Endoscopic internal drainage versus endoscopic vacuum therapy for upper gastrointestinal leaks: what's the real deal?

We read with great interest the article by Jung et al. [1] on their retrospective comparison between endoscopic internal drainage (EID) and endoscopic vacuum therapy (EVT) in the treatment of postsurgical upper gastrointestinal anastomotic leaks. The EID technique showed a higher success rate than EVT (100% vs. 85.2%; P=0.003), does not require constant hospitalization, and was associated with fewer procedures [1], which means a lower cost burden and less anesthetic risk from repeated procedures [2]. Nevertheless, some aspects of the study offer us reason to question these findings. Firstly, the two cohorts of patients were not treated homogeneously, with each center performing only one type of endoscopic treatment. Differences in surgical expertise, patient selection, and endoscopic approach in the different centers could easily have influenced the results. Additionally, the median number of days from surgery to diagnosis was considerably lower for the leaks treated with EID (2 days) than for those treated with EVT (10 days), suggesting that more complex and advanced leaks were present in the EVT group, which could explain both its lower efficacy and higher mortality rate (7.4% versus 0%). Moreover, even if the leaks were homogeneous, data on the efficacy of EID based on size, particularly for the largest leaks (> 20mm), were not reported. In fact, the literature suggests EVT to be the “go-to” approach for larger anastomotic leaks owing to the feasibility of intracavitary placement of the sponge [3]. Our greatest concern is, however, about the EVT technique itself. The authors reported the use of EVT with very low negative pressure applied by the suction pump (between –20 and –50mmHg). In the largest studies on EVT, the mean negative pressure gradients applied have ranged from –80 to –125mmHg, and the use of even higher gradients, with similar outcomes in terms of efficacy and complications, have also been described [4]. This discrepancy could have seriously affected the efficacy of EVT. These concerns highlight the need for larger prospective comparative studies on the endoscopic approaches to upper gastrointestinal anastomotic leaks to standardize the endoscopic work-up of postsurgical complications.