Experiencia con abordaje endoscópico de la dehiscencia esofagogástrica

Tratamiento endoscópico de la dehiscencia en cirugía esofagogástrica: experiencia en un centro de tercer nivel

Endoscopic Management of Anastomotic Dehiscence in Esophagogastric Surgery: Experience from a Tertiary Referral Center

J. Martínez Caballero*, B. Otero Torrón*, S. Fernández Noel*, C. Alegre Torrado*, D. Hernández García-Gallardo*, E. Rodríguez Cuellar*

* Servicio de Cirugía General, Aparato Digestivo y Trasplante de
     Órganos Abdominales. Unidad de Cirugía Colorrectal.
     Hospital Universitario 12 de Octubre. Madrid (España).

DOI: https://doi.org/10.14679/4567

Resumen:

Introducción: La dehiscencia anastomótica (DA) tras cirugía esofagogástrica ocurre hasta en 30% de los casos y se asocia a elevada morbimortalidad. La terapia endoluminal de vacío (TEV) y la prótesis metálica auto-expandible (SEMS) han surgido como alternativas terapéuticas, pero la evidencia comparativa todavía es limitada.
Material y Métodos: Estudio observacional, retrospectivo, unicéntrico (junio-2023/mayo-2025) que incluyó 10 pacientes con DA tratados endoscópicamente. Se analizaron la resolución de la fuga, reintervención quirúrgica, mortalidad intrahospitalaria y complicaciones a 90 días.
Resultados: Cinco pacientes recibieron TEV (80 % localizada la DA a nivel torácico) y cinco SEMS (80% localizada en el abdomen). La mediana del tamaño del defecto fue 6,5 mm; tres fugas afectaron >25 % de la circunferencia. La resolución completa fue superior con TEV (80 % vs 60 %). La duración del tratamiento fue similar (mediana 13 vs 16,5 días). La migración protésica ocurrió en 40 % de SEMS con una tasa de estenosis del 40% a los 90 días. No se registraron complicaciones relacionadas con la TEV. La mortalidad intrahospitalaria fue 20 % (TEV) y 40 % (SEMS).
Discusión: La TEV mostró mayor efectividad y menor tasa de complicaciones que la SEMS, en concordancia con la literatura. La selección del abordaje según localización y tamaño del defecto podría optimizar los resultados.
Conclusión: La TEV se asoció a mayor tasa de resolución, menor morbimortalidad y estancia en UCI frente a la SEMS. Estos hallazgos respaldan su uso preferente en DA seleccionadas y justifican ensayos prospectivos que definan algoritmos terapéuticos.
Palabras Clave: Dehiscencia anastomótica; Cirugía esofagogástrica; Terapia endoluminal de vacío; Prótesis metálica auto-expandible; Tratamiento endoscópico.

Abstract:

Introduction: Anastomotic leak (AL) after esophagogastric surgery occurs in up to 30 % of cases and carries high morbidity and mortality. Endoscopic vacuum therapy (EVT) and self-expanding metallic stents (SEMS) have emerged as alternatives to reoperation, but comparative evidence remains yet limited.
Materials and Methods: We conducted a single-center, retrospective observational study (June-2023/May-2025) including 10 patients with AL managed endoscopically. Primary outcomes were leakage closure, need for surgical re-intervention, in-hospital mortality, and 90-day complications.
Results: Five patients received EVT (thoracic location 80 %) and five SEMS (abdominal location 80 %). Median defect size was 6.5 mm; three leaks involved >25 % of the circumference. Complete closure was higher with EVT (80 % vs 60 %). Treatment duration was comparable (median 13 vs 16.5 days). Stent migration occurred in 40 % of SEMS, and stenosis rate was 40% at 90-day follow-up. No procedure-related complications were observed with EVT. In-hospital mortality was 20 % (EVT) and 40 % (SEMS).
Discussion: In this cohort, EVT achieved greater effectiveness and fewer complications than SEMS, consistent with published series. Selecting the endoscopic approach on the basis of leak location and size may improve outcomes.
Conclusion: EVT was associated with higher closure rate, shorter intensive care stay, fewer complications, and lower mortality than SEMS. These findings support preferential use of EVT in selected leaks and the development of individualized strategies validated in prospective registries.
Key words: Anastomotic leak; Esophagogastric surgery; Endoscopic vacuum therapy; Self-expanding metal stent; Endoscopic treatment.

Bibliografía

1. 1. 1. Joanna Hasson C& CC (2021) The European Oesophageal and Gastric Cancer Roadmap.
      2. Ajani JA, D’Amico TA, Bentrem DJ, et al (2023) Esophageal and Esophagogastric Junction Cancers, Version 2.2023. JNCCN Journal of the National Comprehensive Cancer Network 21:393–422
      3. Obermannová R, Alsina M, Cervantes A, Leong T, Lordick F, Nilsson M, van Grieken NCT, Vogel A, Smyth EC (2022) Oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Annals of Oncology 33:992–1004
      4. Griffiths EA (2022) Rates of Anastomotic Complications and Their Management Following Esophagectomy: Results of the Oesophago-Gastric Anastomosis Audit (OGAA). Ann Surg 275:E382–E391
      5. Lang H, Piso P, Stukenborg C, Raab R, Jähne J (2000) Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 26:168–171
      6. Schaheen L, Blackmon SH, Nason KS (2014) Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 536–543
      7. Verstegen MHP, Bouwense SAW, Van Workum F, Ten Broek R, Siersema PD, Rovers M, Rosman C Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer: a systematic review. https://doi.org/10.1186/s13017-019-0235-4
      8. Mennigen R, Harting C, Lindner K, Vowinkel T, Rijcken E, Palmes D, Senninger N, Laukoetter MG (2015) Comparison of Endoscopic Vacuum Therapy Versus Stent for Anastomotic Leak After Esophagectomy. Journal of Gastrointestinal Surgery 19:1229–1235
      9. Tavares G, Tustumi F, Tristão LS, Bernardo WM (2021) Endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy: a systematic review and meta-analysis. Diseases of the Esophagus. https://doi.org/10.1093/dote/doaa132
      10. Scognamiglio P, Reeh M, Melling N, et al (2022) Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting. BMC Surg. https://doi.org/10.1186/s12893-022-01764-z
      11. Scognamiglio P, Reeh M, Karstens K, Bellon E, Kantowski M, Schön G, Zapf A, Chon SH, Izbicki JR, Tachezy M (2020) Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis. Endoscopy 52:632–642Oliveira C, Pinheiro H, Figueiredo J, Seruca R, Carneiro F. Familial gastric
      12. Murray W, Davey MG, Robb W, Donlon NE (2024) Management of esophageal anastomotic leaks, a systematic review and network meta-analysis. Diseases of the Esophagus 37:1–7
      13. Mandarino FV, Barchi A, Leone L, et al (2023) Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endos 37:7039–7050
      14. Jung DH, Huh CW, Min YW, Park JC (2022) Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video). Gastrointest Endosc 95:281–290
      15. van den Berg MW, Kerbert AC, van Soest EJ, Schwartz MP, Bakker CM, Gilissen LPL, van Hooft JE (2016) Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula. Diseases of the Esophagus 29:572–579
      16. Anderloni A, Genco C, Massidda M, et al (2019) Self-Expanding Metal Stents for the Treatment of Post-Surgical Esophageal Leaks: A Tertiary Referral Center Experience. Dig Surg 36:309–316
      17. Ubels S, Verstegen M, Bouwense S, Klarenbeek B, van Workum F, Rosman C (2021) Commentary: endoscopic vacuum therapy for anastomotic leakage after esophagectomy and total gastrectomy: obstacles to finding true evidence. Diseases of the Esophagus. https://doi.org/10.1093/dote/doab023
      18. Ubels S, Verstegen MHP, Klarenbeek BR, et al (2023) Treatment of anastomotic leak after oesophagectomy for oesophageal cancer: large, collaborative, observational TENTACLE cohort study. Br J Surg 110:852
      19. Tachezy M, Chon SH, Rieck I, et al (2021) Endoscopic vacuum therapy versus stent treatment of esophageal anastomotic leaks (ESOLEAK): study protocol for a prospective randomized phase 2 trial. Trials. https://doi.org/10.1186/S13063-021-05315-4