Aortic hemorrhage following anastomotic leakage after esophagogastric surgery before and after implementation of endoscopic vacuum therapy

Background: Endoscopic vacuum therapy (EVT) has been established as a safe and effective treatment for anastomotic leakage. While rare, major aortic hemorrhage has been reported as a severe complication potentially associated with EVT. However, significant hemorrhages have also been observed in patients with transmural defects in the upper gastrointestinal tract, without the use of EVT. This raises questions about the role of EVT as a direct cause of aortic hemorrhage. Methods: The objective of this study was to further investigate the incidence of major aortic hemorrhage in patients with anastomotic leakage following esophagectomy, both before and after the introduction of EVT. This case series included all patients who experienced an aortic hemorrhage after an anastomotic leak over an 11-year period (January 2013–December 2023). Patients were identified from a prospectively maintained database at Amsterdam UMC and were categorized into two groups: the pre-EVT period and the EVT period. Results: In the pre-EVT period, 355 patients underwent a transthoracic esophagectomy, with 62 (17%) developing anastomotic leakage. In the EVT period, 527 patients underwent the same procedure, with 83 (16%) anastomotic leakages. A total of 7 patients developed a major aortic hemorrhage: 5 in the pre-EVT period (12%) and 2 in the EVT period (2%). Conclusion: Although EVT has been proposed in literature as a potential cause of major aortic hemorrhage, our findings provide a more nuanced perspective. In this cohort, aortic hemorrhages tend to occur in case of severe mediastinitis, also without treatment with EVT.