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septotomy in combination with aggressive axis rectification using achalasia balloons. Septotomy procedures
have better results in abscess with larger cavities. For linear abscess in which a septum dividing the lumen
and the abscess cavity is small or minimal, we opt to use a pigtail catheter to control the abscess with
endoluminal drainage. Unfortunately, some cases end up in esophagojejunostomy operations.

Double-Pigtail stent
Another technique available for late and chronic leaks that has gained more popularity over the recent years
due to its safety, efficacy, lower cost, and good tolerance is the use of double pigtail stents. The procedure
is performed by advancing a guidewire into the communicating collection under fluoroscopic guidance.
Once the guidewire is in place, a double-pigtail stent is placed, which allows drainage of the abscess into
[24]
the gastric cavity . A systematic review included 385 patients with gastric leak after sleeve gastrectomy
that were treated with double-pigtail stents as a primary or secondary procedure. The success rate of leak
resolution by using the double-pigtail stent as a first-line therapy or as a rescue therapy was 84.71% and
78.05%, respectively. The study also reported a complication rate of 13.73%, the most common being
drainage migration. Furthermore, the authors conclude that this technique has proven to be efficient and
[24]
well-tolerated, with the additional benefit of reducing costs by having a shorter length of stay .
Endoscopic vacuum therapy
Endoscopic vacuum therapy (EVT) is a technique that is increasingly used among surgeons and
endoscopists to treat leaks. The procedure consists of the placement of a sponge drainage system into the
perigastric cavity, which drains the content of the leak by applying negative pressure. This system can be
[46]
placed intracavitary or within the stomach lumen at the entrance to the perigastric cavity [46,47] . Archid et al.
reported 8 patients who developed a staple line leak following sleeve gastrectomy that were treated with
EVT. The leak resolved completely in seven of the eight cases, representing an 87.5% success rate. Only
one complication was reported in a patient who developed bleeding from a short gastric vessel. A study
developed an online survey to evaluate the current practice of international expert therapeutic endoscopists
regarding the management of upper gastrointestinal leaks. The study showed that EVT allowed for
[42]
adequate drainage of the cavity and warranted granulation . One major limitation of this procedure is that
the sponge needs to be replaced every 3 to 5 days [42,47] . Nonetheless, EVT is a safe and feasible approach for
leak management.

Weight regain
Weight regain or insufficient weight loss can be challenging to manage and involves a thorough
multifactorial and multidisciplinary evaluation. In our center we start with endoscopic and imaging (UGI)
evaluation to assess for complications. In particular, we assess for gastrojejunal dilation, pouch dilation,
gastro-gastro fistulae, etc. All patients undergo nutritional and psychological evaluation to modify habits
and behaviors. Occasionally, pharmacotherapy is added to the treatment in order to maximize success.

There are several endoscopic options to manage weight regain. The gastrojejunal anastomosis size can be
reduced in order to maximize restriction. Transoral outlet reduction (TORe), aims to reduce the size of the
anastomosis by placing sutures in specific locations surrounding the anastomosis. The OverStitch (Apollo
Endosurgery, Austin, TX) and the EndoCinch (Bard Davol, Murray Hill, NJ) are two devices that can be
used for the TORe procedure. The OverStitch has proven to be more effective for weight loss compared
to the EndoCinch and is used in a similar fashion as for endoscopic sleeve gastroplasty but following
[48]
the TORe technique . The first technique involved placing interrupted sutures at the gastrojejunal
anastomosis and the second, the creation of a pursestring. The latter resulted in greater weight loss at
12 months compared to the traditional interrupted suture pattern (19.8 %EWL with the purse-string
technique vs. 11.7 %EWL with the interrupted technique, P < 0.001) . Various studies have demonstrated
[49]
the safety and feasibility of this procedure. A recent study evaluated the amount of weight loss at 1, 3, and