Endoscopic treatment of anastomotic leakage after upper gastrointestinal surgery: endoscopic self-expandable metallic stent or endoscopic vacuum therapy?

Chul-Hyun Lim; Chan Gyoo Kim

doi:10.5946/ce.2025.229

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Review Endoscopic treatment of anastomotic leakage after upper gastrointestinal surgery: endoscopic self-expandable metallic stent or endoscopic vacuum therapy?: Chul-Hyun Lim¹, Chan Gyoo Kim²; Clinical Endoscopy 2026;59(3):327-332.
DOI: https://doi.org/10.5946/ce.2025.229
Published online: April 1, 2026

¹Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Center for Gastric Cancer, National Cancer Center, Goyang, Korea

Correspondence: Chan Gyoo Kim Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Korea E-mail: glse@ncc.re.kr

• Received: July 12, 2025 • Revised: October 13, 2025 • Accepted: November 5, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
SELF-EXPANDABLE METALLIC STENT AND ENDOSCOPIC VACUUM THERAPY
ESOPHAGEAL CANCER SURGERY
GASTRIC CANCER SURGERY
CONCLUSIONS
NOTES
REFERENCES

Abstract

Anastomotic leakage is a serious complication following upper gastrointestinal (UGI) surgery, associated with high morbidity and mortality rates. Effective management strategies aim to close or cover the defect, contain the leak, and adequately drain the affected area. In recent years, endoscopic techniques have emerged as viable alternatives or adjuncts to surgical interventions. This review discusses two major endoscopic modalities — self-expandable metal stents (SEMS) and endoscopic vacuum therapy (EVT) — in anastomotic leaks after gastric and esophageal cancer surgery. By evaluating the efficacy, indications, and limitations of SEMS and EVT techniques, this article provides a comprehensive overview to assist clinicians in optimizing patient outcomes in UGI postoperative anastomotic leaks.
Keywords: Anastomotic leakage; Endoscopy; Endoscopic vacuum therapy; Self expandable metallic stents; Upper gastrointestinal tract

INTRODUCTION

Surgery is one of the major treatment modalities for upper gastrointestinal (UGI) diseases. Anastomotic leakage is defined as the disruption of a surgical anastomosis resulting in full-thickness gastrointestinal defects. Anastomotic leakage after UGI surgery is one of the most common complications, leading to increased morbidity and mortality rates.¹^-³ Anastomotic leakage rates after esophageal cancer and gastric cancer surgery have been reported as ranging from 10% to 21.2%⁴ and from 3% to 12.5%, respectively.⁵^-⁷ The goals of the management of an anastomotic leakage are closure or coverage of the defect, containment of the leak, and drainage of the contaminated space.⁸ Endoscopic and surgical management are the main options for treating anastomotic leakage.⁴ Endoscopic management of leakage includes primary closure of defects (clips, endoscopic suturing, and fibrin glue), secondary closure with a self-expandable metal stent (SEMS), and endoscopic vacuum therapy (EVT). To date, there are no standardized international guidelines specifically addressing endoscopic treatment selection for UGI anastomotic leaks, and decisions are largely guided by institutional experience and patient-specific considerations. Herein, we review the clinical outcomes of SEMS and EVT for the treatment of anastomotic leakage after UGI surgery, focusing on esophageal and gastric cancer surgery.

SELF-EXPANDABLE METALLIC STENT AND ENDOSCOPIC VACUUM THERAPY

SEMS is one of the standard endoscopic treatment methods for anastomotic leakage after UGI surgery.⁹ The covered surface of deployed SEMS covers the luminal gap at the leakage site and prevents the inflow of luminal contents into the leakage site, which can promote mucosal healing. SEMS placement allows early oral feeding and prevents subsequent stricture formation. Combined external drainage of the contaminated space is usually required. SEMS are usually maintained for 4 to 8 weeks and are removed endoscopically. Complications associated with SEMS placement include migration, bleeding, stenosis, and fistulae formation.

EVT was first reported in 2008¹⁰^,¹¹ and is now widely used as an endoscopic treatment method for anastomotic leakage after UGI surgery. EVT consists of a polyurethane foam sponge connected to a vacuum device via a tube. The sponge is endoscopically applied to the defect cavity, and a vacuum device is used to apply continuous negative pressure. This system enables continuous drainage, promotion of granulation tissue formation, re-epithelialization, and closure of defects. Anastomotic leakage detected shortly after surgery, which is often small and without extraluminal cavities, may be more amenable to SEMS, whereas leaks occurring later, with larger defects and associated extraluminal cavities, may be better treated with EVT. EVT must be changed every 3 to 7 days according to the cavity size until the cavity heals. Disadvantages of EVT include repetitive endoscopic interventions, discomfort due to the nasal tube, and prolonged fasting during treatment.

Both SEMS and EVT have been used to manage anastomotic leakage after UGI surgery. The key indications, mechanisms, clinical outcomes, and advantages and disadvantages of SEMS and EVT are summarized in Table 1. Most previous studies included patients with anastomotic leakage after esophagectomy and total gastrectomy. Systematic reviews and meta-analyses concluded the superiority of EVT in successful defect closure, mortality, adverse events, and duration of treatment compared with SEMS in the management of anastomotic leakage after UGI surgery.¹²^,¹³ However, these reports included studies with heterogeneous operative procedures, including esophagectomy and gastrectomy, and several factors including anastomosis methods, defect characteristics, and medical conditions of the included subjects need to be considered before accepting this conclusion at face value.

ESOPHAGEAL CANCER SURGERY

A major esophageal cancer surgery technique consists of esophagectomy and either cervical or intrathoracic anastomosis between the remaining esophagus and the gastric conduit. Both SEMS placement and EVT have been used to manage esophagogastrostomy site leakage after esophageal cancer surgery. A systematic review analyzed the outcomes of SEMS for the management of anastomotic leak after esophagectomy across 25 studies and reported a 72.2% (299/414) leak resolution rate and a 15% mortality rate.⁸ Another systematic review analyzed outcomes after endoscopic stent placement for esophageal anastomotic leaks and benign esophageal perforations and reported 81.1% (250/308) of clinical success rate.¹⁴ A single-center study of SEMS for 70 patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy reported a 70% clinical success rate.¹⁵ SEMS is potentially beneficial for patients with esophageal anastomotic leaks involving less than 30% of the anastomotic circumference without extensive necrosis, and SEMS is contraindicated for patients with extensive devitalization of esophageal anastomosis, large leaks, or a nonviable conduit.⁴ Initial experiences with EVT for anastomosis site leakage after esophageal cancer surgery showed a high clinical success rate without serious procedure-related adverse events.¹⁶^-¹⁸ Two single-center studies of EVT for anastomosis site leakage after esophageal cancer surgery reported 92.3% (12/13) and 75.0% (15/20) of clinical success rates.¹⁹^,²⁰ A retrospective study comparing EVT and SEMS for anastomotic leak after esophagectomy reported a clinical success rate of 93.3% (14/15) in the EVT group and 63.3% (19/30) in the SEMS group, with statistical significance, and suggested that EVT might be more effective than SEMS in the management of esophageal anastomotic leaks.²¹ A single-center study suggested that EVT seems to be a better treatment option for patients with a large defect size and the presence of an extraluminal cavity compared to SEMS, and that EVT can be safely applied to critically ill patients with large defects.¹⁹ This study also suggested that SEMS seems only warranted in non-septic patients with a small defect size and no extraluminal cavity. A possible explanation for the treatment failure of SEMS after anastomotic leakage after esophagectomy may be incomplete attachment of the gastric side distal to the anastomosis due to the relatively larger diameter of the gastric tube than the esophageal lumen, which contributes to luminal content inflow into the leakage site. EVT provides continuous drainage and has the advantage of preventing luminal content inflow into the leakage site compared to SEMS. Another reason why maintaining a stent is challenging is that if the anastomotic leakage is close to the upper esophageal sphincter, foreign-body sensation and the possibility of aspiration caused by the stent make maintenance difficult. According to studies on the effect of neoadjuvant chemoradiotherapy on the outcome of endoscopic treatment of anastomotic leakage after surgery, neoadjuvant chemoradiotherapy is known to delay anastomotic healing or prolong the treatment period²² and is a significant independent risk factor for EVT failure²³ through mechanisms such as tissue fibrosis and microvascular damage. However, it is difficult to assess whether the presence or absence of neoadjuvant treatment is a major determinant of SEMS placement or EVT for postoperative anastomotic leaks. The selection of SEMS or EVT for the endoscopic treatment of anastomotic leakage after esophagectomy should be based on the medical condition of the patient and the characteristics of the anastomotic defect. Previously, surgical management was recommended rather than endoscopic management in cases in which signs of uncontrolled sepsis are present, early leakage (within the first 72 hours) occurs, or uncontained intrathoracic anastomotic leaks are identified.⁴ However, early intervention with EVT could be selected as the alternative initial management in these situations recently. In cases of primary treatment failure of SEMS or EVT, secondary treatment using another technique may be considered.²¹^,²⁴ Based on these considerations, a practical treatment algorithm for anastomotic leakage after esophagectomy is proposed (Fig. 1A). Further large-scale studies considering defect size, cavity characteristics, and clinical status of patients are required for robust conclusions.

GASTRIC CANCER SURGERY

The majority of anastomotic leakages after gastric cancer surgery have been reported to occur at the esophagoenteric anastomosis after total gastrectomy. Before the advent of endoscopic management, the mortality rates for anastomotic leakage after total gastrectomy were reported to be as high as 64.0% (16 out of 25) after reoperation and 19.0% (11 out of 58) after conservative treatment,⁶ and the occurrence of anastomotic leakage was reported as a major independent prognostic factor for long-term survival.²⁵ Both SEMS and EVT have been reported in the management of leakage at the esophagoenteric anastomosis site after total gastrectomy. SEMS closes the luminal gap of anastomotic leakage at the esophagoenteric anastomosis in total gastrectomy, redirects luminal contents, and promotes mucosal healing. SEMS allows for early oral feeding and reduces the risk of anastomotic strictures. Several single-center studies of SEMS for esophagoenteric anastomosis leakage after total gastrectomy reported clinical success rates ranging from 80.0% to 100%.²⁶^-³⁰ A major SEMS-related complication was stent migration, with an occurrence rate of up to 30.8%.²⁶^,²⁹ Several techniques for preventing stent migration, including endoscopic clips,³¹ endoscopic suturing devices,³² the Shim technique,³³ and new stent designs,³⁴ are available. The Shim technique with a silk thread was reported to be effective and safe for the prevention of stent migration.²⁷^,²⁸ Two studies reported the clinical outcomes of EVT for esophagojejunal anastomosis leakage after total gastrectomy with clinical success rate of 88.9% (8/9)³⁰ and 72.7% (8/11).³⁵ A retrospective study reported the efficacy of EVT and SEMS for postoperative anastomotic leakage in gastric cancer with various surgical techniques, including total, subtotal, and proximal gastrectomy and the clinical success rates of EVT and SEMS were 100% (11/11) and 92.9% (26/28), respectively.³⁶ This study suggested that EVT can be a useful treatment option in postgastrectomy anastomotic leak. Based on these considerations, a practical treatment algorithm for anastomotic leakage after total gastrectomy and subtotal gastrectomy is proposed (Fig. 1B, C). Further large-scale studies considering surgical techniques, defect size, cavity characteristics, and clinical status of patients are required for robust conclusions.

CONCLUSIONS

Management of anastomotic leakage after UGI surgery is very important because of its potential to cause significant and critical morbidity and mortality. Endoscopic management, including SEMS and EVT, has become the primary treatment option for anastomotic leakage after UGI surgery. Both techniques have their advantages and limitations in the management of anastomotic leakage after UGI surgery. SEMS seems to be suitable for anastomotic leakage sites where complete attachment of the stent coverage on both the proximal and distal sides of the anastomosis is possible. EVT appears to have a wider range of indications than SEMS for anastomotic leakage sites, including a large defect size and the presence of an extraluminal cavity. Although many studies have shown that EVT is superior to SEMS in terms of successful defect closure, mortality, adverse events, and treatment duration in managing anastomotic leaks after UGI surgery, SEMS is more appropriate for patients with smaller leak sizes and non-septic conditions and offers the advantages of allowing early resumption of oral intake and a reduced endoscopic workload.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: CGK; Data curation: CHL; Writing–original draft: CHL; Writing–review & editing: all authors.

Fig. 1.

Suggested treatment algorithm for anastomotic leakage after esophagectomy (A), total gastrectomy (B), and subtotal gastrectomy (C). SEMS, self-expandable metal stent; EVT, endoscopic vacuum therapy.

Table 1.

Key characteristics of endoscopic self-expandable metallic stent and endoscopic vacuum therapy in anastomotic leakage after upper gastrointestinal surgery

	Endoscopic self-expandable metallic stent	Endoscopic vacuum therapy
Prioritized indications	Early detection (≤7 days)	Delayed detection (>7 days)
	Small defects	Larger defects
	Absence of extraluminal cavity	Presence of extraluminal cavity or abscess
	Clinically stable patients	Septic patients requiring drainage
Mechanism of action	Intraluminal sealing of the defect	Continuous drainage
	Maintenance of luminal patency	Granulation tissue formation
		Re-epithelialization
Clinical success	Approximately 60%–85%	Approximately 80%–95%
Technical success	High	Very high
Complications	Stent migration	Bleeding
	Pressure ulceration	Sponge dislocation
	Bleeding	Stricture
	Stricture
Advantages	Early resumption of oral intake	Effective cavity drainage
	Less endoscopic workload	Promotion of healing
		Flexible application
Disadvantages	Stent repositioning or replacement	Repetitive endoscopic interventions
		Discomfort of patient
		Long fasting time

REFERENCES

1. Low DE, Kuppusamy MK, Alderson D, et al. Benchmarking complications associated with esophagectomy. Ann Surg 2019;269:291–298.Article PubMed
2. Schmidt HM, Gisbertz SS, Moons J, et al. Defining benchmarks for transthoracic esophagectomy: a multicenter analysis of total minimally invasive esophagectomy in low risk patients. Ann Surg 2017;266:814–821.Article PubMed
3. Chadi SA, Fingerhut A, Berho M, et al. Emerging trends in the etiology, prevention, and treatment of gastrointestinal anastomotic leakage. J Gastrointest Surg 2016;20:2035–2051.Article PubMed PDF
4. Chevallay M, Jung M, Chon SH, et al. Esophageal cancer surgery: review of complications and their management. Ann N Y Acad Sci 2020;1482:146–162.Article PubMed PDF
5. van der Werf LR, Busweiler LAD, van Sandick JW, et al. Reporting national outcomes after esophagectomy and gastrectomy according to the Esophageal Complications Consensus Group (ECCG). Ann Surg 2020;271:1095–1101.Article PubMed
6. Lang H, Piso P, Stukenborg C, et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000;26:168–171.Article PubMed
7. Kim JY, Chung H. Endoscopic intervention for anastomotic leakage after gastrectomy. J Gastric Cancer 2024;24:108–121.Article PubMed PMC PDF
8. Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014;208:536–543.Article PubMed PMC
9. Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023;56:693–705.Article PubMed PMC PDF
10. Weidenhagen R, Gruetzner KU, Wiecken T, et al. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 2008;22:1818–1825.Article PubMed PDF
11. Wedemeyer J, Schneider A, Manns MP, et al. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks. Gastrointest Endosc 2008;67:708–711.Article PubMed
12. do Monte Junior ES, de Moura DTH, Ribeiro IB, et al. Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis. Dig Endosc 2021;33:892–902.Article PubMed
13. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic vacuum therapy (EVT) versus self-expandable metal stent (SEMS) for anastomotic leaks after upper gastrointestinal surgery: systematic review and meta-analysis. Life (Basel) 2023;13:287.Article PubMed PMC
14. Dasari BV, Neely D, Kennedy A, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg 2014;259:852–860.Article PubMed
15. Plum PS, Herbold T, Berlth F, et al. Outcome of self-expanding metal stents in the treatment of anastomotic leaks after ivor lewis esophagectomy. World J Surg 2019;43:862–869.Article PubMed PDF
16. Ahrens M, Schulte T, Egberts J, et al. Drainage of esophageal leakage using endoscopic vacuum therapy: a prospective pilot study. Endoscopy 2010;42:693–698.Article PubMed
17. Wedemeyer J, Brangewitz M, Kubicka S, et al. Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system. Gastrointest Endosc 2010;71:382–386.Article PubMed
18. Weidenhagen R, Hartl WH, Gruetzner KU, et al. Anastomotic leakage after esophageal resection: new treatment options by endoluminal vacuum therapy. Ann Thorac Surg 2010;90:1674–1681.Article PubMed
19. El-Sourani N, Miftode S, Bockhorn M, et al. Endoscopic management of anastomotic leakage after esophageal surgery: ten year analysis in a tertiary university center. Clin Endosc 2022;55:58–66.Article PubMed PMC PDF
20. Chon SH, Brunner S, Müller DT, et al. Time to endoscopic vacuum therapy-lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center. Surg Endosc 2023;37:741–748.Article PubMed PMC PDF
21. Mennigen R, Harting C, Lindner K, et al. Comparison of endoscopic vacuum therapy versus stent for anastomotic leak after esophagectomy. J Gastrointest Surg 2015;19:1229–1235.Article PubMed PDF
22. Seika P, Biebl M, Raakow J, et al. The association between neoadjuvant radio-chemotherapy and prolonged healing of anastomotic leakage after esophageal resection treated with EndoVAC therapy. J Clin Med 2022;11:4773.Article PubMed PMC
23. Jung DH, Huh CW, Min YW, et al. Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 2022;95:281–290.Article PubMed
24. Berlth F, Bludau M, Plum PS, et al. Self-expanding metal stents versus endoscopic vacuum therapy in anastomotic leak treatment after oncologic gastroesophageal surgery. J Gastrointest Surg 2019;23:67–75.Article PubMed PDF
25. Sierzega M, Kolodziejczyk P, Kulig J. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg 2010;97:1035–1042.Article PubMed PDF
26. Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc 2014;28:833–840.Article PubMed PDF
27. Choi CW, Kang DH, Kim HW, et al. Full covered self-expandable metal stents for the treatment of anastomotic leak using a silk thread. Medicine (Baltimore) 2017;96:e7439.Article PubMed PMC
28. Jung GM, Lee SH, Myung DS, et al. Novel endoscopic stent for anastomotic leaks after total gastrectomy using an anchoring thread and fully covering thick membrane: prevention of embedding and migration. J Gastric Cancer 2018;18:37–47.Article PDF
29. Oh HJ, Lim CH, Yoon SB, et al. Temporary self-expandable metallic stent placement in post-gastrectomy complications. Gastric Cancer 2019;22:231–236.Article PubMed PDF
30. Senne M, Werner CR, Schempf U, et al. Comparison of two endoscopic therapeutic interventions as primary treatment for anastomotic leakages after total gastrectomy. Cancers (Basel) 2022;14:2982.Article PubMed PMC
31. Vanbiervliet G, Filippi J, Karimdjee BS, et al. The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study. Surg Endosc 2012;26:53–59.Article PubMed PDF
32. Kantsevoy SV, Bitner M. Esophageal stent fixation with endoscopic suturing device (with video). Gastrointest Endosc 2012;76:1251–1255.Article PubMed
33. Shim CS, Cho YD, Moon JH, et al. Fixation of a modified covered esophageal stent: its clinical usefulness for preventing stent migration. Endoscopy 2001;33:843–848.Article PubMed
34. Kim YI, Kim CG, Lee JY, et al. Effectiveness of a novel covered stent without external thread fixation for anastomotic leakage after total or proximal gastrectomy for gastric cancer. Cancers (Basel) 2021;13:3720.Article PubMed PMC
35. Pattynama LMD, Pouw RE, Henegouwen MIVB, et al. Endoscopic vacuum therapy for anastomotic leakage after upper gastrointestinal surgery. Endoscopy 2023;55:1019–1025.Article PubMed PMC
36. Choi SI, Park JC, Jung DH, et al. Efficacy of endoscopic vacuum-assisted closure treatment for postoperative anastomotic leak in gastric cancer. Gut Liver 2020;14:746–754.Article PubMed PMC

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