Anastomotic leakage (AL) in the upper gastrointestinal tract (uGIT) is a critical condition associated with high mortality and significant morbidity. Effective management requires prompt and specialized diagnostic and therapeutic interventions through an interdisciplinary approach. In current practice, surgical intervention is infrequent and typically reserved for cases of extensive damage. Close collaboration between radiology, endoscopy, and surgery is essential for optimal care. Endoscopic therapy is the primary modality for managing AI in the upper GIT. This review offers an overview of the most common endoscopic treatment strategies for AL in this region.

Significant advancements have been made in the endoscopic management of AL in the uGIT in recent years. Endoscopic sutures and clips remain appropriate for smaller defects, but for larger leakages, endoscopic vacuum therapy (EVT) is gaining prominence over stent placement. Innovative approaches, such as vacuum stents and small diameter filmed drainage (FD), offer promising new therapeutic options for treating AL in the uGIT.

(1) Endoscopy plays a pivotal role in the management of AL in the upper GIT. (2) A growing body of evidence supports EVT as superior to other modalities such as sutures, tissue sealants, or clips. Notably, EVT has a lower complication rate and higher healing success compared to stent therapy in AL treatment. (3) New endoscopic techniques, including the vacuum stent and FD, represent promising advancements in the treatment of AL.

Endoscopic vacuum therapy (EVT) is an increasingly popular endoscopic technique used for the treatment of wall defects in the gastrointestinal tract. Open-pore film drainage (OFD) systems are a new addition to the armamentarium of EVT and have shown encouraging results in a wide spectrum of applications. The aim of this review is to summarize the current literature on the applications of OFD systems in the gastrointestinal tract.

Open-pore film drainage (OFD) systems have been used for the treatment of several defects of the gastrointestinal tract. The small size and easy placement of these devices make them very useful, particularly for the treatment of defects that are small in size or difficult to reach. OFDs have been successfully used for both perforations and anastomotic leaks in various locations, with most reports focusing on the treatment of duodenal defects, although successful applications in the esophagus, stomach, and colon have also been reported. Lately, the role of OFDs in preemptive EVT has also been explored.

OFD systems are easy to use, particularly for small defects and challenging localizations. The current literature, consisting mainly of small case series and case reports, shows encouraging results, but further prospective studies are needed to explore and verify the indications and technical aspects of this innovative method.

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Postoperative reflux can compromise anastomotic healing after Ivor-Lewis oesophagectomy (ILE). We report on Pre-emptive Active Reflux Drainage (PARD) using a new double-lumen open-pore film drain (dOFD) with negative pressure to protect the anastomosis.

To prepare a dOFD, the gastric channel of a triluminal tube (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over 25 cm. The ventilation channel is blocked. The filmcoated segment is placed in the stomach and the intestinal feeding tube in the duodenum. Negative pressure is applied with an electronic vacuum pump (- 125 mmHg, continuous suction) to the gastric channel. Depending on the findings in the endoscopic control, PARD will either be continued or terminated.

PARD was used in 24 patients with ILE and started intraoperatively. Healing was observed in all the anastomoses. The median duration of PARD was 8 days (range 4-21). In 10 of 24 patients (40%) there were issues with anastomotic healing which we defined as "at-risk anastomosis". No additional endoscopic procedures or surgical revisions to the anastomoses were required.

PARD with dOFD contributes to the protection of anastomosis after ILE. Negative pressure applied to the dOFD (a nasogastric tube) enables enteral nutrition to be delivered simultaneously with permanent evacuation and decompression.

To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract.

This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany).

11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak.

EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.

A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.

Endoscopic negative pressure therapy (ENPT) has been adapted for upper gastrointestinal tract applications. More than 400 patients have already been treated with ENPT due to transmural defects in the upper gastrointestinal tract, with a success rate of 87%. The greatest experience exists for the treatment of anastomotic leakages and perforations of the esophagus. The ENPT is also used in the duodenum, pancreas and for complications after bariatric surgery. There are new indications that go beyond treatment in complication management. Innovative drainage types and endoscopic techniques have been developed that broaden the spectrum of applications. The aim of this article is to give an overview of the current status of ENPT in the upper gastrointestinal tract.

Endoscopic negative pressure therapy (ENPT) has been adapted for upper gastrointestinal tract applications. More than 400 patients have already been treated with ENPT due to transmural defects in the upper gastrointestinal tract, with a success rate of 87%. The greatest experience exists for the treatment of anastomotic leakages and perforations of the esophagus. The ENPT is also used in the duodenum, pancreas and for complications after bariatric surgery. There are new indications that go beyond treatment in complication management. Innovative drainage types and endoscopic techniques have been developed that broaden the spectrum of applications. The aim of this article is to give an overview of the current status of ENPT in the upper gastrointestinal tract.

 Endoscopic negative pressure therapy (ENPT) has been developed to treat gastrointestinal leakages. Up to now, ENPT has usually been performed with open-pore polyurethane foam drains (OPD). A big disadvantage of the OPDs is their large diameter. We have developed a new, small-bore open-pore film drainage (OFD). Herein we report our first experience in a case series of 16 patients.

 OFD is constructed with a drainage tube and a very thin double-layered open-pore drainage film (Suprasorb CNP, Drainage Film, Lohmann & Rauscher International, Germany). The distal end of the tube is wrapped with only one layer of film. OFD is placed into the gastrointestinal leakage site with common endoscopic techniques. The tube is connected to an electronic vacuum device and continuous negative pressure of -125 mmHg applied.

 From 2013 to 2016, 16 patients were treated with the new OFD device. In 10 patients, transmural intestinal defects (4 esophageal, 4 rectum/colon, 1 duodenal, 1 pancreatic cyst) were closed with ENPT in median time of 12 days (range 3 - 34 days). Five of the 10 patients were treated solely with OFD devices. In five patients ENPT started with ODP and changed to OFD when the cavity was shrunken to a channel with a small opening. In four patients postoperative gastric reflux was eliminated for 5 to 16 days.

 Small-bore OFD opens up promising new treatment options within ENPT. OFD can be used in endoscopic closure management of intestinal leakages in the upper and lower gastrointestinal tract. Gastric reflux can be eliminated in an active manner. OFD can be inserted nasally. OFD may be an adequate substitute for OPD, especially when placement of the larger OPD is difficult.

The technique of active urinary endoscopic vacuum therapy (uEVT) is described. The surgical technique is demonstrated in detail with the help of a video of the operation, which is available online. Vesical fistulas are a rare complication following rectal surgery. The EVT technique is a novel method for the treatment of gastrointestinal leakage. This endoscopic procedure has been adapted to treat a large bladder defect after abdomino-perineal resection of the rectum with urine flowing out of the perineal wound.

A new open-pore film drainage (OFD) catheter with an external diameter of only a few millimeters was developed and constructed from a very thin open-pore double-layered film and a drainage tube. The OFD was inserted into the bladder by means of flexible endoscopy and channeled out through a suprapubic incision. Continuous suction was applied with an electronic vacuum pump to actively drain the urine completely. A passive catheter drainage of urine from the renal pelvis via a transurethral single J stent was carried out simultaneously during the complete duration of treatment. The healing process was monitored during and after therapy via intravesical endoscopy.

The application of continuous negative pressure via the OFD resulted in total collapse of the bladder. The urine in the bladder was actively and permanently drained through the OFD. Urine leakage from the perineal wound stopped immediately after induction of suction. The bladder defect healed after 18 days of treatment with uEVT. After therapy and removal of the catheters, the patient had normal micturition.

A novel small-bore OFD was developed for EVT. The OFD technique allows for endoscopic application of negative pressure in the bladder. This first successful experience proves uEVT to be a potent interventional alternative in the treatment of bladder defects.

The technique of active urinary endoscopic vacuum therapy (uEVT) is described. The surgical technique is demonstrated in detail with the help of a video of the operation and which is available online. Vesical fistulas are a rare complication following rectal surgery. The EVT technique is a novel method for treatment of gastrointestinal leakage. This endoscopic procedure has been adapted to treat a large bladder defect after abdominoperineal resection of the rectum with urine flowing out of the perineal wound.

A new open-pore film drainage (OFD) catheter with an external diameter of only a few millimeters has been developed and is constructed from a very thin open-pore double-layered film and a drainage tube. The OFD was inserted into the bladder by means of flexible endoscopy and channeled out through a suprapubic incision. Continuous suction was applied with an electronic vacuum pump to actively drain the urine completely. A passive catheter drainage of urine from the renal pelvis via transurethral single J stent was carried out simultaneously during the complete duration of treatment. The healing process was monitored during and after therapy by intravesical endoscopy.

The application of continuous negative pressure via the OFD resulted in total collapse of the bladder. The urine in the bladder was actively and permanently drained through the OFD. Urine leakage from the perineal wound stopped immediately after induction of suction. After 18 days of treatment with the uEVT the bladder defect was healed. After therapy and removal of the catheters the patient had normal micturition.

A novel small-bore OFD has been developed for EVT. The OFD technique now allows endoscopic application of negative pressure in the bladder. This first successful experience proves uEVT to be a potent interventional alternative in the treatment of bladder defects.