture formation or functionally significant scar formation. A continuous high-intensity vacuum of 125 mmHg was applied.[6] Reimer et al conducted a quality-improvement study involving 156 patients over a period of 10 years. Anastomotic site leaks occurred in 64.1% of patients (n = 100). Additional indications included primary perforation at 6.4%, postoperative preventative therapy at 9.6%, and iatrogenic perforation at 19.8%. The patients were divided into two periods (periods 1 and 2), and the outcomes were compared. They reported that more than 90.9% of patients in period 2 had complete leak resolution, compared to 79.9% in period 1, and that 70% in period 2 did not require any additional surgical procedures or percutaneous drain insertion. In period 2, endoscopic vacuum therapy was utilized as the primary treatment for leaks, with early endoscopy (within 6 hours) employed for leak diagnosis, along with lavage and endoscopic removal of necrotic material, and supplementary endoscopic closure techniques. Adverse events were reported, including bleeding in 3 cases, bronchial fistula in 9 cases, and strictures in 17 cases.[7]

Richter et al conducted a multicenter study involving the treatment of 69 patients with anastomotic leaks and 33 patients with perforations using endoscopic vacuum therapy. The anastomotic leak group demonstrated a closure rate of 91%, compared to 79% for perforations. Complications reported in the study included abscess (4%), fistula (9%), bleeding (6%), peritonitis (1.5%), pneumonia (13%), mediastinitis (13%), pleural empyema (7.3%), sepsis (10.1%), renal failure (7.3%), and acute respiratory distress syndrome (4.4%). In 45% of the patients, additional thoracic drainage and lavage were required. The study identified that the presence of mediastinitis and the distance of the defect from the dental arch were significantly associated with the failure of endoscopic vacuum therapy.[8] A recent systematic review of endoscopic vacuum therapy for esophageal leaks demonstrated a high success rate and low complication rates among treated patients.[9] Vacuum therapy has been successfully utilized for leaks following colorectal surgery, analogous to its application in esophageal leaks. Kühn et al conducted a prospective study that collected data from over 281 patients undergoing colorectal surgery who experienced leaks. A significant proportion (83%) underwent surgical intervention for malignancy. A significant proportion experienced leakage from the anastomotic site following rectal or sigmoid colon resection (67%), while 20% exhibited leakage from the rectal stump. Endoscopic vacuum therapy was effective in 91% of cases. The median duration was 25 days. Prior chemoradiation correlated with an extended treatment duration. Multivisceral resection and surgical revision following primary surgery are linked to an increased risk of therapeutic failure. Approximately 50% of the patients received outpatient treatment, resulting in a 15-day reduction in hospital stay. Complications reported included anastomotic stenosis in 10 patients, rectovaginal fistulas in 7 patients, and bleeding in 4 patients. The majority of studies employed pressures between 100 and 125 mmHg.[10] The study conducted by Sundaram et al demonstrated that the healing of upper gastrointestinal leaks can be accomplished at significantly reduced pressures of 25 to 30 mmHg. This study was the first large case series from India, demonstrating the efficacy and safety of low-pressure modified low-cost endoscopic vacuum therapy in patients with anastomotic leaks. The high pressures have the potential to cause chest discomfort in patients with poor lung compliance and to increase the risk of lung infections, demanding a low pressure approach; however, more evidence is needed for wider adoption of this technique.[4] [11] Kühn et al. conducted a systematic review and meta-analysis of studies employing endoscopic vacuum therapy for colorectal leaks. The average success rate was 81.4% (95% confidence interval: 74.0–87.1%), with complications occurring in 12.1% of cases. Current evidence regarding endoscopic vacuum therapy for colorectal leaks is insufficient due to a lack of high-quality data.[12]

Commentary

Post-surgical anastomotic site leaks present a significant challenge that necessitates a multidisciplinary approach.[1] The diversion of secretions, alternative nutritional routes, drainage of collections via drain placement, and surgical buttressing or disconnection procedures have historically resulted in significant morbidity and mortality.[2] [3] Minimally invasive, cost-effective, safe, and efficient endoscopic vacuum therapy presents a promising option for patients experiencing post-surgical leaks in the upper and lower gastrointestinal tract, as well as those with Boerhaave syndrome and esophageal necrosis.[5] [9] [10] Endoscopic vacuum therapy, when combined with appropriate nutritional supplementation and percutaneous drainage of collections, can facilitate the healing of leaks and cavities through secondary intention.[5] Vacuum therapy equipment is readily available and comprises an open-pore polyurethane sponge, fenestrated tubes of 12 French, 14 French, or 16 French (depending on secretion thickness), suture material, a suction machine, and an overtube for insertion.[4] [5] [6] [7] In the majority of instances, vacuum therapy results in defect closure in conjunction with percutaneous drainage of collections, endoscopic lavage of the cavity to remove necrotic debris and pus, and placement of over-the-scope clips for residual defects.[4] [5] [6] [7] [8] [9] [10] Endoscopic sponge placement involves holding the sponge in place using foreign body forceps and guiding it into the cavity with an endoscope. Periodic sponge replacement is essential because its pores become saturated, resulting in loss of suction. Most studies utilize high-pressure suction[5] [6] [7] [8] [9] [10]; however, low pressures may also demonstrate effectiveness.[4] In addition, outpatient treatment is an option, particularly for colorectal leakage.[10] Research indicates complications such as bleeding, fistulization—particularly rectovaginal fistula formation—stricture formation, empyema, pneumothorax, sepsis, and respiratory distress in certain patients. Overall, vacuum therapy appears to be successful and safe in treating post-surgical leakage. It is also employed to treat Boerhaave syndrome and esophageal perforations with an acceptable success rate.[6]

In conclusion, endoscopic vacuum therapy demonstrates safety and efficacy as a minimally invasive approach for managing post-surgical gastrointestinal leaks, esophageal perforation, or rupture. Further studies are necessary to evaluate the appropriate selection of patients, optimal pressures, sponge size, catheter size, and to compare these factors with other modalities such as clip closure, clip–loop closure, and fully covered self-expandable stents to establish its position within the treatment algorithm.


 

 

Conflict of Interest

None declared.


Address for correspondence

Vaneet Jearth, MD, DM
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research
Chandigarh 160012
India   

Publikationsverlauf

Artikel online veröffentlicht:
22. August 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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