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Latorre-Rodríguez et al. Mini-invasive Surg 2023;7:6 https://dx.doi.org/10.20517/2574-1225.2022.104 Page 5 of 10

SEMS are partially or fully covered metal prosthetic biomedical devices that can be placed endoscopically.
Their purpose is to cover the anastomotic defect while preserving an open lumen as the tissue is healing
[4]
[Figure 2] . SEMS have been used within the GI tract since 1990 for the management of biliary obstruction
of malignant origin [22,23] and are now widely used in the upper GI tract.

Clinical experience with the use of SEMS in the foregut is extensive; these devices are commonly used for
the palliative management of dysphagia in patients with malignant esophageal obstruction and for treating
esophageal ALs . In general, SEMS are an adequate alternative for the management of symptomatic
[24]
esophageal ALs for patients with symptomatic early ALs with < 70% esophageal diameter compromise
without sepsis or critical comorbidities if there is a viable conduit and drainage site [4,25] .

The clinical success rate associated with endoscopic management of ALs with SEMS is close to 85%, and
there is no statistically significant difference in the clinical success rate between fully covered and partially
covered SEMS (85% and 86%, respectively, P = 0.97) . The average healing time after SEMS placement is 4
[26]
to 8 weeks ; however, the result depends directly on the defect size and the time since diagnosis [4,16,28] . The
[27]
use of SEMS is recommended in small-to-medium diameter leaks with a smaller luminal opening size. On
the other hand, the use of this device for the management of proximal (cervical) esophageal ALs is related to
a higher risk of failure due to challenging fixation in the proximal esophagus . Healing of ALs uniformly
[4]
leads to strictures, but the use of stents may decrease the extent and prevalence of anastomotic strictures
associated with AL healing.

Complications related to the use of SEMS occur in 34% to 78% of patients. The highest risk is stent
migration, occurring in 16% to 62% of cases [26,28] ; other adverse events include post-extraction esophageal
stenosis, tissue overgrowth, enlargement of the anastomotic defect, bleeding, esophageal perforation,
tracheal perforation, vascular compression, discomfort, pain, fistula development, reflux, and aspiration
pneumonia [4,13] .

E-Vac is a more recent novel technique for the endoscopic management of esophageal ALs. Although this
technology was already widely used in the field of GI surgery for the management of intestinal perforations,
its use for the management of esophageal AL only began in 2005, with the first clinical trial results in
[29]
2010 .

E-Vac uses an endoscopically placed tube to administer negative pressure to the anastomotic leak location.
A polyurethane endosponge that provides suction and seals the leak cavity is located in the distal end of the
device, which is suitable for intracavitary or intraluminal placement [Figure 3] . Currently, the commercial
[30]
product Endo-SPONGE (B. Braun SE) is not widely available worldwide, including in the United States.
However, several centers in the U.S. have reported improvising the device with a wound-vac sponge
(GranuFoam; 3M) at the end of a nasogastric tube .
[31]

As the use of E-Vac for the management of esophageal ALs has increased, it has proven to be a safe
therapeutic option, and the reported clinical success in the closure of esophageal ALs is 67% to 78% [32,33] .
Studies on the prophylactic use of E-Vac have shown a reduction in the incidence of ALs after
esophagectomy [34,35] .

The use of E-Vac is indicated for but not limited to large ALs, early or late ALs, ALs with cavitary
collections, and symptomatic or asymptomatic patients in critical condition [4,30] . The endosponge should be
replaced every 3 to 4 days, and therapy must continue until the defect is corrected and there are no signs of