Endoscopic Management of Anastomotic Insufficiencies in the Lower GI Tract

Background: Anastomotic leaks and fistulas are a feared and challenging postoperative complication in colorectal surgery. Traditionally managed with protective ileostomy and revisional surgery, less-invasive endoscopic approaches are increasingly being utilized. Summary: This article provides a comprehensive overview of current endoscopic treatment principles for managing anastomotic leaks after colorectal surgery. These approaches can be categorized into three main strategies: endoscopic negative pressure therapy - using negative pressure via polyurethane foam drains to promote wound healing and drain secretions; direct closure techniques - including endoscopic suturing systems (e.g., OverStitch) and clipping devices (e.g., over-the-scope clip) to approximate tissue and close defects; and vacuum stenting - a hybrid approach that combines negative pressure therapy with defect coverage using a covered self-expanding metal mesh stent (VAC-stent). Each method offers unique advantages depending on the leak characteristics and timing of detection. Early diagnosis and individualized treatment selection are critical to successful outcomes. Key Messages: Endoscopic treatment of anastomotic insufficiencies represents a minimally invasive, effective and safe alternative to traditional surgical interventions, particularly in clinically stable patients.