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This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m 2 , or with a BMI of 27.0-29.9 kg/m 2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population., Competing Interests: The following authors disclosed financial relationships: P. Jirapinyo: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Erbe, and Spatz Medical; advisory board for Apollo Endosurgery; research support from Apollo Endosurgery, Boston Scientific Corporation, GI Dynamics, Fractyl, and USGI Medical. A. Hadefi: Research support from Endo Tools Therapeutics. C. C. Thompson: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Medtronic, Endoquest Robotics, Fractyl, FujiFilm, GI Dynamics, EnVision Endoscopy, Olympus/Spiration, Softac, USGI Medical, Xenter, Enterasense Ltd, and Lumendi; research support from Apollo Endosurgery, Boston Scientific Corporation, Endoquest Robotics, Erbe, Fractyl, FujiFilm, GI Dynamics, Olympus/Spiration, USGI Medical, and Lumendi; advisory board for Fractyl and USGI Medical; founder of Bariendo, BlueFlame Healthcare Venture Fund, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, and Enterasense Ltd, and GI Windows; board member for Bariendo, ELLES, EnVision Endoscopy, GI Windows, and Enterasense Ltd; ownership in Bariendo, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, Softac, Xenter, and Enterasense Ltd; partner in BlueFlame Healthcare Venture Fund; president of the Society for Metabolic and Bariatric Endoscopy Inc; Scientific Advisory Board for Xenter. R. Pannala: Research support from Fractyl Labs; general payments from Boston Scientific Corporation; consultant for HCL Technologies; advisory board for Nestle Healthsciences and Bluestar Genomics. S. K. Goelder: Travel compensation from Apollo Endosurgery. V. Kushnir: Consultant for BSCI, Noah Medical, Steres, and ConMed. M. Barthet: Consultant for Boston Scientific Corporation, Endotools, and Taewoong. C. M. Apovian: Advisory board for Altimmune, Inc, CinFina Pharma, Inc, Cowen and Company, LLC, Currax Pharmaceuticals, LLC, EPG Communication Holdings Ltd, Form Health, Inc, Gelesis, Srl, L-Nutra, Inc, NeuroBo Pharmaceuticals, Inc, Novo Nordisk, Inc, OptumRx, Inc, Pain Script Corporation, Palatin Technologies, Inc, Pursuit By You, ReShape Lifesciences Inc, Riverview School, and Xeno Biosciences; research support from the National Institutes of Health, Patient-Centered Outcomes Research Institute, and GI Dynamics, Inc. I. Boskoski: Consultant for Boston Scientific Corporation (Apollo Endosurgery), Nitinotes, and EndoTools. C. G. Chapman: Consultant for Boston Scientific Corporation, Olympus, Steris, and Apollo Endosurgery; speaker for Apollo Endosurgery. V. Kumbhari: Consultant for Boston Scientific Corporation. J. Esker: Consultant for Pendulum Therapeutics. A. D. Pryor: Speaker for Gore, Medtronic, and Stryker. R. Maselli: Consultant for Apollo Endosurgery. A. R. Schulman: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Olympus, and MicroTech; research support from GI Dynamics and Fractyl. N. Thosani: Consultant for Boston Scientific Corporation, Ambu, and Pentax America; royalties from UpToDate; ownership in ROSEAId. V. Huberty: Shareholder in, board member for, and research support from EndoTools Therapeutics. S. Sullivan: Consultant for Allurion Technologies, Biolinq, BariaTek, Pentax, Fractyl, and Endo Tools Therapeutics; research support from Allurion Technologies, ReShape Medical/Obalon Therapeutics, and Rebiotix; stock ownership in Biolinq. All other authors disclosed no financial relationships.The following authors disclosed financial relationships: P. Jirapinyo: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Erbe, and Spatz Medical; advisory board for Apollo Endosurgery; research support from Apollo Endosurgery, Boston Scientific Corporation, GI Dynamics, Fractyl, and USGI Medical. A. Hadefi: Research support from Endo Tools Therapeutics. C. C. Thompson: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Medtronic, Endoquest Robotics, Fractyl, FujiFilm, GI Dynamics, EnVision Endoscopy, Olympus/Spiration, Softac, USGI Medical, Xenter, Enterasense Ltd, and Lumendi; research support from Apollo Endosurgery, Boston Scientific Corporation, Endoquest Robotics, Erbe, Fractyl, FujiFilm, GI Dynamics, Olympus/Spiration, USGI Medical, and Lumendi; advisory board for Fractyl and USGI Medical; founder of Bariendo, BlueFlame Healthcare Venture Fund, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, and Enterasense Ltd, and GI Windows; board member for Bariendo, ELLES, EnVision Endoscopy, GI Windows, and Enterasense Ltd; ownership in Bariendo, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, Softac, Xenter, and Enterasense Ltd; partner in BlueFlame Healthcare Venture Fund; president of the Society for Metabolic and Bariatric Endoscopy Inc; Scientific Advisory Board for Xenter. R. Pannala: Research support from Fractyl Labs; general payments from Boston Scientific Corporation; consultant for HCL Technologies; advisory board for Nestle Healthsciences and Bluestar Genomics. S. K. Goelder: Travel compensation from Apollo Endosurgery. V. Kushnir: Consultant for BSCI, Noah Medical, Steres, and ConMed. M. Barthet: Consultant for Boston Scientific Corporation, Endotools, and Taewoong. C. M. Apovian: Advisory board for Altimmune, Inc, CinFina Pharma, Inc, Cowen and Company, LLC, Currax Pharmaceuticals, LLC, EPG Communication Holdings Ltd, Form Health, Inc, Gelesis, Srl, L-Nutra, Inc, NeuroBo Pharmaceuticals, Inc, Novo Nordisk, Inc, OptumRx, Inc, Pain Script Corporation, Palatin Technologies, Inc, Pursuit By You, ReShape Lifesciences Inc, Riverview School, and Xeno Biosciences; research support from the National Institutes of Health, Patient-Centered Outcomes Research Institute, and GI Dynamics, Inc. I. Boskoski: Consultant for Boston Scientific Corporation (Apollo Endosurgery), Nitinotes, and EndoTools. C. G. Chapman: Consultant for Boston Scientific Corporation, Olympus, Steris, and Apollo Endosurgery; speaker for Apollo Endosurgery. V. Kumbhari: Consultant for Boston Scientific Corporation. J. Esker: Consultant for Pendulum Therapeutics. A. D. Pryor: Speaker for Gore, Medtronic, and Stryker. R. Maselli: Consultant for Apollo Endosurgery. A. R. Schulman: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Olympus, and MicroTech; research support from GI Dynamics and Fractyl. N. Thosani: Consultant for Boston Scientific Corporation, Ambu, and Pentax America; royalties from UpToDate; ownership in ROSEAId. V. Huberty: Shareholder in, board member for, and research support from EndoTools Therapeutics. S. Sullivan: Consultant for Allurion Technologies, Biolinq, BariaTek, Pentax, Fractyl, and Endo Tools Therapeutics; research support from Allurion Technologies, ReShape Medical/Obalon Therapeutics, and Rebiotix; stock ownership in Biolinq. All other authors disclosed no financial relationships., (American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy. Published by Elsevier Inc on behalf of American Society for Gastrointestinal Endoscopy and by Georg Thieme Verlag KG Stuttgart on behalf of European Society of Gastrointestinal Endoscopy. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Background: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM., Methods: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events., Results: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy ( P  = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [ P  = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients ( P  < 0.05)., Conclusions: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required., Competing Interests: M.A. Khashab is a consultant for Boston Scientific, Olympus, Medtronic, GI Supply, and Triton. B.J. Elmunzer is a consultant for Takeda Pharmaceuticals. V. Kumbhari is a consultant for Apollo Endosurgery, Boston Scientific, Medtronic, FuijFilm, Pentax Medical, ReShape Lifesciences, and Obalon, and has received research support from ERBE and Apollo Endosurgery. D.J. Yang is a consultant for Boston Scientific, Lumendi, and Steris. G.G. Ginsberg is a consultant for Olympus Inc. and Boston Scientific. M. Ujiki is a consultant for Olympus, Boston Scientific, and Cook, and receives grant funding from Medtronic; he is also a speaker for Medtronic and Gore, and receives fellowship funding from Boston Scientific. J.M. Nieto is a consultant for Boston Scientific and ERBE. S. Andrawes is a consultant for Olympus. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Traditional endoscopic treatments have limited success in gastric sleeve stenosis (GSS). Gastric peroral endoscopic myotomy (G-POEM) could conceivably obliterate the twist/angulation that causes GSS through a tunneled stricturotomy. We report early outcomes of G-POEM for GSS treatment., Methods: We retrospectively reviewed all patients with GSS treated with G-POEM at our center. The primary end point was clinical success, defined as symptom improvement with resumption of adequate oral intake, without requiring further intervention., Results: 13 patients (mean age 43 ± 10.9 years; 12 female) underwent G-POEM for predominantly helical (11/13, 85 %) GSS. Three (23 %) had concurrent sleeve leak and 10 (77 %) had prior GSS treatment. Two intraoperative complications occurred, with no deviation to the procedure; no major complications occurred. At median follow-up of 175 (interquartile range [IQR] 119-260) days, clinical success was achieved in 10 patients (77 %). Median Gastroparesis Cardinal Symptom Index score in responders decreased from 2.06 (IQR 1.5-2.8) to 0.39 (IQR 0.2-0.5). Three patients (23 %) required surgical revision., Conclusions: G-POEM was feasible and safe, and may provide an alternative option for those averse to undergoing surgical revision for treatment of GSS., Competing Interests: Mouen Khashab is on the advisory board for Boston Scientific and Olympus. He is also a consultant for Medtronic and GI supply. Vivek Kumbhari is a consultant for Boston Scientific, Pentax Medical, Medtronic, and Fujifilm. He has also received research support from Apollo Endosurgery and ERBE. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe., Methods: We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019., Results: The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement., Conclusion: As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe., Competing Interests: Mouen A. Khashab is a consultant for Boston Scientific, Medtronic, and Olympus America. Vivek Kumbhari is a consultant for Medtronic, Pentax Medical, Boston Scientific, FujiFilm, Apollo Endosurgery, and Obalon. He has also received research support from ERBE USA and Apollo Endosurgery. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)

BACKGROUND : There is heterogeneity regarding the technical aspects of endoscopic sleeve gastroplasty (ESG), such as applying fundal sutures. Our aim was to determine whether ESG with fundal suturing (ESG-FS) affects weight loss and the serious adverse event (SAE) rate when compared with ESG with no fundal suturing (ESG-NFS). METHODS:  We conducted a two-center retrospective analysis of 247 patients who underwent ESG with or without fundal suturing. The primary outcome was percentage excess weight loss (%EWL) at 3, 6, and 12 months post-ESG. The secondary outcomes included the SAE rate and procedure duration. RESULTS:  At 3, 6, and 12-months, ESG-NFS had a significantly greater mean %EWL compared with ESG-FS (38.4 % [standard deviation (SD) 15.3 %] vs. 31.2 % [SD 13.9 %], P  = 0.001; 54.7 % [SD 19.2 %] vs. 37.7 % [SD 17.3 %], P  < 0.001; 65.3 % [SD 21.1 %] vs. 40.6 % [SD 23.5 %], P  < 0.001, respectively). There was no statistically significant difference in the SAE rates for ESG-NFS (n = 2; 2.0 %) and ESG-FS (n = 4; 2.6 %; P  > 0.99). The mean procedure time was significantly shorter in the ESG-NFS group at 59.1 minutes (SD 32.7) vs. 93.0 minutes (35.5; P  < 0.001), and a lower mean number of sutures were used, with 5.7 (SD 1.1) vs. 8.4 (SD 1.6; P  < 0.001). CONCLUSION : ESG-NFS demonstrated greater efficacy and shorter procedure duration. Therefore, fundal suturing should not be performed., Competing Interests: Christopher McGowan is a consultant for Apollo Endosurgery. Mouen A. Khashab is on the medical advisory board of Boston scientific and Olympus America. He is also a consultant for Medtronic, Boston Scientific and Olympus America. Vivek Kumbhari is a consultant for Medtronic,Boston Scientific,Reshape Lifesciences, Pentax medical,and Apollo Endosurgery. He also receives research support from ERBE USA and Apollo Endosurgery. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM)., Methods: A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development., Results: Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62., Conclusion: Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity., Competing Interests: B. Joseph Elmunzer is a consultant for Takeda Pharmaceuticals. Mouen A. Khashab is a consultant for Boston Scientific, Olympus, and Medtronic, and is also on the medical advisory board for Boston Scientific and Olympus. Vivek Kumbhari is a consultant for Apollo Endosurgery, Boston Scientific, Medtronic, and ReShape Life Science. Bu Hayee is a consultant for Apollo Endosurgery, Boston Scientific, Fuji, Medtronic, Obalon, Pentax Medical, and ReShape Life Sciences. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)

Background: Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered., Methods: This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula., Results: 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases., Conclusions: The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula., Competing Interests: A.L. Chang has received consultancy fees and research support from Boston Scientific; T.E. Kowalski has received consultancy fees from Boston Scientific and Medtronic; T.H. Baron has received consultancy fees from Boston Scientific, Cook Endoscopy, W.L. Gore, Medtronic, and Olympus America, and speaker’s fees from Medtronic; J. Nieto has received consultancy fees from Boston Scientific and Olympus America, and speaker’s fees from AbbVie; J.Y. Nasr has received consultancy fees from Boston Scientific; H.S. Khara has received consultancy fees from Boston Scientific and speaker’s fees from Olympus America, Covidien, Gyrus ACMI, Inc., and US Endoscopy; S. Irani has received research support from Boston Scientific; R.J. Law has received consultancy fees from Boston Scientific, Olympus America, and ERBE, and research support from Cook Medical; D.E. Loren has received consultancy fees from Boston Scientific and Olympus America; D.L. Diehl has received consultancy fees from Boston Scientific, Cook Endoscopy, Olympus America, Pentax Medical, Lumendi, US Endoscopy, and C2 Therapeutics, and speaker’s fees from Boston Scientific and Olympus America; M.A. Al-Haddad has received consultancy fees and research support from Boston Scientific; D.K. Pleskow has received consultancy fees from Boston Scientific, Olympus, Fuji, Nine Point Medical, and Medtronic; M. Huggett has received consultancy fees from Boston Scientific and Cook Endoscopy, and speaker’s fees from Boston Scientific, Cook Endoscopy, and Olympus; A.J. Trindade has received consultancy fees from Olympus America, C2 Therapeutics, and Pentax Medical; V. Kumbhari has received consultancy fees from Apollo Endosurgery, Boston Scientific, Medtronic, Pentax Medical, and ReShape Lifescience, and research support from ERBE, C2 Therapeutics, and Ovesco; M.A. Khashab has received consultancy fees from and is on the advisory board of Boston Scientific and Olympus America, and has received consultancy fees from Medtronic. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: Dr. Kumbhari is a consultant for Apollo Endosurgery, Boston Scientific, Medtronic, FuijiFilm, Pentax Medial, Obalon, and ReShape Life Sciences, and has received research support from Erbe and Apollo Endosurgery. Dr. Khashab is a consultant for Boston Scientific, Medtronic, and Olympus. All other authors declare that they have no conflict of interest.

Background: Cryoballoon ablation could induce stricture formation to achieve outlet and pouch reduction in patients regaining weight after Roux-en-Y gastric bypass (RYGB). This pilot study aimed to assess technical feasibility and short-term efficacy., Methods: A retrospective chart review (January - November 2018) at two academic centers identified patients with weight regain post-RYGB, treated with cryoablation if pouch > 4 cm and/or outlet > 15 mm. Patients were scheduled for surveillance endoscopies at 8 weeks., Results: 22 patients presented 10.5 years (SD 4.42) post-RYGB with weight regain of 30.9 kg (SD 13.7). Technical success was 89.5 % for outlet ablation and 93.0 % for pouch ablation. From baseline to 8 weeks, the outlet was reduced from 24.1 mm (95 % confidence interval [CI] 19.8 to 28.5) to 17.1 mm (95 %CI 13.1 to 21.1; P  < 0.001), and pouch from 5 cm (95 %CI 4.1 to 5.9) to 3.9 cm (95 %CI 2.6 to 5.1; P  < 0.05). Total body weight loss at 8 weeks was 8.1 % (SD 12.8 %)., Conclusion: Cryoablation appears technically feasible and effective for outlet and/or pouch reduction in the short term., Competing Interests: Dr. Khashab is on the medical advisory board for Boston Scientific and Olympus America, and is a consultant for Boston Scientific, Olympus America, and Medtronic. Dr. Kalloo is a founding member, equity Holder, and consultant for Apollo Endosurgery. Dr. Kumbhari is a consultant for Medtronic, Pentax, Reshape Lifesciences, Boston Scientific, and Apollo Endosurgery; he also receives research support from ERBE USA and Apollo Endosurgery. Dr. Trindade is a consultant for Pentax Medical and CSA Medical. Dr. Benias is a consultant for Apollo Endosurgery. Dr. Thompson is a consultant for Boston Scientific, Medtronic, USGI Medical, Olympus, Apollo Endosurgery, GI Windows, Aspire Bariatrics, Fractyl, Spatz, and GI Dynamics. Dr. Canto is a consultant for Exigo and has received research grants from Pentax and Endogastric Solutions. All other authors have nothing to disclose., (© Georg Thieme Verlag KG Stuttgart · New York.)

Backgrounds: Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events., Methods: We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria)., Results: Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P  = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P  < 0.001), despite having larger WON collections (transverse axis 118.2 vs. 101.9 mm, P  = 0.003; anteroposterior axis 95.9 vs. 80.1 mm, P  = 0.01). There was no difference in overall adverse events (21.6 % vs. 15.2 %; P  = 0.72) and bleeding events (4.9 % vs. 3.4 %; P  = 0.54) between the 20-mm and 15-mm LAMS groups, respectively., Conclusions: The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution., Competing Interests: Drs. Arlt, Ellrichmann, Aparicio, Sejpal, Irani, Pawa, Ahmed, Sedarat, Hampe, Sharaiha, Berzin, Stevens, Willingham, Kushnir, Ngamruengphong, Hugget, Baron, Repici, Adler, Nasr, Kowalski, Kumbhari, and Khashab are consultants for Boston Scientific. Dr. Trindade is a consultant for Pentax Medical and CSA Medical. Dr. Benias is a consultant for Fujifilm, Medtronic, and Apollo. Dr. Sejpal is also a consultant for Olympus America. Dr. Ahmed is also a consultant for Cook Medical. Dr. Hampe is also a consultant for Cook Medical, Olympus America, and B. Braun. Dr. Sharaiha is also a consultant for Olympus America and Apollo. Dr. Chahal is a consultant for Medtronic. Dr. Willingham is also a consultant for RedPath, Cook Medical, Xlumena, Oncolys Biopharma, and has received research funding to the university from Cancer Prevention Pharmaceuticals. Dr. Hugget is also a consultant for Cook Medical. Dr. Repici has also received research funding from Boston Scientific. Dr. Kumbhari is also a consultant for Medtronic, Reshape Lifesciences, and Apollo Endosurgery, and has received research support from ERBE and Apollo Endosurgery. Dr. Singh is a consultant for Abbvie and Novo Nordisk, and is a member of an advisory board for Akcea. Dr. Khashab is also a consultant for Olympus America and Medtronic. All other authors have no conflict of interest to disclose., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs)., Methods: We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery., Results: Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P  = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P  = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P  = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P  = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P  = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P  = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P  = 0.31)., Conclusion: When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events., Competing Interests: S. Friedland is a consultant for Boston Scientific and C2 Therapeutics; T. Stevens is a speaker and consultant for Boston Scientific and a speaker for AbbVie pharmaceuticals; C. J. DiMaio is a consultant for Boston Scientific and Medtronic; L. H. Jamil is a consultant for Aries pharmaceutical; P. S. Yachimski is a consultant for Boston Scientific; J. Nieto is a consultant for Boston Scientific; V. Kumbhari is a consultant for ReShape Life Sciences, Apollo Endosurgery, Medtronic, and Boston Scientific, and has received consulting fees from Pentax Medical and C2 Therapeutics; V. Singh is a consultant for Abbvie, D-Pharm, and Santarus; E. J. Shin is a consultant for Boston Scientific and C2 Therapeutics; M. Khashab is a consultant for Boston Scientific and Olympus, and is also on the medical advisory board for Boston Scientific and Olympus. All other co-authors have no conflict of interest disclosures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Mouen A. Khashab is a consultant and on the medical advisory board for Boston Scientific and Olympus America. Vivek Kumbhari is a consultant for ReShape Life Sciences, Apollo Endosurgery, Medtronic, and Boston Scientific, and receives consulting fees from Pentax Medical and C2 Therapeutics. Anthony N. Kalloo is a founding member and equity holder for Apollo Endosurgery. The other authors have nothing to declare. There is no funding support related to this submitted manuscript.

Background: Multiple studies have examined the use of lumen-apposing metal stents (LAMSs) for the drainage of peripancreatic fluid collections. Data on the use of LAMSs for postoperative fluid collections (POFCs) are scarce. POFCs may lead to severe complications without appropriate treatment. We aimed to study the outcomes (technical success, clinical success, rate/severity of adverse events, length of stay, recurrence) of the use of LAMSs for the drainage of POFCs., Methods: This international, multicenter, retrospective study involved 19 centers between January 2012 and October 2017. The primary outcome was clinical success. Secondary outcomes included technical success and rate/severity of adverse events using the ASGE lexicon., Results: A total of 62 patients were included during the study period. The most common etiology of the POFCs was distal pancreatectomy (46.8 %). The mean (standard deviation) diameter was 84.5 mm (30.7 mm). The most common indication for drainage was infection (48.4 %) and transgastric drainage was the most common approach (82.3 %). Technical success was achieved in 60/62 patients (96.8 %) and clinical success in 57/62 patients (91.9 %) during a median (interquartile range) follow-up of 231 days (90 - 300 days). Percutaneous drainage was needed in 8.1 % of patients. Adverse events occurred intraoperatively in 1/62 patients (1.6 %) and postoperatively in 7/62 (11.3 %). There was no procedure-related mortality., Conclusion: This is the largest study on the use of LAMSs for POFCs. It suggests good clinical efficacy and safety of this approach. The use of LAMSs in the management of POFCs is a feasible alternative to percutaneous and surgical drainage., Competing Interests: Dr. Amrita Sethi is a Consultant for Olympus and Boston Scientific. Dr. Reem Z. Sharaiha is a consultant for Boston Scientific and Apollo Endosurgery. Dr. Thomas Kowalski is a consultant for Boston Scientific and Medtronic. Dr. Jose Nieto is a consultant for Boston Scientific. Dr. Sachin Wani is a consultant for and received grant support from Boston Scientific and Medtronic, and grant support from Cook. Dr. Mihir S. Wagh has served as a consultant for Boston Scientific and Medtronic. Dr. Ali Mir Ahmed is a consultant for Boston Scientific and Cook Medical. Dr. Andrea Anderloni is a consultant for Boston Scientific. Dr. Douglas G. Adler is a consultant for Boston Scientific. Dr. Nikhil A. Kumta is a consultant for Apollo Endosurgery, Boston Scientific and Olympus. Dr. Frank P. Vleggaar is a consultant for Boston Scientific Dr. Isaac Raijman is a consultant for Boston Scientific. Dr. Shayan Irani is a consultant for Boston Scientific. Dr. Vivek Kumbhari is a consultant for ReShape Lifesciences, Apollo Endosurgery, Boston Scientific and Medtronic. Dr. Vikesh Singh is consultant for Abbvie, Novo Nordisk, and Ariel and advisory board participant for Nordmark. Dr. Douglas Pleskow is a consultant for Boston Scientific, Olympus, Nine Point and CSA. Dr. Mouen A. Khashab is a consultant for Boston Scientific, Olympus and Medtronic and is on the medical advisory board for Boston Scientific and Olympus, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Intragastric balloon (IGB) placement and endoscopic sleeve gastroplasty (ESG) are reported to be safe and effective endoscopic bariatric therapies. This study aimed to compare the patient demographics and therapeutic outcomes between the IGB and ESG procedures., Methods: This was a retrospective review of prospectively collected data from consecutive patients between December 2015 and October 2017 who underwent IGB or ESG at a single academic center. Fluid-filled IGBs implanted for a 6-month duration were used. IGB and ESG patients were subjected to identical post-procedure dietary instructions and follow-up protocols. Body weight was recorded at 1, 3, 6, and 12 months post-procedure., Results: A total of 47 patients underwent IGB insertion and 58 underwent ESG. The IGB cohort had a lower baseline body mass index (BMI) than the ESG (34.5 vs. 41.5 kg/m 2 ; P  < 0.001) and a significantly lower proportion of men (2.1 % vs. 41.4 %; P  < 0.001). IGB patients showed a mean (standard deviation [SD]) percentage total body weight loss (%TBWL) that was significantly lower than ESG patients at 1 month (6.6 % [2.6 %] vs. 9.9 % [2.4 %]; P  < 0.001), 3 months (11.1 % [4.4 %] vs. 14.3 % [4.6 %]; P  = 0.004), 6 months (15.0 % [7.6 %] vs. 19.5 % [5.7 %]; P  = 0.01), and 12 months (13.9 % [9.0 %] vs. 21.3 % [6.6 %]; P  = 0.005). The IGB cohort also experienced significantly more adverse events compared with the ESG (17 % vs. 5.2 %; P  = 0.048)., Conclusions: IGB placement and ESG result in clinically meaningful weight loss. However, ESG appears to provide clinically superior and more enduring weight loss with fewer adverse events compared with an IGB., Competing Interests: Mouen A. Khashab is on the medical advisory board for Boston Scientific and Olympus America and is a consultant for Boston Scientific, Olympus America, and Medtronic. Anthony N. Kalloo is a founding member, equity holder, and consultant for Apollo Endosurgery. Vivek Kumbhari is a consultant for Medtronic, Reshape Lifesciences, Boston Scientific, and Apollo Endosurgery; he also receives research support from ERBE USA and Apollo Endosurgery. The remaining authors have nothing to disclose., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this study is to report a novel, multicenter experience with the diverticular peroral endoscopic myotomy (D-POEM) technique in the management of esophageal diverticula., Methods: This is a multicenter, international, retrospective study involving three centers. D-POEM was performed using the principles of submucosal endoscopy., Results: A total of 11 patients with an esophageal diverticulum (Zenker's 7, mid-esophagus 1, epiphrenic 3) were included. The mean size of the esophageal diverticula was 34.5 mm. The overall technical success rate of D-POEM was 90.9 %, with a mean procedure time of 63.2 minutes. There were no adverse events. Clinical success was achieved in 100 % (10 /10), with a decrease in mean dysphagia score from 2.7 to 0.1 ( P  < 0.001) during a median follow-up of 145 days (interquartile range 126 - 273)., Conclusion: Endoscopic management of esophageal diverticula using the novel technique of D-POEM appears promising. This first case series on D-POEM suggests that the procedure is feasible, safe, and effective in the management of esophageal diverticula. D-POEM offers the distinct advantage of ensuring a complete septotomy. Larger studies are needed to confirm these intriguing results., Competing Interests: Kenneth Chang provides consultancy for and receives educational grants from Cook Medical, Olympus, and Medtronic. Vivek Kumbhari is a consultant for ReShape Lifesciences, Apollo Endosurgery, Boston Scientific, and Medtronic. Vikesh K. Singh is a consultant for Abbvie, Novo Nordisk, and Ariel and is an advisory board participant for Nordmark. Marcia Canto is a consultant for Pentax and the recipient of a research grant from C2 Therapeutics. Anthony N. Kalloo is a founding member and equity holder in Apollo Endosurgery. Mouen Khashab is a consultant for Boston Scientific, Olympus, and Medtronic and is on the medical advisory board for Boston Scientific and Olympus. The remaining authors have nothing to disclose., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Dr. Khashab is a consultant and is on the medical advisory board for Boston Scientific and Olympus. Dr. Kumbhari is a consultant for Boston Scientific, Apollo Endosurgery, ReShape Life Sciences, and Medtronic., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Anthony N. Kalloo is a founding member and Equity Holder of Apollo Endosurgery. Vivek Kumbhari is a consultant for Apollo Endosurgery, ReShape Life Sciences, Medtronic, and Boston Scientific. Mouen A. Khashab is a consultant and on the medical advisory boards for Boston Scientific and Olympus. The remaining authors have no disclosures.

Background and Study Aim: Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle., Patients and Methods: Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes., Results: Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively ( P  > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group ( P  = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P  = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P  = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P  = 0.71) were similar in the slow-pull and suction groups, respectively., Conclusions: The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA., Competing Interests: Boston Scientific provided a research grant for the study but had no involvement in study design, data collection or data analysis., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Competing interests: V. Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery. M. A. Khashab is a consultant for Boston Scientific. All other authors have no relevant disclosures.

Competing Interests: Competing interests: Dr. Mouen A. Khashab is a consultant for Boston Scientific. Dr. Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery. All other authors disclosed no financial relationships relevant to this publication.

Background and study aims  The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methods  All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of < 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI). Results  A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m 2 ) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 - 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 - 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Conclusion  Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique., Competing Interests: Competing interests: Dr. Khashab is a consultant for Boston Scientific and Olympus America, and has received research support from Cook Medical. Dr Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and aims  Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Roux-en-Y gastric bypass (RYGB) is technically challenging. We describe our multicenter experience using lumen-apposing metal stents (LAMSs) to create an endoscopic ultrasound-guided transgastric fistula (EUS-TG) to facilitate peroral ERCP in these patients. Patients and methods  Thirteen patients with RYGB who underwent EUS-TG at three tertiary centers were included. EUS was used to guide puncture of the excluded stomach from the gastric pouch or jejunum; a LAMS was placed across the transgastric fistula. ERCP was performed via a duodenoscope passed through the LAMS. Results  The technical success of EUS-TG was 100 % (13/13). ERCP through the LAMS was successful and clinical success was achieved in all patients. LAMS dislodgement during ERCP occurred in two patients and the stent was successfully repositioned without sequelae. After removal of the LAMS, the fistula was closed in 92 % of patients, either by endoscopic closure devices or argon plasma coagulation. None of the patients experienced procedure-related adverse events. Conclusion  EUS-TG is an effective and safe method of accessing the excluded stomach and performing ERCP in patients with RYGB., Competing Interests: Competing interests: Mouen Khashab is a consultant for Boston Scientific. All authors have no conflicts of interest relevant to the subject of this article., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Competing interests: Dr. Khashab is a consultant for Boston Scientific. Dr. Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery.

Competing Interests: Competing interests: Dr. Mouen A. Khashab serves as a consultant for Boston Scientific.Dr. Vivek Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery. Drs. Agarwal, Fang, Pezhouh and Ngamruengphong do not have any financial disclosures.

Background and study aims  Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods  We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results  Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions  Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome., Patients and Methods: This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared., Results: A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups., Conclusions: Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Precise identification of the gastroesophageal junction (GEJ) is a challenging prerequisite for adequate length of an esophageal myotomy. Multiple standard methods to identify the GEJ have been described; however, a more objective modality is needed to ensure effective peroral endoscopic myotomy (POEM)., Patients and Methods: In the double-endoscope transillumination for extent confirmation technique (DETECT), an ultraslim gastroscope is passed to the most distal aspect of the submucosal tunnel created during POEM. A regular gastroscope is advanced into the stomach, and the visualization of transillumination from the ultraslim gastroscope enables identification of the extent of the submucosal tunnel., Results: A total of 10 patients underwent POEM with DETECT. Initial submucosal tunneling was performed based on a determination of the GEJ location via standard methods. DETECT indicated the tunnel extent to be inadequate in 50% of patients, and the tunnel was extended a further 1 to 2cm. The mean initial tunnel length was 15.4cm, with a mean initial myotomy length of 11.9cm. DETECT was performed in less than 10 minutes without complications., Conclusion: DETECT is an objective method for determining the adequacy of the submucosal tunnel length during POEM.

Background and Study Aims: A new on-demand enteroscopy (ODE) device has been designed to allow deep enteroscopy using a standard adult colonoscope with the aid of a novel through-the-scope balloon. The aims of the current study were to establish the feasibility, efficacy, and safety of ODE in performing anterograde and retrograde enteroscopy., Patients and Methods: A retrospective, single-center study of 28 consecutive deep ODE procedures (11 anterograde and 17 retrograde) was performed. Diagnostic yield, therapeutic yield, technical success, procedure time, depth of maximal insertion (DMI), time to DMI, and adverse events were recorded., Results: The mean diagnostic and therapeutic yields were 45 % and 36 % for anterograde enteroscopy and 59 % and 47 % for retrograde enteroscopy, respectively. Technical success was achieved in 100 %. For anterograde enteroscopy, the mean total procedure time was 24 minutes, with a mean DMI of 1.2 m. For retrograde enteroscopy, the mean total procedure time was 31 minutes, with a mean DMI of 1.1 m. No adverse events were recorded., Conclusion: Deep enteroscopy using a novel through-the-scope balloon and standard endoscope appeared to be feasible and safe, with rapid procedures times., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Endoscopic submucosal dissection (ESD) is a technically challenging procedure. A novel gel can facilitate ESD due to its submucosal dissecting properties. This prospective porcine survival study evaluated clinical and histologic parameters of hybrid ESD using the gel., Patients and Methods: Gastric submucosal lesions were created in six pigs and hybrid ESD was performed. Healing was assessed weekly until necropsy at Day 28., Results: En bloc resection was achieved in all lesions (mean size 40.7 mm). The mean total procedure time was 13.5 minutes and the mean resection time was 5.5 minutes. The mean total histologic injury score was 4. At necropsy, four ulcers had healed completely and two were < 6 mm in size., Conclusion: Hybrid ESD of large gastric lesions in a porcine model can be facilitated by the novel gel, dramatically reducing procedure and resection times by eliminating the need for time-consuming submucosal dissection. The novel gel is safe and easy to use, and has the potential to simplify ESD. Further prospective human studies are needed to validate these findings., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Peroral endoscopic myotomy (POEM) is technically challenging and time consuming. Repeated injection of dyed saline during tunneling is performed to enhance the demarcation between the submucosal layer and the muscularis propria. This process requires exchanging the knife for a catheter to spray dyed saline and is time consuming. This study aimed to describe a new method of injecting dyed saline through an integrated water jet channel during POEM., Patients and Methods: POEM was performed using a triangular tip knife. Repeated jet injection of saline mixed with indigo carmine was performed whenever the submucosal dissection plane became unclear., Results: The study cohort consisted of nine patients (8 achalasia, 1 Jackhammer esophagus). All procedures were technically feasible and successful without any complications and resulted in the patients' Eckhardt's scores returning to normal. The mean submucosal tunnel length was 13.3 cm and the mean myotomy length was 9.9 cm. The mean procedure time was 127 minutes., Conclusion: The modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient than the standard dissection method., (© Georg Thieme Verlag KG Stuttgart · New York.)