Relay therapy with endovac and endoscopic stents for anastomotic leaks after minimally invasive esophagectomy

Background: Esophagectomy with gastric pull up is the most commonly performed surgical treatment for esophageal cancer. Esophagogastric anastomosis leak (EAL) is one of the most frequent and feared complications after esophagectomy. While there is a broad therapeutic spectrum from conservative endoscopic to surgical options, a precise therapeutic algorithm has not been clearly established. There are no reports in the literature of combined endoscopic vacuum therapy (EVT) and fully covered self -expanding metal stents (FSEMS) in subsequent steps (relay therapy). Methods: Six patients were treated with relay therapy (RT) for EAL after minimally invasive esophagectomy. We described the RT approach and evaluated time of EVT start, number of vacuum system changes, time of FSEMS placement, time to final healing, ICU and hospital stay, morbidity and mortality rates, and stricture rate with follow-up at 6 months. Results: The median time of EAL appearance was 2 (IQR 2-2.75) days. EVT was completed in all patients (6/6) after an average of 7 (IQR 6.5-7.75) days, requiring 2 (IQR 2-2.75) endoscopic vacuum system changes. The time of FSEMS placement was 7.1 days (IQR 6-8.25). The median time to final healing was 19.5 (IQR 17-21.5) days, and one patient required reoperation (anastomotic dehiscence and empyema). There were no complications directly related to the use of RT. The median length of stay was 16.5 (IQR 13-28) days. Anastomotic stricture occurred in 2/6 patients (33.3%). Conclusions: RT is a promising new approach for upper gastrointestinal leaks management, demonstrating that it is a safe and effective treatment for postoperative anastomotic leaks after IL-MIE.