Upper-GI postsurgical leaks are a major complication after esophagectomy, gastrectomy or bariatric surgery. Endoscopic techniques for leak management have evolved — from simple stent-based sealing toward strategies combining luminal coverage with cavity drainage and negative-pressure therapy. Among these, three widely adopted methods are: (1) fully covered self-expanding metal stents (FCSEMS) combined with naso-cavitary drainage (NTCD), (2) endoscopic vacuum therapy (EVT) using sponge devices (e.g., EsoSponge), and (3) hybrid systems combining stent and vacuum therapy such as VACStent. A missing datum in the available literature is to establish a correct rationale in terms of selected ideal indications to  understand their real efficacy and limitations.

A retrospective study to evaluate the efficacy related to predecided indications was performed and data on technical and clinical successes of our cohorts were compared to the ones available in the international literature. The pre-established indication were based on the morphology of the leak: FCSEMS+ naso-cavitary drainage was used to treat dehiescence associated with not-drained cavity with or without fistolous tract, EsoSponge EVT was used in case of wide paraluminal cavity, and VACStent was used for early detected leaks without paraluminal collections or well-drained paraluminal collections. Data on the three groups were compared in terms of clinical success and timing to complete closure of the leak.

A total of 110 patients were included in the present study, 53 with gastric leaks and 57 with esophageal leaks, from 2018 to november 2025

97 patients were treated with FCSEMS + NTCD, 5 with gastric leak and 92 with esophageal leak. This technique provides leak coverage while allowing drainage of the external collection. In 89 patients, an intrastent naso-luminal tube in continuos suction was placed. Reported clinical success (leak closure) rates range between 60–80%. Our technical success was 100% while clinical success was 90%. Mean time for closure was 21 days.

10 patients were treated by EVT, 2 with gastric leak, 8 with esophageal leaks. EVT exerts continuous negative-pressure therapy that promotes collapse of the leak cavity, granulation tissue formation, and closure. Several series report closure rates of 75–95%. Our technical success was 100% and clinical success was 100% in our case series. Mean time for closure was 32 days.

Remaning 3 patients were treated by VACStent. Two patients had esophageal leaks, 1 patient had gastric leak post-bariatric surgery. By combining a fully covered stent with an external vacuum sponge, VACStent offers internal drainage plus maintenance of luminal patency. Early clinical reports indicate closure rates around 80–90%. Our technical success was 100% but clinical success was 67% with significant lower time to closure than standard stenting (7 days vs 21 days).

From comparison of the three technqiues, technical success was not different while clinical success was not statistically different between FCSEMS+NTCD (p=0,8). However, clinical success of VAC stent was statistically lower than the other tecniques (p<0,01). This finding can be limited by small case series both in EVT and VACStent group.

On the other hand, the VACStent when successful, has the most rapid time to closure (p<0,05). The other two techniques showed no statistically different time to closure (p=0,09).

Tailored endoscopic management of upper-GI postsurgical leaks can be effectively improved by the study of leak morphology, size of leak cavity, and patient condition. FCSEMS + NTCD remains an option for leaks with not well-drained collections; EVT is preferred when rapid cavity collapse and granulation of parluminal cavities are required; and VACStent appears as a promising hybrid in case of early detected leaks. Prospective multicentric larger comparative studies are warranted to define standardized treatment algorithms and identify predictors of success and failure for each modality.