Original article|Articles in Press

Endoscopic vacuum therapy as a first-line treatment option for gastric leaks after bariatric surgery: evidence from 10 years of experience

Published:February 14, 2023DOI:



      Gastric (anastomotic or staple-line) leaks after bariatric surgery are rare but potentially life-threatening complications. Endoscopic vacuum therapy (EVT) has evolved as the most promising treatment strategy for leaks associated with upper gastrointestinal surgery.


      The aim of this study was to evaluate the efficiency of our gastric leak management protocol in all bariatric patients over a 10-year period. Special emphasis was placed on EVT treatment and its outcome as a primary treatment or as a secondary treatment when other approaches failed.


      This study was performed at a tertiary clinic and certified center of reference for bariatric surgery.


      In this retrospective single-center cohort study, clinical outcomes of all consecutive patients after bariatric surgery from 2012 to 2021 are reported, with special emphasis placed on gastric leak treatment. The primary endpoint was successful leak closure. Secondary endpoints were overall complications (Clavien-Dindo classification) and length of stay.


      A total of 1046 patients underwent primary or revisional bariatric surgery, of whom 10 (1.0%) developed a postoperative gastric leak. Additionally, 7 patients were transferred for leak management after external bariatric surgery. Of these, 9 patients underwent primary and 8 patients underwent secondary EVT after futile surgical or endoscopic leak management. The efficacy of EVT was 100%, and there were no deaths. Complications did not differ between primary EVT and secondary treatment of leaks. Length of treatment was 17 days for primary EVT versus 61 days for secondary EVT (P = .015).


      EVT for gastric leaks after bariatric surgery led to rapid source control with a 100% success rate both as primary and secondary treatment. Early detection and primary EVT shortened treatment time and length of stay. This study underlines the potential of EVT as a first-line treatment strategy for gastric leaks after bariatric surgery.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benedix F.
        • Poranzke O.
        • Adolf D.
        • et al.
        Staple line leak after primary sleeve gastrectomy—risk factors and mid-term results: do patients still benefit from the weight loss procedure?.
        Obes Surg. 2017; 27: 1780-1788
        • Reimer S.
        • Seyfried F.
        • Flemming S.
        • et al.
        Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study.
        Surg Endosc. 2022; 36: 9169-9178
        • Jacobsen H.J.
        • Nergard B.J.
        • Leifsson B.G.
        • et al.
        Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-Y gastric bypass.
        Br J Surg. 2014; 101: 417-423
        • de Moura D.T.H.
        • de Moura B.F.B.H.
        • Manfredi M.A.
        • et al.
        Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects.
        World J Gastrointest Endosc. 2019; 11: 329-344
        • Eisendrath P.
        • Deviere J.
        Major complications of bariatric surgery: endoscopy as first-line treatment.
        Nat Rev Gastroenterol Hepatol. 2015; 12: 701-710
        • Seyfried F.
        • Reimer S.
        • Miras A.D.
        • et al.
        Successful treatment of a gastric leak after bariatric surgery using endoluminal vacuum therapy.
        Endoscopy. 2013; 45: E267-E268
        • Markus A.
        • Henrik B.J.
        • Benedikt R.
        • et al.
        Endoscopic vacuum therapy in salvage and standalone treatment of gastric leaks after bariatric surgery.
        Langenbecks Arch Surg. 2022; 407: 1039-1046
        • Morell B.
        • Murray F.
        • Vetter D.
        • Bueter M.
        • Gubler C.
        Endoscopic vacuum therapy (EVT) for early infradiaphragmal leakage after bariatric surgery-outcomes of six consecutive cases in a single institution.
        Langenbecks Arch Surg. 2019; 404: 115-121
        • Schmidt F.
        • Mennigen R.
        • Vowinkel T.
        • et al.
        Endoscopic vacuum therapy (EVT): a new concept for complication management in bariatric surgery.
        Obes Surg. 2017; 27: 2499-2505
        • Laopeamthong I.
        • Akethanin T.
        • Kasetsermwiriya W.
        • Techapongsatorn S.
        • Tansawet A.
        Vacuum therapy and internal drainage as the first-line endoscopic treatment for post-bariatric leaks: a systematic review and meta-analysis.
        Visc Med. 2022; 38: 63-71
        • Kuehn F.
        • Loske G.
        • Schiffmann L.
        • Gock M.
        • Klar E.
        Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract.
        Surg Endosc. 2017; 31: 3449-3458
        • Billmann F.
        • Pfeiffer A.
        • Sauer P.
        • et al.
        Endoscopic stent placement can successfully treat gastric leak following laparoscopic sleeve gastrectomy if and only if an esophagoduodenal megastent is used.
        Obes Surg. 2022; 32: 64-73
        • Gero D.
        • Vannijvel M.
        • Okkema S.
        • et al.
        Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional, and reversal procedures.
        Ann Surg. 2021; 274: 821-828
        • Flum D.R.
        • Belle S.H.
        • King W.C.
        • et al.
        Perioperative safety in the longitudinal assessment of bariatric surgery.
        N Engl J Med. 2009; 361: 445-454
        • Vanetta C.
        • Dreifuss N.H.
        • Schlottmann F.
        • Baz C.
        • Masrur M.A.
        Bariatric surgery conversions in MBSAQIP centers: current indications and outcomes.
        Obes Surg. 2022; 32: 3248-3256
        • Kamocka A.
        • McGlone E.R.
        • Pérez-Pevida B.
        • et al.
        Candy cane revision after Roux-en-Y gastric bypass.
        Surg Endosc. 2020; 34: 2076-2081
        • Stroh C.
        • Köckerling F.
        • Volker L.
        • et al.
        Obesity Surgery Working Group, Competence Network Obesity. Results of more than 11,800 sleeve gastrectomies: data analysis of the German Bariatric Surgery Registry.
        Ann Surg. 2016; 263: 949-955
        • Jaruvongvanich V.
        • Matar R.
        • Storm A.C.
        • et al.
        Endoscopic management of refractory leaks and fistulas after bariatric surgery with long-term follow-up.
        Surg Endosc. 2021; 35: 2715-2723
        • Rogalski P.
        • Swidnicka-Siergiejko A.
        • Wasielica-Berger J.
        • et al.
        Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis.
        Surg Endosc. 2021; 35: 1067-1087
        • Rayman S.
        • Staierman M.
        • Ben-David M.
        • et al.
        Laparoscopic revision to total gastrectomy or fistulo-jejunostomy as a definitive surgical procedure for chronic gastric fistula after laparoscopic sleeve gastrectomy.
        Surg Obes Relat Dis. 2020; 16: 1893-1900
        • Intriago J.M.V.
        • de Moura D.T.H.
        • do Monte Junior E.S.
        • et al.
        Endoscopic vacuum therapy (EVT) for the treatment of post-bariatric surgery leaks and fistulas: a systematic review and meta-analysis.
        Obes Surg. 2022; 32: 3435-3451
        • Rausa E.
        • Asti E.
        • Aiolfi A.
        • et al.
        Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis.
        Dis Esophagus. 2018; 31
        • Aburajab M.A.
        • Max J.B.
        • Ona M.A.
        • et al.
        Covered esophageal stenting is effective for symptomatic gastric lumen narrowing and related complications following laparoscopic sleeve gastrectomy.
        Dig Dis Sci. 2017; 62: 3077-3083
        • El-Sayes I.A.
        • Frenken M.
        • Weiner R.A.
        Management of leakage and stenosis after sleeve gastrectomy.
        Surgery. 2017; 162: 652-661
        • Garofalo F.
        • Noreau-Nguyen M.
        • Denis R.
        • et al.
        Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents.
        Surg Obes Relat Dis. 2017; 13: 925-932
        • Klimczak T.
        • Klimczak J.
        • Szewczyk T.
        • Janczak P.
        • Juralowicz P.
        Endoscopic treatment of leaks after laparoscopic sleeve gastrectomy using MEGA esophageal stents.
        Surg Endosc. 2018; 32: 2038-2045
        • Shehab H.
        Enteral stents in the management of post-bariatric surgery leaks.
        Surg Obes Relat Dis. 2018; 14: 393-403
        • Donatelli G.
        • Dumont J.L.
        • Dhumane P.
        • et al.
        Double pigtail stent insertion for healing of leaks following Roux-en-Y gastric bypass: our experience (with videos).
        Obes Surg. 2017; 27: 530-535
        • Gutschow C.A.
        • Schlag C.
        • Vetter D.
        Endoscopic vacuum therapy in the upper gastrointestinal tract: when and how to use it.
        Langenbecks Arch Surg. 2022; 407: 957-964
        • Leeds S.G.
        • Burdick J.S.
        Management of gastric leaks after sleeve gastrectomy with endoluminal vacuum (E-Vac) therapy.
        Surg Obes Relat Dis. 2016; 12: 1278-1285
        • Archid R.
        • Wichmann D.
        • Klingert W.
        • et al.
        Endoscopic vacuum therapy for staple line leaks after sleeve gastrectomy.
        Obes Surg. 2020; 30: 1310-1315