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Purpose of review: Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric operations, but it is associated with a high rate of gallstone-related complications. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred therapeutic modality to treat choledocholithiasis; however, biliary access is compromised due to altered surgical anatomy after RYGB. Endoscopic ultrasound-guided transgastric ERCP (EDGE) is a recent endoscopic procedure developed to overcome this limitation. In this review, we discuss the recent literature surrounding technical and clinical considerations of the EDGE procedure and its prospects. Recent findings: The EDGE procedure has high technical and clinical success rates in the management of choledocholithiasis after RYGB. Long-term side effects related to the site of fistula creation, particularly weight regain and persistent fistula, are worrisome and require careful consideration during the procedure planning. As the procedure gains momentum, the scope of interventions has expanded to include several other indications beyond ERCP. Summary: EDGE is a safe and cost-effective endoscopic treatment modality in patients who have had RYGB. It has a higher technical success rate than device-assisted enteroscopy and comparable rate to laparoscopic-assisted ERCP with lower rate of adverse events. In expert hands and with proper patient selection, EDGE can save patients from more invasive interventions and decrease the burden on the healthcare system. [ABSTRACT FROM AUTHOR]

Background/Aim: Training endoscopists to perform endoscopic retrograde cholangiopancreatography (ERCP) is critical to address the increasing patient population with pancreatobiliary diseases. Concerns remain about ERCP safety and success involving trainees. We compared the technical success and immediate adverse events between ERCP with and without trainee involvement. Methods: Retrospective analysis of 28,271 ERCP procedures in a national sample of the United States over 12 years. Demographics, procedure and fluoroscopy time, visualization and cannulation of main structures, adverse events, and technical success rates were compared between ERCP with and without trainees. Categorical variables were compared using Pearson's chi-square test and continuous variables using a standard t-test. Univariate and multivariate regressions were performed adjusting for age, gender, ethnicity, US region, ASA class and clinical setting. Results: Approximately 49.5% of ERCPs had a trainee involved. The ampulla was visualized in 97.4% with trainee vs. 97.3% without trainee involvement (P = 0.858). The common bile duct was visualized and cannulated in 90.4% with trainees vs. 91.7% without trainees involved (P < 0.001). The ERCP was incomplete in 5.9% of cases with trainees vs. 6.4% without trainees involved (P = 0.207). Trainee participation added 8.7 min to average procedure time (aOR: 1.02, P < 0.001) and 2.0 min to fluoroscopy time (aOR: 1.00, P = 0.796). Adverse events (aOR: 0.89, P = 0.704) and technical success (aOR: 0.83, P = 0.571) were similar in both groups. Conclusions: Trainee involvement leads to increased procedure duration but is not associated with increased immediate adverse events, or technical failure. Our study supports ERCP safety and success with trainee participation. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery (BSx) is one of the most common surgical procedures performed in the USA. Nonetheless, data regarding 11-month period after BSx remain limited. Methods: A retrospective cohort study using the 2016 National Readmission Database. Adult patients admitted for BSx in January were included. The follow-up period was 11 months (February–December). The primary outcome was all-cause 11-month readmission. Secondary outcomes were index admission (IA) and readmission in-hospital mortality rate and healthcare resource use associated with readmission. Multivariate regression was performed to identify independent risk factors for readmission. Results: A total of 13,278 IA were included. The 11-month readmission rate was 11.1%. The mortality rate of readmission was 1.4% and 0.1% for IA (P < 0.01). The most common cause of readmission was hematemesis. Independent predictors were Charlson comorbidity index (CCI) score ≥ 3 (adjusted hazard ratio [aHR] 1.34; P = 0.05), increasing length of stay (aHR 1.01; P < 0.01), transfer to rehabilitation facilities (aHR 5.02; P < 0.01), undergoing laparoscopic Roux-en-Y gastric bypass (aHR 1.71; P = 0.02), adjustable gastric band (aHR 14.09; P < 0.01), alcohol use disorder (2.10; P = 0.01), and cannabis use disorder (aHR 3.37; P = 0.01). Private insurance as primary payer (aHR 0.65; P < 0.01) and BMI 45–49 kg/m2 (aHR 0.72; P < 0.01) were associated with less odds of readmission. The cumulative total hospitalization charges of readmission were $69.9 million. Conclusions: The 11-month readmission rate after BSx is 11.1%. Targeting modifiable predictors of readmission may help reduce the burden of readmissions on our healthcare system. [ABSTRACT FROM AUTHOR]

Background: The introduction of new technologies in endoscopy has been met with uncertainty, skepticism, and lack of standardization or training parameters, particularly when disruptive devices or techniques are involved. The widespread availability of a novel endoscopic suturing device (OverStitch™) for tissue apposition has enabled the development of applications of endoscopic suturing. Methods: The American Gastroenterological Association partnered with Apollo Endosurgery to develop a registry to capture in a pragmatic non-randomized study the safety, effectiveness, and durability of endoscopic suturing in approximating tissue in the setting of bariatric revision and fixation of endoprosthetic devices. Results: We highlight the challenges of the adoption of novel techniques by examining the process of developing and executing this multicenter registry to assess real-world use of this endoscopic suturing device. We also present our preliminary data on the safety and effectiveness of the novel device as it is applied in the treatment of obesity. Conclusions: The Prospective Registry for Trans-Orifice Endoscopic Suturing Applications (ES Registry) was an effective Phase 4, postmarketing registry aimed at capturing pragmatic, real-world use of a novel device. These findings serve to solidify the role of endoscopic suturing in clinical practice. [ABSTRACT FROM AUTHOR]

Background and Aims: As the pig model has similar gastrointestinal anatomy and physiology to humans, we used pigs to create a gastric mucosal devitalization (GMD) model in preparation for clinical translation of this technique as an endoscopic bariatric therapy (EBT). The aims of this study were to determine the ablation parameters and technique for a successful, safe, and feasible large surface area GMD that produces weight loss. Methods: We performed GMD using argon plasma coagulation (APC) in 3 phases. Phase 1 assessed the ablation energy required to accomplish selective mucosal ablation using ex vivo pig stomachs (n = 2). Phase 2 assessed the optimal percentage of mucosal surface area to be treated and was performed on 10 pigs. Phase 3 assessed feasibility, efficacy, and safety with 8 pigs randomized into GMD (n = 4) or sham (SH, n = 4) and survived for 1 month. Body weights (GMD, n = 4, SH, n = 4) were measured daily in phase 3 for 1 month, and relative body weights were calculated and analyzed using one-tailed Student's t-test. Percent body fat was compared between GMD and SH at baseline and 1 month post-GMD. Results: Phase 1 identified the optimal ablation parameters (120 W) that were then used in phase 2. Phase 2 revealed a trend that was suggestive that the optimal percent surface area to ablate was similar to that which is removed at laparoscopic sleeve gastrectomy. In phase 3, GMD was performed over 70% surface area of the greater curvature of the stomach in four pigs. GMD pigs had significantly lower relative body weight increase compared to SH at 1 month (1.375 ± 0.085 vs 1.575 ± 0.047, p = 0.0435). MRI showed a significantly lower body fat mass at 1 month in GMD pigs (5.9 ± 0.4% vs 12.7 ± 2.3%, p = 0.026) compared to SH. Conclusions: GMD resulted in decreased weight gain in the GMD group as evidenced by a lower relative body weight at 1 month. GMD in an animal model appears to show promise as a potential weight loss therapy. [ABSTRACT FROM AUTHOR]

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass. [ABSTRACT FROM AUTHOR]

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric surgery. Although considered a safe procedure, adverse events such as staple line leak in the context of sleeve stenosis can result in significant patient morbidity and health economic burden. Correction of the downstream stenosis is mandatory for closure of the staple line leak. Conventional endoscopic therapies offer high initial success rates, though ultimately a significant proportion proceed to revision surgery. Gastric per-oral endoscopic myotomy (G-POEM) is a novel, minimally invasive procedure which allows for a full-thickness myotomy of the stenosed segment, potentially conferring similar anatomical correction to surgical seromyotomy. We present a case of recalcitrant chronic proximal staple line leak in the context of a downstream gastric stenosis managed by G-POEM. [ABSTRACT FROM AUTHOR]

A dilated gastrojejunal anastomosis (GJA) diameter is an independent predictor of weight regain following Roux-en-Y gastric bypass (RYGB). Despite this, there is no standardized method for GJA diameter measurement. We performed a retrospective analysis to compare endoscopic visual estimation and endoluminal functional impedance planimetry (EndoFLIP) for measuring GJA diameter in patients with weight regain post-RYGB. Visual estimation was found to overestimate GJA diameter by a mean of 4.2mm ± 4.6mm when compared with EndoFLIP. Furthermore, we identified symptomatic patients with normal GJA diameter but increased distensibility, which may represent a previously unrecognized subgroup. Our findings suggest the potential utility of EndoFLIP in the evaluation of post-RYGB weight regain and support the need for prospective studies to investigate the relationship between GJA distensibility and weight regain [ABSTRACT FROM AUTHOR]

Gastrointestinal (GI) strictures are difficult to treat in a variety of disease processes. Currently, there are no Food and Drug Administration (FDA) approved drugs for fibrosis in the GI tract. One of the limitations to developing anti-fibrotic drugs has been the lack of a reproducible, relatively inexpensive, large animal model of fibrosis-driven luminal stricture. This study aimed to evaluate the feasibility of creating a model of luminal GI tract strictures. Argon plasma coagulation (APC) was applied circumferentially in porcine esophagi in vivo. Follow-up endoscopy (EGD) was performed at day 14 after the APC procedure. We noted high grade, benign esophageal strictures (n = 8). All 8 strictures resembled luminal GI fibrotic strictures in humans. These strictures were characterized, and then successfully dilated. A repeat EGD was performed at day 28 after the APC procedure and found evidence of recurrent, high grade, fibrotic, strictures at all 8 locations in all pigs. Pigs were sacrificed and gross and histologic analyses performed. Histologic examination showed extensive fibrosis, with significant collagen deposition in the lamina propria and submucosa, as well as extensive inflammatory infiltrates within the strictures. In conclusion, we report a porcine model of luminal GI fibrotic stricture that has the potential to assist with developing novel anti-fibrotic therapies as well as endoscopic techniques to address recurring fibrotic strictures in humans. [ABSTRACT FROM AUTHOR]

Purpose: Weight regain after balloon retrieval is a concern with all intra-gastric balloons (IGBs). The aim of this study was to evaluate the efficacy of liraglutide, a glucagon-like peptide-1 (GLP-1) agonist, to prevent weight regain following IGB retrieval. Materials and Methods: This was a case-matched study of patients undergoing Spatz3 adjustable IGB (Spatz FGIA, Inc. NY, USA) at three outpatient clinics in Brazil between November 2015 and January 2019. Seventy-seven patients that opted to take liraglutide following IGB retrieval (IGB-L) were matched 1:1 to 198 patients that declined the medication—IGB-Alone (IGB-A). Propensity score adjustment was performed at the time of balloon retrieval on factors known to influence the choice of liraglutide. Weight and percent body fat (%BF) was measured at baseline and 9 months after IGB retrieval. % BF is defined as the total mass of fat divided by total body mass, multiplied by 100. The primary outcome was weight regain, and the secondary outcome was change in %BF 9 months after IGB retrieval. Results: Propensity score matching yielded 53 matched pairs. Weight regain to the starting point was not observed in either group. There was significantly less weight regain in IGB-L compared to IGB-A, − 1.15 ± 0.94 kg versus − 0.66 ± 0.99 kg (p = 0.010) 9 months after balloon retrieval. Additionally, %BF decline in IGB-L was superior to IGB-A − 10.83 ± 1.50 versus − 7.94 ± 2.02 (p < 0.01). There was no difference in weight regain or decline in %BF based on liraglutide dose. Conclusion: Liraglutide has an additive benefit with respect to efficacy and a reduction in body fat when commenced after IGB retrieval. Future randomized control studies will be needed to determine the optimal dose and duration of liraglutide to achieve superior outcomes. [ABSTRACT FROM AUTHOR]

Background: Laterally spreading tumor (LST) is a type of precancerous lesion of colorectal cancer with high malignant potential. The present study aimed to evaluate long-term outcomes of endoscopic treatment for LST in Chinese patients. Methods: This study was a retrospective review of data collected from 653 included patients with LST from six regional representative hospitals in China between January 2007 and January 2017. Demographic characteristics, endoscopic features of LST, operation-related data, and follow-up results were collected and analyzed. Results: LST-granular type (LST-G, 80.3%) was much more common than LST-non-grandular type (LST-NG, 19.7%). The overall submucosal invasion rate of all LSTs was 6.1% and the submucosal invasion rate of LST-NG was significantly higher than that of LST-G (6.79% vs. 3.87%, p = 0.000). The en bloc resection rate of ESD and EMR treatment was 96% and 93.7%, respectively, with pathologic R0 resection rate of 90.1% and 82.8%. After an average duration of follow-up about 34.52 ± 11.76 months, the recurrence rate of ESD was 3.47%, and the recurrence rate of EMR was 8.8% after an average follow-up of about 38.44 ± 4.42 months. However, the recurrence rate of ESD was much lower than piecemeal EMR for LST (3.47% vs. 8.62%, p = 0.017). Retroflexion-assisted technique applied for resection of rectal LST was associated with a significantly shortened operating time (85.40 min vs. 174.18 min, p = 0.002). Conclusion: Endoscopic resection is a safe and efficient modality for the treatment of colorectal LST with a relatively low recurrence rate and shortened operating time with the use of retroflexion. [ABSTRACT FROM AUTHOR]

Purpose of Review: Obesity is a chronic relapsing disease that results in cardiovascular disease, diabetes mellitus, and non-alcoholic fatty liver disease. Currently, surgery represents the most effective treatment. However, the advent of minimally invasive endoscopic bariatric therapy (EBT) has shifted the treatment paradigm to less invasive, cost-effective procedures with minimal complications and recovery time that are preferred by patients. In this review, we will describe current and future EBTs, focusing on outcomes and safety. Recent Findings: The endoscope has provided an incisionless portal into the gastrointestinal tract for placement of space-occupying devices and intraluminal procedures. EBTs are no longer solely manipulating anatomic alterations; instead, they aim to improve metabolic parameters such as glycated hemoglobin, low-density lipoprotein, cholesterol, and hepatic indices by targeting the mucosal layer of the gastrointestinal tract. Summary: The endoscope has succeeded in facilitating clinically meaningful weight loss and improvement of metabolic parameters. Future, solutions to the obesity epidemic will likely entail genetic testing, evaluation of the microbiome, and delivery of personalized therapy, utilizing combination endoscopic modalities that change the anatomy and physiology of individual patients, with new targets such as the abnormal metabolic signal. [ABSTRACT FROM AUTHOR]

Background and Aims: Minimally invasive therapies for obesity are a bridge between lifestyle interventions and bariatric surgery. We developed a novel device to reduce weight gain rate and evaluated its safety and efficacy in juvenile pigs. Methods: The intragastric satiety-inducing device (ISD) comprises a self-expandable esophageal metal stent connected to a star-shaped disc placed in the stomach fundus. Eight juvenile pigs were randomized into ISD (n = 5) and control (n = 3) groups. Body weight and serum ghrelin hormone were monitored weekly for 6 weeks. One pig was followed up for 4 additional weeks (rebound pig) after ISD removal. Histological examination and immunohistochemistry for the interstitial cells of Cajal (ICCs) were performed. Results: ISD placement was successful in all pigs. Two ISDs (40%) migrated at 4 and 5 weeks after placement. Weight gain rates were significantly lower in the ISD group than in the control group from week 1 to 6 but were higher in the rebound pig than in a control pig from week 7 to 10. Mean ghrelin hormone level was higher in the control group than in the ISD group from week 1 to 6. ISD induced reversible inflammatory changes in the esophagus and stomach fundus. The number of ICCs was lesser in ISD pigs than in control and rebound pigs. Conclusions: ISD placement is feasible and safe in juvenile pigs. It decreases weight gain rate but induces reversible inflammatory reaction and tissue hyperplasia. Its mechanism may be related to pressure exertion on the stomach fundus or gastric motility alteration. [ABSTRACT FROM AUTHOR]

Purpose of review: Bariatric surgery and endoluminal bariatric therapies (EBTs) form an increasingly utilized therapeutic approach to treat obese patients but may worsen gastroesophageal reflux disease (GERD). In this updated article, we review the evidence on the effects of bariatric procedures on GERD. Findings: Recent evidence implicates sleeve gastrectomy with the highest rates of de novo GERD and Barrett's esophagus (BE), whereas malabsorptive-restrictive procedures such as Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) were shown to have significantly lower reported rates. The intragastric balloon (IGB) has been associated with increased likelihood of GERD, whereas insufficient evidence exists linking endoscopic sleeve gastroplasty (ESG) to GERD. Summary: Gastroesophageal reflux disease may be treated with some bariatric procedures but is often developed de novo as a result of the change in anatomy. Patients set to undergo bariatric surgery may benefit from pre-procedural endoscopy to choose the more suitable therapy. Further studies with objective measurements of GERD post procedure may provide more insight into the effects of bariatric therapies on reflux, especially more novel ones such as ESG. [ABSTRACT FROM AUTHOR]

Background and Aims: The mechanism of weight loss with the intra-gastric balloon (IGB) is thought to be a decrease in gastric emptying (GE); however the evidence is conflicting. Nausea, abdominal pain, and gastroesophageal reflux disease (GERD) can cause intolerance resulting in early removal. This is demoralizing for the patient and costly for the healthcare system. The ability to predict which patients will have superior weight loss and tolerance is invaluable. We sought to investigate if the IGB induced weight loss by reducing GE and the effect of the IGB on the DeMeester score. Methods: We retrospectively reviewed prospectively collected data for patients undergoing IGB placement at a single hospital. Manometry and pH studies were performed before and with the IGB in place. Weight was measured at baseline, at removal, and 6 months later. Adverse events leading to early removal were recorded. Results: Twenty-four patients were evaluated. There was a statistically significant decrease in GE for solids with the IGB (117.92 ± 150.23 vs 281.48 ± 206.49 min; p = 0.0048), but not for liquids (54.44 ± 17.97 vs 56.08 ± 43.96 min; p = 0.7228). The lower esophageal sphincter (LES) pressure did not change significantly with placement of the IGB (17.76 ± 7.39 vs 14.74 ± 7.24 mmHg; p = 0.09). On multivariate analysis, increase in DeMeester score was associated with total body weight loss (p = 0.0125) and change in GE (p = 0.038) independently. Conclusion: The IGB delays GE for solids, but not for liquids, and increases the DeMeester score by a mechanism other than a loss of LES pressure. [ABSTRACT FROM AUTHOR]

Background: The combination of intragastric balloons (IGB) with comprehensive lifestyle and behavioral changes is critical for ongoing weight loss. Many community and rural practices do not have access to robust obesity resources, limiting the use of IGBs. Online aftercare programs were developed in response to this need, delivering lifestyle coaching to maximize effectiveness. How these programs compare to traditional follow-up is currently unknown. Methods: Using propensity scoring (PS) methods, two large prospective databases of patients undergoing IGB therapy were compared to estimate the difference in percent total body weight loss (%TBWL) between groups while identifying predictors of response. Results: Seven hundred fifty-eight unique patients across 78 different participating practices (online n = 437; clinical registry n = 321) was analyzed. The mean %TBWL at balloon removal was 11% ± 6.9 with an estimated treatment difference (ETD) between online and traditional follow-up of − 1.5% TBWL (95% CI − 3–0.4%; p = 0.125). Three months post-balloon removal, the combined %TBWL was 12.2% ± 8.3 with an ETD of only 1% TBWL (95%CI – 3–3%; p = 0.08). On multivariable linear regression, each incremental follow-up was associated with increased %TBWL (β = 0.6% p = 0.002). Conclusion: Online IGB aftercare programs provide similar weight loss compared with traditional programs. Increased lifestyle coaching whether in person or remotely is associated with more %TBWL at removal and during follow-up. Close follow-up for clinical symptoms is still warranted. [ABSTRACT FROM AUTHOR]

Background: The use of fully covered self-expandable metallic stents (FCSEMS) has opened the door to treat stenosis in the post-bariatric stomach. We hypothesized that endoscopically securing a FCSEMS would be technically feasible, effective, and safe for > 30-day dwell time. Objectives: To assess the technical feasibility, clinical efficacy, and safety of endoscopically secured FCSEMS in the stomach for > 30 days. Methods: A retrospective review (September 2016 to April 2018) of consecutive patients who underwent FCSEMS suturing in the stomach at a single academic institution was reviewed. Technical success, stent dwell time, symptoms, and adverse events were recorded. Results: Fifteen patients (median age of 49 (31–70)) were included. Stents were inserted for gastrojejunal (GJ) stricture or gastric stenosis in 9/15 and 6/15 of patients, respectively. All procedures were technically successful (100%). Immediate and short-term clinical success (prior to stent removal) was 100% in patients who did not have stent migration. Stent migration was seen in 3 cases (20%) after a median dwell time of 211 days. However, 2/3 (66.6%) had not attended their scheduled removal. Recurrence of symptoms after stent removal was seen in 53.3% of patients with 40% undergoing repeat stenting. Median stent dwell was 117 (30–342) days. Sixty percent and 33% of patients had stent dwell of at least 90 and 180 days, respectively. Conclusions: A FCSEMS, if secured, may be safe and effective for even > 90-day dwell time in the post-bariatric stomach and may result in long-term clinical success for GJ stricture after stent removal. [ABSTRACT FROM AUTHOR]

New approaches for refractory stenosis in post-bariatric surgical patients include fully covered lumen-apposing metallic stents (LAMS); however, stent migration continues to be a problem. Endoscopic suture placement to LAMS can reduce the migration. Aiming to assess the feasibility and safety of the procedure, we evaluated nine consecutive patients with inability to tolerate a solid diet due to a benign gastrointestinal stricture recalcitrant to previous attempts at endoscopic therapy. All patients were symptom-free starting from 1-week follow-up. Median stent dwell time was nearly 3 months. During the removal procedures, three incidental foreign bodies were found and removed. No stent migration was observed in any patients. Suturing LAMS is a feasible technique allowing for prolonged stent dwell times; however, it requires a high level of expertise plus additional procedure time. [ABSTRACT FROM AUTHOR]

Laparoscopic sleeve gastrectomy (LSG) has become the most common form of bariatric surgery performed worldwide. However, it is associated with potentially debilitating adverse events such as post-operative stenosis. Finding effective and minimally invasive treatments for such complications is of paramount importance. Gastric per-oral endoscopic myotomy (G-POEM) is a novel procedure developed over the past decade to treat conditions that delay gastric emptying. We present a case demonstrating the use of G-POEM in the successful endoscopic management of post-LSG gastric stenosis. [ABSTRACT FROM AUTHOR]

Background and Aims: Transoral outlet reduction (TORe) by devitalization and/or endoscopic suturing (ES) has been implemented in the management of weight regain post-RYGB. This study aims to assess the efficacy and safety of TORe following an insurance-based algorithm. Methods: A prospectively maintained database of patients who underwent TORe between September 2015 and January 2018 at a single academic center was reviewed. An algorithm was followed whereby management was based on insurance coverage. As part of the algorithm, all patients presented for a repeat endoscopy at 8 weeks. Patients did not receive any diet, lifestyle intervention, or pharmacotherapy. Results: In total, 55 patients were included (median age 48 years), out of which 50 were females (90.9%). Patients presented for evaluation at a mean of 8.7 years post-RYGB. The main presenting symptom was combined dumping syndrome (DS) and weight regain (49.1%), followed by weight regain alone (45.5%). Twenty-nine patients required treatment at their second procedure, and 11 required treatment at their third procedure. Average percent total body weight loss (%TBWL) after TORe observed at 3-, 6-, 9-, and 12-month follow-up was 8.2, 9.3, 8.4, and 5.5%, respectively. The mean DS Severity Score was significantly reduced from 23.3 ± 12.4 before TORe to 16.3 ± 6.51 after TORe (p < 0.01). The adverse event rate from TORe was 14.5%. Conclusion: TORe is effective in halting ongoing weight regain and achieving moderate short-term weight loss as well as improving DS in post-RYGB patients. Durability at 1 year remains questionable due to weight recidivism. [ABSTRACT FROM AUTHOR]

Background: Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence.Aims: To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS).Methods: Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication.Results: Eleven patients (age range 31-60; all females) with mean BMI of 27.72 ± 5.93 kg/m2 underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3-120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported.Conclusion: Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU. [ABSTRACT FROM AUTHOR]

Objective: Endoscopic sleeve gastroplasty (ESG), an incisionless endoscopic bariatric procedure, has shown impressive results in case series. This study examines the reproducibility, efficacy, and safety in three centers across two countries, and identifies key determinants for procedural success.Design: Patients who underwent ESG between February 2016 and May 2017 at one of three centers (Australia and USA) were retrospectively analyzed. All procedures were performed on an outpatient basis using the Apollo OverStitch device (Apollo Endosurgery, Austin, TX). Primary outcomes included absolute weight loss (ΔWeight, kg), change in body mass index (∆BMI, in kg/m2), total body weight loss (TBWL, %), excess weight loss (EWL, in %), and immediate and delayed adverse events.Results: In total, 112 consecutive patients (male 31%, age 45.1 ± 11.7 years, baseline BMI 37.9 ± 6.7 kg/m2) underwent ESG. At 1, 3, and 6 months, Δweight was 9.0 ± 4.6 kg (TBWL 8.4 ± 4.1%), 12.9 ± 6.4 kg (TBWL 11.9 ± 4.5%), and 16.4 ± 10.7 kg (TBWL 14.9 ± 6.1%), respectively. The proportion of patients who attained greater than 10% TBWL and 25% EWL was 62.2 and 78.0% at 3 months post-ESG and 81.0 and 86.5% at 6 months post-ESG. Weight loss was similar between the three centers. Multivariable analysis showed that male sex, greater baseline body weight, and lack of prior endoscopic bariatric therapy were predictors of greater Δweight at 6 months. Three (2.7%) severe adverse events were observed.Conclusions: ESG is an effective, reproducible, and safe weight loss therapy that is suitable for widespread clinical adoption. [ABSTRACT FROM AUTHOR]

Background and Aims: Partially covered self-expandable metallic stents (PCSEMS), although an effective treatment for anastomotic/staple line leaks and strictures, can be difficult to remove. This study examines the effectiveness of the inversion technique for the removal of PCSEMS in the treatment of leaks and strictures that occurred post-sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Methods: Consecutive patients who underwent PCSEMS removal for a leak and/or stricture post-SG or RYGB between July 2013 and December 2016 at the Johns Hopkins Medical Institutions were reviewed. All PCSEMS removals were first attempted via the inversion technique, which involves grasping the distal end of the stent and inverting it through itself. Results: Fourteen patients (four males) underwent PCSEMS removal via the inversion technique for an anastomotic/staple line leak (50%), stricture (29%) or both (21%) post-SG (79%) or RYGB (21%). Technical success (successful removal of the stent) was achieved in one endoscopic session for 13 of the 14 PCSEMS (93%). One PCSEMS required the use of the stent-in-stent technique for removal. The median dwell time was 47 days (range 5-72). A distal partial occlusion developed in five patients (35%) due to tissue overgrowth and one PCSEMS (7%) migrated, necessitating premature removal. Eight patients (57%) experienced clinical success at follow-up, and six patients (43%) required subsequent treatment due to persistence or recurrence of the pathology. Conclusions: The inversion technique is a safe, effective, and efficient method of removing PCSEMS placed to correct anastomotic/staple line leaks and strictures post-SG and RYGB. [ABSTRACT FROM AUTHOR]

Background: Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG. Methods: Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB). Results: Total of 17 patients underwent a median of 2 (range 1-4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score ± SD, was in the following items: nausea (3 ± 1.9, P < 0.001), heartburn during day (2.8 ± 1.5, P = 0.003), heartburn on lying down (3.4 ± 1.4, P < 0.001), reflux during day (2.8 ± 1.9, P < 0.001), and reflux on lying down (3.0 ± 1.9, P < 0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB. Conclusions: Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB. [ABSTRACT FROM AUTHOR]

Background: Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy.Methods: A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded.Results: A total of 32 patients (mean age 54 years, Caucasian 81.6%, female 42.1%, mean BMI 25.4 kg/m2) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43 min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n = 31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation.Conclusion: TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic enteral stenting (ES) in malignant gastric outlet obstruction (GOO) is limited by high rates of stent obstruction. EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers sustained patency without tumor ingrowth/overgrowth. The aim of this study is to compare EUS-GE with ES in terms of (1) symptom recurrence and need for re-intervention, (2) technical success (proper stent positioning as determined via endoscopy and fluoroscopy), (3) clinical success (ability to tolerate oral intake without vomiting), and (4) procedure-related adverse events (AEs).Methods: Multicenter retrospective study of all consecutive patients who underwent either EUS-GE at four centers between 2013 and 2015 or ES at one center between 2008 and 2010.Results: A total of 82 patients (mean age 66-years ± 13.5 and 40.2% female) were identified: 30 in EUS-GE and 52 in ES. Technical and clinical success was not significantly different: 86.7% EUS-GE versus 94.2% ES (p = 0.2) and 83.3% EUS-GE versus 67.3% ES (p = 0.12), respectively. Symptom recurrence and need for re-intervention, however, was significantly lower in the EUS-GE group (4.0 vs. 28.6%, (p = 0.015). Post-procedure mean length of hospitalization was comparable at 11.3 days ± 6.6 for EUS-GE versus 9.5 days ± 8.3 for ES (p = 0.3). Rates and severity of AEs (as per the ASGE lexicon) were also similar (16.7 vs. 11.5%, p = 0.5). On multivariable analysis, ES was independently associated with need for re-intervention (OR 12.8, p = 0.027).Conclusion: EUS-GE may be ideal for malignant GOO with comparable effectiveness and safety to ES while being associated with fewer symptom recurrence and requirements for re-intervention. [ABSTRACT FROM AUTHOR]

Background and Aims: Spastic esophageal disorders (SEDs) include spastic achalasia (type III), diffuse esophageal spasm (DES), and nutcracker/jackhammer esophagus (JH). Per-oral endoscopic myotomy (POEM) has demonstrated efficacy and safety in the treatment of achalasia. Recently, POEM has been indicated for the treatment of SEDs. We conducted a systematic review and meta-analysis to determine the clinical success and safety of POEM in SEDs.Methods: We searched several databases from 01/01/2007 to 01/10/2016 to identify studies (with five or more patients) on POEM for the treatment of SEDs. Weighted pooled rates (WPRs) for clinical success and adverse events (AEs) were calculated for all SEDs. Clinical success was defined as Eckardt scores of ≤3 and/or improvement in severity of dysphagia based on achalasia disease-specific health-related quality of life questionnaire. The WPRs for clinical success and AEs were analyzed using fixed- or random-effects model based on heterogeneity. The proportionate difference in clinical success and post-procedure adverse event rates among individual types of SEDs was also calculated.Results: A total of eight observational studies with 179 patients were included in the final analysis. Two studies were of good quality and six were of fair quality based on the National Institutes of Health quality assessment tool. The WPR with 95% confidence interval (CI) for cumulative clinical success of POEM in all SEDs was 87% (78, 93%), I 2 = 37%. The total number of patients for individual disorders, i.e., type III achalasia, JH, and DES, was 116, 37, and 18, respectively. The WPRs for clinical success of POEM for type III achalasia, DES, and JH were 92, 88, and 72%, respectively. Proportion difference of WPR for clinical success was significantly higher for type III achalasia in comparison with JH (20%, P = 0.01). The WPR with 95% CI for AEs of POEM in all SEDs was 14% (9, 20%), I 2 = 0%. The WPRs for post-procedure adverse events for type III achalasia, DES, and JH were 11, 14, and 16%, respectively. There was no difference in safety of POEM among individual SEDs.Conclusion: POEM is an effective and safe therapeutic modality for the treatment of spastic esophageal disorders. [ABSTRACT FROM AUTHOR]

Background and Aims: To facilitate access for interventional EUS, flexible (nitinol) 19-G needles have been introduced to permit needle puncture even when the echoendoscope is in an angulated position, such as in the second part of the duodenum. The aims of the study were to evaluate the performance of a flexible 19-G needle during interventional EUS procedures and compare outcomes when the echoendoscope was in the straight versus angulated position.Methods: A retrospective review was undertaken of 162 consecutive patients that underwent a variety of interventional EUS procedures with a flexible 19-G needle across five centers. Patients were subdivided into categories (straight or angulated) depending on the echoendoscope position used for obtaining access to the area of interest (Fig. 1). Fig. 1 Flexible 19-G needle design. a The needle is able to exit the sheath despite the rotated position. b The needle beveled needle tip RESULTS: In the entire cohort, needle-specific technical success was achieved in 93.2 %, procedural success in 85.2 %, and overall clinical success in 76.5 % of cases at a mean follow-up of 3.1 months. Needle-specific technical success was similar between the straight and angulated cohorts (94.0 vs. 91.2 %, p = 0.74). Procedural success (86.7 vs. 77.2 %, p = 0.05), and rate of clinical success was similar between the cohorts (83.3 vs. 86.4 %, p = 0.79), respectively. Overall adverse events were noted in 14.2 % of patients with no difference between the straight and angulated cohorts (p = 0.48).Conclusions: This study demonstrates equivalent technical success, clinical success and safety of using a flexible 19-G needle in straight and angulated endoscope positions for interventional EUS. Therefore, a flexible needle may be considered where an angulated echoendoscope position is encountered. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to surgical myotomy. The endoluminal functional lumen imaging probe (endoFLIP) evaluates esophagogastric junction (EGJ) distensibility based on cross-sectional area and pressure in response to volume distension. The aim of this study was to evaluate whether there is a correlation between endoFLIP measurements during POEM and postoperative clinical outcomes in terms of symptom relief and development of post-procedure reflux.Methods: We conducted a retrospective review of achalasia patients who underwent POEM and intraoperative endoFLIP at three tertiary centers. Patients were divided into two groups based on clinical response measured by Eckardt score (ES): good response (ES < 3) or poor response (ES ≥ 3). Post-procedure reflux was defined as the presence of esophagitis and/or abnormal pH study. EGJ diameter, cross-sectional area, and distensibility measured by endoFLIP were compared.Results: Of the 63 treated patients, 50 had good and 13 had poor clinical response. The intraoperative final EGJ cross-sectional area was significantly higher in the good-response group versus poor-response group; median (interquartile range): 89.0 (78.5-106.7) versus 72.4 (48.8-80.0) mm(2) [p = 0.01]. The final EGJ cross-sectional area was also significantly higher in patients who had reflux esophagitis after POEM: 99.5 (91.2-103.7) versus 79.3 (57.1-94.2) mm(2) [p = 0.02].Conclusion: Intraoperative EGJ cross-sectional area during POEM for achalasia correlated with clinical response and post-procedure reflux. Impedance planimetry is a potentially important tool to guide the extent and adequacy of myotomy during POEM. [ABSTRACT FROM AUTHOR]

Background: Endoscopic therapy is considered first line for management of benign biliary strictures (BBSs). Placement of plastic stents has been effective but limited by their short-term patency and need for repeated procedures. Fully covered self-expandable metallic stents (FCSEMSs) offer longer-lasting biliary drainage without the need for frequent exchanges.Aims: The aim of this study was to assess the efficacy and safety of FCSEMS in patients with BBS.Methods: A retrospective review of all patients who underwent ERCP and FCSEMS placement at five tertiary referral US hospitals was performed. Stricture resolution and adverse events related to ERCP and/or stenting were recorded.Results: A total of 123 patients underwent FCSEMS placement for BBS and 112 underwent a subsequent follow-up ERCP. The mean age was 62 years (±15.6), and 57% were males. Stricture resolution occurred in 81% of patients after a mean of 1.2 stenting procedures (mean stent dwell time 24.4 ± 2.3 weeks), with a mean follow-up of 18.5 months. Stricture recurrence occurred in 5 patients, and 3 patients required surgery for treatment of refractory strictures. Stent migration (9.7%) was the most common complication, followed by stent occlusion (4.9%), cholangitis (4.1%), and pancreatitis (3.3%). There was one case of stent fracture during removal, and one stent could not be removed. There was one death due to cholangitis.Conclusions: Majority of BBS can be successfully managed with 1-2 consecutive FCSEMS with stent dwell time of 6 months. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic pharyngoesophageal perforations are a rare but serious complication of endoscopy. Surgical and non-surgical approaches have been reported but result in a significant morbidity and extended hospital stay. Therefore, an unmet need exists for an alternative management technique. We demonstrate a new endoscopic approach for the management of iatrogenic pharyngoesophageal perforations through the use of esophageal fully covered self-expandable metallic stents (FCSEMS). Patients and methods: Two patients who underwent flexible endoscopy each suffered a large iatrogenic perforation detected intraprocedurally. After emergency intubation, an esophageal FCSEMS was deployed in the hypopharynx and the patient admitted to the intensive care unit. On day 3, the patients underwent an esophagogastroduodenoscopy with stent removal. Results: There was complete closure of the perforations on day 3. The patients were extubated and subsequently tolerated a soft diet. The patients were discharged home on day 4. Conclusions: The placement of a removable FCSEMS in the setting of an acutely diagnosed perforation may be a suitable minimally invasive approach for the management of iatrogenic pharyngoesophageal perforations. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic ultrasound-guided biliary drainage (EGBD) may be a safe, alternative technique to percutaneous transhepatic biliary drainage (PTBD) in patients who fail ERCP. However, it is currently unknown how both techniques compare in terms of efficacy, safety, and cost. The aims of this study were to compare efficacy, safety, and cost of EGBD to that of PTBD. Methods: Jaundiced patients with distal malignant biliary obstruction who underwent EGBD or PTBD after failed ERCP were included. Technical success, clinical success, and adverse events between the two groups were compared. Results: A total of 73 patients with failed ERCP subsequently underwent EGBD ( n = 22) or PTBD ( n = 51). Although technical success was higher in the PTBD group (100 vs. 86.4 %, p = 0.007), clinical success was equivalent (92.2 vs. 86.4 %, p = 0.40). PTBD was associated with higher adverse event rate (index procedure: 39.2 vs. 18.2 %; all procedures including reinterventions: 80.4 vs. 15.7 %). Stent patency and survival were equivalent between both groups. Total charges were more than two times higher in the PTBD group ( p = 0.004) mainly due to significantly higher rate of reinterventions (80.4 vs. 15.7 %, p < 0.001). Conclusion: EGBD and PTBD are comparably effective techniques for treatment of distal malignant biliary obstruction after failed ERCP. However, EGBD is associated with decreased adverse events rate and is significantly less costly due to the need for fewer reinterventions. Our results suggest that EGBD should be the technique of choice for treatment of these patients at institutions with experienced interventional endosonographers. [ABSTRACT FROM AUTHOR]

Background: Marginal ulceration post Roux-en-Y gastric bypass (RYGB) with associated bleeding, although infrequently encountered, can be challenging to treat. Flexible endoscopic therapy is preferred over surgery due to its minimally invasive nature. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis, or clips. Here, we describe our treatment with endoscopic suturing for a massively bleeding marginal ulcer after RYGB. Methods: A 56-year-old female 10 days post RYGB underwent her fourth endoscopy for investigation and management of hematemesis and was found to have a large bleeding anastomotic ulcer. A Rothnet was utilized to remove large blood clots which obstructed endoscopic visualization. Two marginal ulcers were noted, and these were successfully oversewn with endoscopic suturing. The multimedia video (7 min) demonstrates the management of massively bleeding marginal ulcer after RYGB by endoscopic suturing. Results: Patient had no further bleeding and tolerated diet the subsequent day. She was discharged home with no further episodes of hematemesis, and follow-up at 6 weeks showed well-healed ulcer on endoscopy. Conclusion: Endoscopic suturing of a bleeding marginal ulcer appears technically feasible and safe. It should be considered in the treatment algorithm prior to emergency surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVES:There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia.METHODS:We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation 'on demand'. A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate.RESULTS:Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4 years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients.CONCLUSIONS:In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review. [ABSTRACT FROM AUTHOR]

Background: Acute (<24 h) staple line bleeding is not common but a known complication after bariatric surgery at a rate of 1-3 %. In most cases, acute postoperative bleeding is mild and can be managed conservatively. Nonetheless, there are times when massive hemorrhage is encountered. Endoscopic treatment of these patients within 24 h of Roux-en-Y (RYGB) is controversial, due to fear of staple line dehiscence and/or perforation. Therefore, most surgeons prefer to undergo diagnostic laparoscopy for exploration and treatment. However, it has been reported that laparoscopic management of acute bleeding can be technically challenging with a high rate of morbidity as well as conversion to laparotomy. We herein present a multimedia video (6 min) demonstrating the management of acute massive hemorrhage after RYGB. Methods: A 46-year-old female with hemodynamic instability after massive hematemesis and melena underwent endoscopy. An overtube was utilized to allow removal of large blood clots which obstructed endoscopic visualization. Two bleeding points were noted, and these were successfully treated with adrenaline and endoscopic clips. Results: The patient rapidly improved during her hospital stay and commenced oral intake on day 1. A surveillance endoscopy was performed on day 5, and no stigmata of recent bleeding was noted. She was discharged home and is progressing well. Conclusions: We suggest endoscopy is an appropriate first step for the investigation and management of acute intraluminal bleeding post bariatric surgery. [ABSTRACT FROM AUTHOR]

The article discusses a study to determine the role of high-risk human papillomavirus (hr-HPV) infection in the Barrett's metaplasia– dysplasia– adenocarcinoma sequence. It mentions that esophageal specimens positive for hr-HPV-16 obtained from 83 patients were used to examine viral load and integration status. The study revealed a potential role for hr-HPV in the pathogenesis of esophageal adenocarcinoma.

The name of author Vivek Kumbhari was misspelled in the original article. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction" which appeared in the previous issue.

The article presents a case study of a 72-year-old female with a 6-month history of iron deficiency anemia, abdominal pain, and imaging evidence of ileum's mural thickening. The study used a through-the-scope balloon catheter-assisted retrograde enteroscopy system to investigate the patient's condition.