Reply to Danese et al.

We thank Prof. Danese and colleagues for their comments on our article [1]. As noted, bias pertaining to the surgical and endoscopic expertise of each center is indeed a concern and multicenter studies could help in attenuating this bias. Here, the treatment choices were down to the poor availability of endoscopic vacuum therapy (EVT) in France, coupled with the experience in endoscopic internal drainage (EID), as opposed to the high expertise in EVT in Germany. As co-morbidity and leak sizes were well balanced in both groups, the anatomic site of the leaks (intrathoracic vs. intraabdominal) and prior chemoradiotherapy could explain the inferior treatment success observed in the EVT group. Indeed, the EVT cohort hadmore patients with intrathoracic leaks (70.4% vs. 60.0%) and more patients treated with neoadjuvant chemoradiotherapy (40.7% vs. 8.0%). The characteristics of the negative pressure used in EVT are still a point of debate. No studies comparing the different pressure levels have been published in humans. Our own experience has shown comparable results between low negative pressure and −125mmHg EVT [2]. Low negative-pressure EVT most likely works by deviating the biologic fluids (bile, gastric and pancreatic juice) away from the anastomotic site. Recently, Loske et al. confirmed the crucial role of gastroesophageal reflux in the development of anastomotic leaks by showing the efficacy of pre-emptive active drainage of reflux in patients with Ivor Lewis esophagectomy [3]. As stressed by Danese et al., for leaks of > 20mm, EID may not be the best option, because the double-pigtail stents can migrate through the anastomotic dehiscence: initial EVT or a self-expandable metal stent (SEMS) is therefore advisable in this situation [4]. We cannot but agree on the need for large prospective multicenter studies on the endoscopic treatments for anastomotic leaks in order to determine the respective efficacy of different negative pressures in EVT, and the optimal treatment sequences.