S4449 Endoscopic Vacuum Therapy for Postoperative Esophageal Perforation: A Minimally Invasive Salvage Approach With Complete Healing

Introduction: Esophageal perforation remains a life-threatening complication with significant morbidity. Traditional management includes surgical repair or esophageal stenting, but each approach carries limitations—ranging from procedural morbidity to incomplete defect sealing and stent migration. Endoscopic vacuum therapy (EVT), a minimally invasive technique that applies negative pressure to a polyurethane sponge placed endoscopically, has emerged as a promising alternative. EVT promotes wound granulation, controls infection through continuous drainage, and enables real-time monitoring. Case Description/Methods: A 27-year-old woman with achalasia underwent laparoscopic Heller myotomy with Dor fundoplication. Postoperatively, she developed gastric content leakage through her drain. Imaging and esophagogastroduodenoscopy revealed a large distal esophageal defect with exposed intra-abdominal drains. She underwent relaparoscopy with drainage and jejunostomy, followed by an interdisciplinary decision to initiate EVT. A custom Endovac system was constructed using a duodenal tube and polypropylene sponge, exchanged every 3–5 days. Over 27 days, 7 EVT sessions were performed. Endoscopic reassessment showed progressive healing: initial wound edge debridement and granulation by session 1, near-complete defect closure with small residual fistulas by session 4, and full epithelialization with cicatricial remodeling by session 6. The patient resumed oral intake, was discharged in stable condition, and had a normal follow-up esophagogastroduodenoscopy at 2.5 months. Discussion: This case illustrates EVT’s value as a first-line salvage therapy for transmural esophageal defects. Compared to stents—which seal but do not drain—EVT achieves superior outcomes by simultaneously closing the defect and evacuating septic fluid. Recent meta-analyses cite EVT closure rates of 85–90%, exceeding the 70–78% success seen with esophageal stents. EVT is also associated with fewer adverse events and reduced mortality. Though it necessitates multiple endoscopic sessions and inpatient care, it has a favorable safety profile with low rates of strictures and bleeding. Early initiation correlates with higher success. Our patient’s complete healing without surgical revision underscores EVT’s potential to preserve esophageal integrity and avoid more invasive interventions. For gastroenterologists, especially those managing post-surgical leaks, EVT represents a paradigm shift in perforation care—minimally invasive, dynamic, and organ-sparing.