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Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1–6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.

Background/Aims: STRETTA improves the quality of life and reduces the need for anti-reflux medication in select patients, especially those with uncomplicated gastroesophageal reflux disease (GERD). We aimed to review the outcomes of STRETTA in patients with medically refractory GERD, who had undergone previous gastric surgery.Methods: This was a review of a prospective database in a British center. Since 2016, all GERD patients who underwent STRETTA and had a history of previous gastric surgery were studied (n=11). Anti-reflux medication pre- and post-STRETTA was evaluated. The outcomes were assessed objectively by the change in anti-reflux medication and subjectively through a pre- and post-procedure GERD-health-related quality of life (HRQL) questionnaire.Results: The median length of follow-up was 23 months. Nine patients demonstrated improved GERD-HRQL scores following STRETTA (82%). Of the 7 patients who underwent fundoplication, all reported improved symptoms, with 3 patients discontinuing the medication and 3 patients on a reduced dose of proton pump inhibitor. Four patients underwent surgery other than fundoplication, of which 2 reported improvement and discontinued the proton pump inhibitor. Two patients reported no improvement.Conclusions: This study demonstrates that STRETTA is successful in reducing refractory GERD in patients with previous gastric surgery. The outcomes were comparable to published outcomes in patients with uncomplicated GERD with no previous history of gastric surgery.

Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.

Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with perforations, the clinical prognosis will be affected, which can lead to legal issues. We describe here the proper approach to the management of perforations, including deciding on endoscopic or surgical treatment, selection of endoscopic devices, endoscopic closure procedures, and general management of perforations that occur during diagnostic or therapeutic colonoscopy. Clin Endosc 2020;53:29-36

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

Background/Aims STRETTA improves the quality of life and reduces the need for anti-reflux medication in select patients, especially those with uncomplicated gastroesophageal reflux disease (GERD). We aimed to review the outcomes of STRETTA in patients with medically refractory GERD, who had undergone previous gastric surgery. Methods This was a review of a prospective database in a British center. Since 2016, all GERD patients who underwent STRETTA and had a history of previous gastric surgery were studied (n=11). Anti-reflux medication pre- and post-STRETTA was evaluated. The outcomes were assessed objectively by the change in anti-reflux medication and subjectively through a pre- and post-procedure GERD-health-related quality of life (HRQL) questionnaire. Results The median length of follow-up was 23 months. Nine patients demonstrated improved GERD-HRQL scores following STRETTA (82%). Of the 7 patients who underwent fundoplication, all reported improved symptoms, with 3 patients discontinuing the medication and 3 patients on a reduced dose of proton pump inhibitor. Four patients underwent surgery other than fundoplication, of which 2 reported improvement and discontinued the proton pump inhibitor. Two patients reported no improvement. Conclusions This study demonstrates that STRETTA is successful in reducing refractory GERD in patients with previous gastric surgery. The outcomes were comparable to published outcomes in patients with uncomplicated GERD with no previous history of gastric surgery.

Anastomotic stricture (AS) is one of the complications of liver transplantation (LT) and can occur in up to 40% of living-donor LTs. Endoscopic management has become the first-line treatment of AS, and multiple plastic stents insertion has been mainly used in the past. Recently, many treatments utilizing fully covered self-expandable metal stents (cSEMSs) have been attempted, and results showing adequate treatment outcome have been reported. In this review, we look into the treatment performance and cautionary steps needed when using cSEMS as a treatment for AS.

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage. Clin Endosc 2020;53:255-260

Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through—(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

Submucosal tumors (SMTs) originate from tissues that constitute the submucosal layer and muscularis propria, and are covered by normal mucosa. Esophageal SMTs are rare, accounting for

Gastrointestinal (GI) leakage, fistulae, and perforations can be serious and life threatening. There has been a paradigm shift in the management approach of these conditions, from surgical to conservative, including endoscopic management. Here, we report two cases of endoscopic closure of a GI fistula and perforation using polyglycolic acid (PGA) sheets with fibrin glue. The first case is of an anastomotic leak detected after subtotal gastrectomy with gastroduodenostomy. After failed application of endoclips, a PGA sheet was applied, and the fistula was successfully closed. The second case was of a 15-mm large perforated gastric ulcer, which was also successfully closed with a PGA sheet. This is the first case report that PGA sheet was used for the treatment of overt perforation. The outcome of these cases suggest that endoscopic closure using PGA sheets can be considered as a useful alternative for the management of GI leakage, fistulae, and perforations.

Endoscopic treatment of biliary strictures involving plastic stent placement has been used widely. The use of self-expandable metal stents (SEMSs) has been described for anastomotic strictures following liver transplantation (LT). This review aimed to assess and compare the efficacy of plastic stents with SEMS in LT patients. Information was retrieved regarding technical success, stricture resolution, the number of endoscopic retrograde cholangiography procedures, follow-up, immediate, and late complications. Eight studies involving plastic stents had a stricture resolution rate of 84.5%, with the rates ranging from 63% to 100%. These rates are comparable with the stricture resolution rate of 75% determined from six studies that involved 236 patients who received metal stents and the rates ranged from 53% to 81%. The observed success rate for metal stents used to manage post-LT anastomotic biliary strictures was below the reported rate for multiple plastic stents. Hence, the currently available metal stents should not be offered for the management of post-LT anastomotic biliary strictures.

Endoscopic accessories describe an extensive variety of auxiliary instruments used for diagnostic and therapeutic endoscopy. Various endoscopic accessories have been developed over the previous few decades and are mostly used for treating neoplastic lesions, such as early gastrointestinal (GI) carcinomas and premalignant lesions. Because of extensive research on natural orifice endoluminal surgery (NOTES) in the early 2000s and recent technological developments, new devices have been developed for various advanced endoluminal therapeutic procedures. In particular, a remarkable development of endoscopic management was achieved in the field of gastroesophageal reflux disease (GERD) and obesity. In both conditions, there is treatment gap between medical and surgical therapy. A large proportion of the patients who do not respond to medical treatment and lifestyle modification, still hesitate to directly undergo surgical treatment. To bridge this gap, endoscopic management has been receiving increasing attention. In this article, I review endoscopic and/or endoluminal devices used for the treatment of GERD and obesity with proposed mechanisms of their function.

Pancreaticobiliary complications following various surgical procedures, including liver transplantation, are not uncommon and are important causes of morbidity and mortality. Therapeutic endoscopy plays a substantial role in these patients and can help to avoid the need for reoperation. However, the endoscopic approach in patients with surgically altered gastrointestinal (GI) anatomy is technically challenging because of the difficulty in entering the enteral limb to reach the target orifice to manage pancreaticobiliary complications. Additional procedural complexity is due to the need of special devices and accessories to obtain successful cannulation and absence of an elevator in forward-viewing endoscopes, which is frequently used in this situation. Once bilioenteric anastomosis is reached, the technical success rates achieved in expert hands approach those of patients with intact GI anatomy. The success of endoscopic therapy in patients with surgically altered GI anatomy depends on multiple factors, including the expertise of the endoscopist, understanding of postoperative anatomic changes, and the availability of suitable scopes and accessories for endoscopic management. In this issue of Clinical Endoscopy, the focused review series deals with pancreatobiliary endoscopy in altered GI anatomy such as bilioenteric anastomosis and post-gastrectomy. Clin Endosc 2016;49:502-505

Endoscopic procedures have been well-documented in the obesity field, but have not yet reached a sufficient level of evidence as stand-alone methods for treating obesity. It is unclear if they should take over. Although expanding, the array of bariatric surgical techniques does not fully meet the current needs, and there are not enough resources for increasing surgery. Surgery is avoided by a majority of patients, so that less aggressive procedures are necessary. For the time being, relevant endoscopic methods include intra-gastric balloons, gastric partitioning (Endo-plication), and the metabolic field (Endo-barrier). Surgical novelties and basic research are also important contributors owing to their potential combination with endoscopy. Conditions have been listed for implementation of bariatric endoscopy, because innovation is risky, expensive, and faces ethical challenges. A scientific background is being built (e.g., hormonal studies). Some techniques require additional study, while others are not ready but should be priorities. Steps and goals include the search for conceptual similarities and the respect of an ethical frame. Minimally invasive bariatric techniques are not ready for prime time, but they are already being successful as re-do procedures. A time-frame for step-strategies can be defined, and more investments from the industry are mandatory.

Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.

Acute upper gastrointestinal bleeding is a common medical emergency around the world and the major cause is peptic ulcer bleeding. Endoscopic treatment is fundamental for the management of peptic ulcer bleeding. Despite recent advances in endoscopic treatment, mortality from peptic ulcer bleeding has still remained high. This is because the disease often occurs in elderly patients with frequent comorbidities and are taking ulcerogenic medications. Therefore, the management of peptic ulcer bleeding is still a challenge for clinicians. This article reviews the various endoscopic methods available for management of peptic ulcer bleeding and the techniques in using these methods.

A Dieulafoy's lesion is a vascular abnormality consisting of a large caliber-persistent tortuous submucosal artery. A small mucosal defect with the eruption of this protruding vessel can cause bleeding. In fact, a Dieulafoy's lesion is a relatively rare but potentially life-threatening condition. It accounts for 1% to 2% of cases of acute gastrointestinal bleeding. Although there is no consensus on the treatment of Dieulafoy's lesions; treatment options depend on the mode of presentation, site of the lesion, and available expertise. Endoscopic therapy is usually successful in achieving primary hemostasis, with hemostasis success rates reaching 75% to 100%. Although various therapeutic endoscopic methods are used to control bleeding in Dieulafoy's lesions, the best method for endoscopic intervention is not clear. Combination endoscopic therapy is known to be superior to monotherapy because of a lower rate of recurrent bleeding. In addition, mechanical therapies including hemostatic clipping and endoscopic band ligation are more effective and successful in controlling bleeding than other endoscopic methods. Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion-from 80% to 8%-and consequently, the need for surgical intervention has been reduced. Currently, surgical intervention is used for cases that fail therapeutic endoscopic or angiographic interventions.

Although endoscopic hemostasis remains initial treatment modality for nonvariceal gastrointestinal (GI) bleeding, severe bleeding despite endoscopic management occurs in 5% to 10% of the patients, requiring surgery or transcatheter arterial embolization (TAE). TAE is now considered the first-line therapy for massive GI bleeding refractory to endoscopic management. GI endoscopists need to be familiar with indications, principles, outcomes, and complications of TAE, as well as embolic materials available.

Upper gastrointestinal (GI) endoscopy is the most basic part of endoscopy field. Although old and basic procedures are still in use, a line of innovative techniques and devices are being introduced to allow much complex and difficult procedures in endoscopy unit. High quality upper endoscopic procedures can replace or obviate surgical treatment. Selected reviews dealing with non-variceal upper GI bleeding, challenging esophageal stenting, endoscopic management of subpeithelial tumor, and endoscopic evaluation for candidate lesions of endoscopic submucosal dissection were selected among the topics from International Digestive Endoscopy Network 2012.

Mallory-Weiss tearing (MWT) is a common cause of non-variceal upper gastrointestinal bleeding. Although the majority of patients with bleeding MWT require no intervention other than hemodynamic supports, spectrum of MWT is wide, and the condition sometimes results in a fatal outcome. Endoscopic management to stop the bleeding may be required during the index endoscopy, especially in those with active bleeding or stigmata of recurrent bleeding. Most commonly used endoscopic treatment for actively bleeding MWT is injection therapy, argon plasma coagulation, hemoclip placement, and band ligation. Selection of the optimal endoscopic hemostasis depends on the physician's ability and patient's clinical status.

Background/Aims Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy. Methods A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented. Results Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae. Conclusions The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.

Rectal Dieulafoy's lesion (DL) is rare cause of lower gastrointestinal bleeding. Because of its rarity, there is no consensus on the optimal endoscopic hemostasis technique for rectal DL. We analyzed six patients who underwent endoscopic management for rectal DL after presenting with hematochezia at a single institute over 10 years. Of the six patients, three underwent endoscopic band ligation (EBL) and three underwent endoscopic hemoclip placement (EHP). Only one patient was treated with thermocoagulation. There were no immediate complications in any of the patients. None of the patients required a procedure or surgery for the treatment of rebleeding. Mean procedure times of EBL and EHP were 5.25 minutes and 7 minutes, respectively. Both EHP and EBL are shown to be effective in the treatment of bleeding rectal DL. We suggest that EBL may have potential as the preferred therapy owing to its superiority in technical and economic aspects, especially in elderly and high-risk patients.

Uneventful duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is an uncommon but occasionally fatal complication. ERCP-related perforations may occur during sphincterotomy and improper manipulation of the equipment and scope. Traditionally, duodenal perforation has been treated with early surgical repair. Recently, nonoperative early endoscopic management techniques including clips or fibrin glue have been reported. In the present paper we review the literature pertaining to the treatment of perforations.

Although there is no survival advantage, inoperable hilar cholangiocarcinoma managed by palliative drainage may benefit from symptomatic improvement. In general, biliary drainage is divided into endoscopic or percutaneous approaches and surgical drainage. Plastic or metal stent is the most preferred device for palliative drainage in endoscopic approach. Considering cost-effectiveness, use of metallic stent is preferred than plastic stents in patients with more than 3 months of life expectancy with inoperable malignant biliary obstruction. In patients with unresectable malignant hilar obstruction, the endoscopic approach with biliary stent placement by experts has been considered as the treatment of choice. However, the endoscopic management of hilar obstruction is often more challenging and complex than distal malignant biliary obstructions. There is still a lack of clear consensus on the use of plastic versus metal stents and unilateral versus bilateral drainage since the decision should be made under many grounds such as the volume of liver drainage more than 50%, life expectancy, and expertise of the facility.