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Background: Post-operative collections are a recognized source of morbidity after abdominal surgery. Percutaneous drainage is currently considered the standard treatment but not all collections are accessible using this method. Since the adoption of EUS, endoscopic transmural drainage has become an attractive option in the management of such complications. The present study aimed to assess the efficacy, safety and modalities of endoscopic transmural drainage in the treatment of post-operative collections. Methods: Data of all patients referred to our dedicated multidisciplinary facility from 2014 to 2017 for endoscopic drainage of symptomatic post-operative collections after failure of percutaneous drainage or when it was deemed impossible, were retrospectively analyzed. Results: Thirty-two patients (17 males and 15 females) with a median age of 53 years old (range 31-74) were included. Collections resulted from pancreatic (n = 10), colorectal (n = 6), bariatric (n = 5), and other type of surgery (n = 11). Collection size was less than 5 cm in diameter in 10 (31%), between 5 and 10 cm in 17 (53%) ,and more than 10 cm in 5 (16%) patients. The median time from surgery to endoscopic drainage was 38 days (range 6-360). Eight (25%) patients underwent endoscopic guided drainage whereas 24 (75%) patients underwent EUS-guided drainage. Technical success was 100% and clinical success was achieved in 30 (93.4%) after a mean follow-up of 13.5 months (1.2-24.8). Overall complication was 12.5% including four patients who bled following trans-gastric drainage treated with conservative therapy. Conclusions: The present series suggests that endoscopic transmural drainage represents an interesting alternative in the treatment of post-operative collection when percutaneous drainage is not possible or fails.

We welcomed with great interest the masterpiece of Nedelcu et al. [1] concerning the outcome of leaks after laparoscopic sleeve gastrectomy (LSG) based on a new algorithm addressing leak size and gastric stenosis. The article stressed the importance of adopting this new algorithm in order to standardize leak management, thus reducing the number of endoscopic procedures. We agree with the authors about the use of endoscopic internal drainage (EID) by means of double pigtail to achieve complete healing. As already reported by our team [2], since March 2013, we adopted EID as the only endoscopic treatment in case of fistulas after LSG or gastric bypass, irrespective to leak size. Moreover, we believe in the importance of introducing a well-defined algorithm in order to standardize the endoscopic treatment modality for leak following bariatric surgery. However, according to our experience, we have some remarks to do. Here, we report a case of a 59-year-old woman, presenting an early fistula [3] following laparoscopic sleeve gastrectomy. At day 12 after surgery, she underwent reoperation for peritonitis with lavage and drainage of peritoneal cavity, and two peri-gastric surgical drainage were left in place. No primary repair was attempted due to severe local tissue inflammation. Endoscopy showed a 2-cm-long dehiscence, of the last staple fire line, allowing passing through with the scope. Swallow study through the scope showed the persistence of intra-abdominal collection in the left hypochondrium and the presence of a left bronchial tree fistula (Fig. 1). EID was performed and two 10 Fr double pigtail drains (DPD) were positioned with the aim to drain and promote re-epithelialization of the cavity. After four endoscopic sessions, an Ovesco® clip (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany) was delivered to close the remaining blind cross-fistula.