This retrospective, single-center case series evaluated complex MBS complications’ management with EVT via pull-through technique and an alternative to common EVT placement. Over 7 years (01/2018-06/2025), 7 patients were treated with EVT for SLL or AL at the MUV, achieving successful leak closure in 6/7 (85.7%) cases. This is a sub-analysis of Gensthaler et al., who analyzed all patients, receiving EVT after MBS and observed a 95.2% success rate with EVT in a cohort of 21 patients [11], supporting EVT via pull-through technique as a favorable alternative to surgical reintervention or SEMS [8,9,10, 14]. It can be easily applied during or after surgical reintervention, if a targeted drainage is in place and close to the dehiscence. It’s safe and minimally invasive for managing hardly accessible leaks in in high-risk patients, allowing precise intracavitary placement and optimal drainage at anatomically challenging locations. It seems to be more effective in acute or early leakage, but this assumption may be influenced by the moment of diagnosis in this case series. Nevertheless, early detection, prompt intervention and opportunity for ICU admission remain essential and treatment of these complex patients should be centralized in specialized, high-volume MBS centers.

Patients in this case series represent a high-risk population regarding morbidity and mortality with severe obesity (mean BMI 43.8 kg/m²) and multiple obesity-associated comorbidities. All patients required ICU care due to sepsis, organ dysfunction or invasive monitoring and treatment. Similar to the results of this study, Kollmann et al. [15] described a 100% success of EVT for MBS leaks in 17 patients, emphasizing the feasibility of EVT in critically ill and complex patients and importance of specialized, high-volume MBS centers with ICU capability for managing complex postoperative complications.

Leaks mainly occurred within 1–6 days after index surgery (n = 6/7; 85.7%), with radiologic imaging showing high diagnostic reliability [16]. Delayed diagnosis was often associated with local peritonitis or abscess, emphasizing early diagnostic re-laparoscopy, when complication is suspected [10, 17].Therefore, careful postoperative monitoring and clinical follow-up is essential to detect complications early and prevent delay in diagnosis and therapy.

Median duration of pull-through EVT was similar to a meta-analysis by Intriago et al., but longer than in the publication by Gensthaler et al. with duration of 30.8 vs. 25.7 days and 9.6 vs. 6 device exchanges [18], suggesting that patients with pull-through EVT suffered from more complex and severe dehiscence [11]. The main therapeutic approach consisted of surgical reintervention combined with pull-through EVT placement at the MUV. In the larger EVT cohort published by Gensthaler et al., endoscopic treatment alone was sufficient in selected cases and should be considered on an individual basis. Main advantages include minimally invasive placement and ability to promote epithelialization in hardly accessible locations, particularly relevant in critically ill patients. Nevertheless, at outward MBS centers, SEMS was preferred (n = 2/3; 42.9%) and possibly delayed sufficient therapeutic approach, highlighting the importance for training to promote EVT usage on a low threshold in daily clinical practice [8]. Prompt EVT initiation, ideally at index endoscopy, can potentially reduce patient’s morbidity [11, 15, 19].

Despite effective leak control, overall morbidity and mortality remained high, reflecting the fragility of this cohort. All patients required ICU care (mean 43.9 days) and prolonged hospitalization (118.4 days), Table 1. One patient died at ICU due to pulmonary embolism (PE) and two during follow-up due to short bowel syndrome and acute kidney failure - none were directly linked to EVT but rather patient’s fragile/critically ill condition. Complete leak closure was achieved in 85.7%, confirming EVT’s efficacy in critically ill patients. Similar outcomes with 100% success were reported by Engelke et al. (2025) with pull-through EVT [19].

All procedures were performed by the same specialized surgical team, ensuring therapeutic consistency. EVT is safe, minimally invasive and a favorable alternative to surgery, with reduced morbidity and effective local leak control [18]. Optimized management at ICU/hospital stay with perioperative nutrition and physiotherapy optimizes outcome.

Limitations include the small, heterogeneous and multimorbid sample size, requiring individualized treatment approaches. Leak orifices and cavity size were not assessed routinely. EVT requires prolonged therapy and therefore patient compliance. A delay from diagnosis to EVT implementation was observed, suggesting earlier EVT implementation in these critically ill patients. Due to combined use of SEMS in some cases, it is difficult to attribute therapeutic success solely to pull-through EVT and has to be interpreted with caution.