Marcelo Mochate Flor

A 56-year-old man underwent rectosigmoidectomy, partial cystectomy, and derivative colostomy for locally advanced distal rectal adenocarcinoma, persistent after chemoradiation. On the 25th postoperative day, he presented clinical worsening and increased abdominal drain output, and was submitted to tomography with intravesical contrast infusion, which showed a rectovesical fistula communicating with the surgical drain ([Fig. 1]). Rectoscopy showed a semi-circumferential leak of the colorectal anastomosis. Endoscopic exploration of the pelvic cavity allowed removal of clots and necrosis, and cleansing with 3 % hydrogen peroxide was done. While the surgical drain was in place, tube-in-tube endoscopic vacuum therapy in the intracavitary position was performed. A guidewire was inserted through the pelvic drain and captured with a grasper. The guidewire was then used to introduce a 14-Fr Levine tube into the surgical drain. Continuous aspiration with 125 mmHg negative pressure was started ([Video 1]). The pump was disconnected daily so tubes could be used to irrigate the cavity [1] [2] [3]. Video 1 Tube-in-tube endoscopic vacuum therapy method (TT-EVT). After 10 days, a new rectoscopy showed significant reduction of leakage and the pelvic cavity, with granulation tissue formation. A full-thickness endoscopic clip was deployed, achieving complete closure of the colorectal anastomotic fistula ([Fig. 2]). The decision was to maintain the intracavitary tube-in-tube endoscopic vacuum therapy to drain the urinary fistula. After another 10 days, a third rectoscopy showed sustained closure of the anastomotic fistula. An ultra-slim endoscope (4.9 mm) was inserted through the drain path, which was thin and long, mimicking a remaining “cystostomy.” Negative pressure was turned off and a Penrose drain was left near the vesical wall. Repeat tomography with intravesical contrast infusion 25 days later showed a well-positioned clip without extravasation of contrast. The pelvic drain was removed and the patient discharged. Control rectoscopy confirmed a defective closure and allowed reconstructive surgery. Tube-in-tube endoscopic vacuum therapy can be done through previously placed surgical drains into the intracavitary position. It is an effective, easy-to-assemble, and low-cost treatment option even for complex digestive fistulas. Endoscopy_UCTN_Code_TTT_1AQ_2AG Publication Date: 15 November 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Our patient, a 58-year-old woman, was being followed-up for ulcerative colitis. Computed tomography (CT) showed the presence of a pancreatic nodule, which after endoscopic ultrasonography (EUS)-guided puncture and biopsy was diagnosed as pancreatic head adenocarcinoma. The patient developed jaundice and acute cholangitis, and biliary drainage by endoscopic retrograde cholangiopancreatography was carried out. One month later, the disease had progressed, with duodenal invasion and obstructive symptoms. Endoscopic palliation of the obstructive symptoms was opted for with EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a unique double-balloon tube (Tokyo Medical University type; Create Medic, Yokohama, Japan) and a novel electrocautery-tipped stent delivery system equipped with a lumen-apposing metal stent (Hot Axios stent; Boston Scientific, Marlborough, Massachusetts, USA) ([Fig. 1]). At follow-up, the patient presented good resolution of the obstructive symptoms and was referred for continuation of chemotherapy ([Video 1]). Video 1 Endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Surgical gastrojejunostomy, which has been the standard palliative treatment for malignant obstruction of the gastric outlet, is associated with good functional outcome and long-term relief of symptoms [1] [2]. Endoscopic placement of a metal stent has been gaining popularity as an alternative to surgical gastrojejunostomy to treat malignant obstruction of the gastric outlet, because of its high technical success rates and lower degree of invasiveness [3]. To sum up, we established the feasibility of an EUS-guided gastrojejunostomy technique using a unique double-balloon tube and a novel electrocautery-tipped stent delivery system equipped with a lumen-apposing metal stent. Endoscopy_UCTN_Code_TTT_1AS_2AB Publication Date: 17 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Intragastric balloons (IGB) are the most widely used endoscopic bariatric and metabolic therapies. We aimed to evaluate the efficacy of IGB in comparison with sham or lifestyle interventions for weight loss in overweight and obese patients. This systematic review and meta-analysis was performed following the PRISMA guidelines. Electronic searches were performed to identify randomized controlled trials, which compared IGB with sham or lifestyle intervention. Thirteen RCTs with 1523 patients were included. The difference in mean %EWL and %TWL at follow-up was 17.98%, and 4.40%, respectively, which was significantly higher in the IGB group. Similarly, the difference in mean AWL and BMIL was 6.12 kg, and 2.13 kg/m², respectively. IGB therapy is more effective than lifestyle intervention alone for weight loss in overweight and obese adults.