Fatal cerebral gas embolism during endoluminal vacuum therapy for esophageal leak

Endoluminal vacuum therapy (EndoVAC/EVT) is widely used for managing esophageal anastomotic leaks, with high closure rates and a favorable safety profile compared with stent placement or surgical revision. Serious neurological complications associated with endoVAC treatment appear to be exceptionally rare.

We present the case of a 60-year-old patient who underwent open Ivor Lewis esophagectomy for pT2N0 esophageal adenocarcinoma. On postoperative day (POD) 8, fever and leukocytosis developed, and imaging confirmed an intrathoracic anastomotic leak. EVT was initiated on POD 12 with intracavitary sponge placement at - 80 mmHg continuous suction. Seven subsequent exchanges were uneventful, with progressive reduction of the leak cavity. On POD 37, during the eighth exchange using CO₂ insufflation, sudden neurological collapse occurred immediately after sponge removal and irrigation. Brain CT demonstrated extensive intracranial gas within supratentorial and infratentorial compartments, predominantly in the dural venous sinuses, with cerebral edema. The patient died six days later.

A plausible mechanism was retrograde venous gas embolization via the posterior mediastinum and Batson's plexus, facilitated by direct endoscopic access to the leak cavity. Preventive strategies include minimizing insufflation pressure, gentle irrigation, and careful reassessment of the need for continued intracavitary therapy.

This case of fatal cerebral gas embolism during EVT highlights an exceptionally rare and potentially catastrophic complication and the need for procedural vigilance.