The Vac Stent system, combining the mechanical properties of self-expandable metal stents with endoluminal negative pressure therapy, has emerged as a promising option for the treatment of post-esophagectomy leaks. However, its role in the management of esophageal perforations following interventional endoscopy has not yet been clearly defined [1].

All consecutive patients with esophageal perforation after interventional endoscopic procedures treated with a Vac Stent at San Raffaele Hospital, Milan, between May 2024 and September 2025 were prospectively included. Placement was performed under fluoroscopic guidance and managed according to the manufacturer’s recommendations, including continuous negative pressure settings and predefined timing and modality of removal.

The primary outcome was clinical success, defined as complete closure of the perforation, confirmed by endoscopy, fluoroscopy, and/or CT imaging, along with clinical resolution of symptoms. Secondary outcomes included technical success (successful placement and removal of the Vac Stent), adverse events, total treatment duration, and length of hospital stay.

Five patients (4/5 male; median age 66 years, range 55–78) with esophageal perforation were included: four following endoscopic submucosal dissection (ESD) and one following 30-mm balloon dilation for type II achalasia. Histological analysis of the ESD specimens revealed adenocarcinoma in all cases. The mean maximum perforation size was 13 mm (range 5–30).

In three cases, post-procedural CT imaging demonstrated a leak-associated cavity, with a mean cavity size of 17 mm (range 12–24).

Clinical and technical success were achieved in 100% of cases. The mean total Vac Stent treatment duration was 11 days (range 6–14), with a mean of 1.6 devices per patient (range 1–2). The mean length of hospital stay was 19.4 days (range 7–33). No Vac Stent–related adverse events occurred, and no patient required surgical rescue therapy. Notably, the patient treated after a fully circumferential esophageal ESD did not develop post-procedural esophageal stricture.

In this prospective case series, Vac Stent therapy proved to be a safe and effective treatment for esophageal perforations following interventional endoscopy. In addition, it may contribute to the prevention of post-resection esophageal stricture after extensive mucosal resections. Larger, controlled studies are warranted to confirm these preliminary findings.