Transmural defects in the upper gastrointestinal (GI) tract are defined as a disruption or injury extending through all layers of the oesophageal or gastric wall [1]. These defects can result from various causes, including anastomotic leakage (AL) after oesophago-gastric surgery, iatrogenic perforation, Boerhaave syndrome or trauma. Transmural defects in the upper GI tract are associated with serious consequences, such as leakage of saliva, gastric contents and bile into the mediastinum, triggering an inflammatory response. Untreated or inadequately managed mediastinitis can lead to serious morbidity, sepsis and mortality. Therefore, timely diagnosis and treatment of these defects is crucial [2].

There are several treatment options for transmural defects in the upper GI tract. Conservative management involves a nil by mouth protocol, antibiotics and (percutaneous) drainage. Endoscopic treatments include self-expandable metallic stents (SEMS), through-the-scope clips, over-the-scope clips, suturing with overstitch, and most recently, endoscopic vacuum therapy (EVT) [2,3]. Historically, SEMS has been the most used treatment option for transmural defects in the upper GI tract. However, persisting leakage and complications such as dislocation of the stent are not uncommon [[4], [5], [6]]. Besides that, not all defects are suitable for stenting and additional percutaneous drainage is often necessary, but not always possible.

Surgical treatment, such as a re-anastomosis or resection of the gastric conduit with construction of a cervical esophagostomy is generally required in severely septic patients [2]. The choice of treatment depends on factors such as the location and size of the leakage, severity of symptoms, and presence of conduit ischemia or necrosis.

In the past decade, EVT has been established as an effective and safe endoscopic treatment option, and it was found to be superior in terms of success rate in AL healing compared to other treatments [[7], [8], [9], [10]].

However, the implementation of EVT in clinical practice might be hindered by multiple challenges and questions regarding indications and techniques. Sharing expertise on the topic, including mechanism, (contra)indications, procedures, types of EVT, comparison with other treatment options and how to overcome challenges could help facilitate implementation of EVT and avoid common mistakes in daily practice. To prevent centers from having to re-invent the wheel, it is very important to provide clear and accessible guidance on the technique.