Integrating Endoscopic Vacuum Therapy into a Staged Management Pathway for Colorectal Anastomotic Leak: A Linked Retrospective Cohort Study

Background: Endoscopic vacuum therapy (EVT) is increasingly used for colorectal anastomotic leaks (AL), but its role within the preceding operative and clinical course remains poorly defined. We described EVT as part of a staged, time-centered pathway anchored to the index operation. Methods: This retrospective single-center cohort linked a colorectal resection database with an EVT registry. AL was classified by ISREC grade and by anastomotic height, circumferential extent, and initial sponge count. The index operation, including intraoperative colonoscopy (IOC) when performed, was defined as time zero. Results: Among 422 left-sided colorectal or rectal resections, 38 early AL occurred (9.0%): 9 ISREC A (23.7%), 11 B (28.9%), and 18 C (47.4%). IOC was performed in 26/38 patients (68.4%); 19/26 (73.1%) had a well-constructed anastomosis at the index operation. EVT was used in 17/38 patients (44.7%) (10 ISREC B and 7 C). Morphology was available in 14/17 (82.4%): median anastomotic height was 8 cm (IQR, 6–10), 13/14 defects (92.9%) were posterior or posterolateral, and 8/14 (57.1%) involved ≥50% of the circumference. Pelvic peritoneal closure was present in 15/17 EVT-treated patients (88.2%). No EVT-related complications occurred, and 11/17 patients (64.7%) had a restorative outcome. Conclusions: EVT was used mainly for ISREC B leaks and selected ISREC C leaks after operative source control. Linking defect morphology, EVT sessions, and clinical endpoints to the index operation frames EVT as one component of a staged management pathway rather than an isolated endoscopic intervention.