Should We Be Treating Postsurgical Leaks Endoscopically?

Postoperative leaks are difficult to treat; however, the evolution of therapeutic endoscopy has allowed less-invasive repair techniques in an attempt to avoid repeat surgery. This international, multicenter, retrospective study assessed the effectiveness of endoscopic therapy for upper gastrointestinal (UGI) postoperative leaks, evaluated associated adverse events (AEs), and identified factors associated with successful endoscopic therapy and AE occurrence.

The study from 10 institutions included 206 patients with postoperative leaks. The index surgeries were sleeve gastrectomy (39.3%), gastrectomy (23.8%), and esophagectomy (22.8%). A total of 775 therapeutic endoscopic procedures were performed, which included stenting, clipping, suturing, endoscopic vacuum therapy, endoscopic internal drainage, septotomy, and tissue sealant placement. Eighty-six patients additionally underwent surgery for attempted repair, jejunostomy placement, drainage, or washout. Surgical or percutaneous drain placement was additionally performed in 69.9% of the patients also underwent surgical or percutaneous drain placement; therefore, multimodality therapy was performed in 40.8% of the patients. The median time between the original surgery and the start of endoscopic therapy was 16 days. 

Endoscopic closure was achieved in 80.1% of the patients after a median follow-up of 52 days (interquartile range, 33-81.3). Factors associated with better outcomes included smaller leaks, hospitalization in the general ward as opposed to the intensive care unit, hemodynamic stability, absence of respiratory failure, previous gastrectomy, a fewer number of therapeutic endoscopies, shorter length of stay, and shorter times to leak closure. Of endoscopic-related AEs, 102 occurred in 81 patients (39.3%), and the majority were managed nonoperatively. The leak-related mortality rate was 12.4%.