Endoscopic Management of Postsurgical Complications

In surgery, less has sometimes proven to be more. As early as the late 1980s, the concept of managing postsurgical complications through minimally invasive techniques began gaining traction. Endoscopic and sonographically guided interventions have since evolved into critical components of modern complication management. With this paradigm shift, surgeons developed a growing interest in mastering endoscopic techniques themselves, ushering in a new era of interdisciplinary collaboration.

Today, endoscopy plays a pivotal role not only in the therapy but also in the early detection of complications. Contrary to long-held reservations, early postoperative endoscopy, particularly in experienced hands, poses no significant threat to anastomotic integrity. Instead, it offers the highest diagnostic yield in detecting anastomotic leaks and ischemic changes, often long before clinical deterioration becomes apparent [1].

Historically, the pioneering work by Heiner Groitl and coworkers [2] in 1987 laid the groundwork for endoscopic therapy. They introduced the instillation of fibrin sealant into abscess cavities, demonstrating promising healing rates and granulation formation even in complex upper gastrointestinal anastomotic leak cases. Follow-up studies reinforced the role of fibrin application, sometimes combined with Vicryl plugs, as a minimally invasive treatment option, particularly in high-risk or inoperable patients [3].

The next technological leap came with self-expanding covered metal stents. These devices provided coverage of leaks and restored luminal continuity, allowing for enteral nutrition, which is a critical factor in recovery. However, issues like stent migration and insufficient drainage of infected cavities prompted the search for alternative approaches. In this context, large over-the-scope clips emerged as a solution for small defects, offering improved closure over traditional hemoclips [4, 5].

The 2000s marked a breakthrough with the intraluminal application of vacuum therapy (EVT), initially adapted from open surgical techniques. First implemented in rectal leaks, EVT later found success in the upper gastrointestinal tract, offering a transformative, physiologically sound method for controlled granulation and drainage. Today, commercial systems exist for both upper and lower gastrointestinal applications [6–8]. Recent innovations in intraluminal suturing techniques offer further therapeutic potential, particularly in the early postoperative phase, though robust data are still forthcoming [9].

Beyond the esophagus and stomach, the biliopancreatic system presents unique challenges. The rise of laparoscopic cholecystectomy led to an initial surge in bile duct injuries, now routinely addressed via endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. After pancreatic resections, endosonographically guided drainages, transmural stent placement, and even EVT have become critical in managing pancreatic fistulas and fluid collections.

In metabolic and bariatric surgery, endoscopic strategies have adapted to altered anatomy and patient-specific comorbidities. Leaks at the angle of His or gastrojejunal anastomoses post-Roux-en-Y are now increasingly managed using endoluminal vacuum therapy or internal drainage with pigtail stents. These approaches emphasize pressure modulation and secondary wound healing, tailoring therapy to the unique physiological conditions of bariatric patients [10]. Endoscopic management of complications in pediatric patients remains constrained by anatomical limitations, but tailored solutions are emerging often requiring close coordination between pediatric surgeons and interventional endoscopists [11].

This special issue of Visceral Medicine addresses the nuanced and highly specialized role of endoscopy in the diagnosis and therapy of postsurgical complications across the full spectrum of visceral surgery. From esophageal anastomoses to biliopancreatic reconstructions and bariatric interventions, the articles in this issue reflect the evolution, evidence, and experience that shape this rapidly developing field.

The management of surgical complications has matured into a discipline of its own, where endoscopy is not merely an adjunct but a central, often definitive, therapeutic modality. This transformation underscores a core truth of modern medicine: interdisciplinary collaboration is not an option, it is a necessity.

Conflict of Interest Statement

M.E. received consultancy fees and study support by Boston Scientific, microtech, Fujifilm, and Olympus. J.B. is consultant by microtech GmbH.

Funding Sources

The study was supported by internal funding.

Author Contributions

J.B. and M.E.: literature research, data comparison, and writing of the manuscript. All authors approved the final version of the manuscript.

Funding Statement

The study was supported by internal funding.