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Zenker's diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed. This document reviews current endoscopic techniques and devices used to treat ZD. The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations. Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives. [ABSTRACT FROM AUTHOR]

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge. [ABSTRACT FROM AUTHOR]

Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management. In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use. Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support. Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed. [ABSTRACT FROM AUTHOR]

Residual neoplasia after macroscopically complete EMR of large colon polyps has been reported in 10% to 32% of resections. Often, residual polyps at the site of prior polypectomy are fibrotic and nonlifting, making additional resection challenging. This document reviews devices and methods for the endoscopic treatment of fibrotic and/or residual polyps. In addition, techniques reported to reduce the incidence of residual neoplasia after endoscopic resection are discussed. Descriptions of technologies and available outcomes data are summarized for argon plasma coagulation ablation, snare-tip coagulation, avulsion techniques, grasp-and-snare technique, EndoRotor endoscopic resection system, endoscopic full-thickness resection device, and salvage endoscopic submucosal dissection. Several technologies and techniques discussed in this document may aid in the prevention and/or resection of fibrotic and nonlifting polyps. [ABSTRACT FROM AUTHOR]

Objective: To perform a structured systematic review and meta-analysis to evaluate changes in ghrelin, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and gastric inhibitory peptide (GIP) gut hormone levels in patients after sleeve gastrectomy. Background: Despite sleeve gastrectomy becoming the most common surgical weight loss procedure, weight loss mechanisms remain less clear. Methods: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through April 1, 2019, in accordance with PRISMA and MOOSE guidelines. Randomized controlled trials and prospective observational studies evaluating pre and post-procedure hormones fasting ghrelin, postprandial GLP-1, postprandial PYY, and fasting GIP levels were included. Hedge g with random-effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs). Results: A total of 28 studies (n = 653; 29.56% male) were included. Mean age was 42.00-5.48 years, with average follow-up of 11.70-11.38 months. Pre-procedure body mass index (BMI) was 46.01-4.07 kg/m2 with a postsleeve gastrectomy BMI of 34.07-3.73 kg/m2, representing total body weight loss of 25.13-4.44% and excess weight loss of 57.48-9.64% (P < 0.001). Ghrelin decreased (Hedge g 1.486, 95% CI 1.884 to 1.089, I2 = 91.95%), whereas GLP-1 and PYY increased post-procedure (Hedge g 1.095, 95% CI 0.509 to 1.642, I2 = 84.38%; and Hedge g 1.396, 95% CI 0.781 to 2.011, I2 = 84.02%, respectively). GIP did not significantly change (Hedge g 0.213, 95% CI 1.019 to 0.592, I2 = 79.65%). Conclusions: Fasting ghrelin levels decreased, whereas postprandial GLP-1 and PYY increased after sleeve gastrectomy. Fasting GIP levels remained unchanged. Future studies are needed to assess the role of these gut hormones and relationship to weight loss and metabolic outcomes. [ABSTRACT FROM AUTHOR]

Although traditional transoral outlet reduction (TORe) involves argon plasma coagulation (APC) before endoscopic suturing, modified endoscopic submucosal dissection (ESD) has also been used. This study aims to evaluate the safety and efficacy of modified ESD-TORe in comparison with traditional APC-TORe. This was a retrospective study of prospectively collected data from patients who underwent modified ESD-TORe and APC-TORe for weight regain after Roux-en-Y gastric bypass (RYGB). Our outcomes were technical success, adverse events as categorized by the American Society for Gastrointestinal Endoscopy lexicon, and percent total weight loss (TWL) at 6 and 12 months and patients who underwent ESD-TORe were matched 1:3 based on gastrojejunal anastomosis (GJA) and pouch sizes to those who underwent APC-TORe. TWL between groups was compared. A linear regression was performed to control for any confounders. Nineteen RYGB patients underwent ESD-TORe. Technical success rate was 100%, with no severe adverse events. At 6 and 12 months, patients experienced 13.4% ± 6.6% and 12.1% ± 9.3% TWL, respectively (P <.05 for both). Nineteen ESD-TORe patients were also matched with 57 APC-TORe patients based on GJA and pouch sizes. At 12 months, the ESD-TORe group experienced greater weight loss compared with the APC-TORe group (12.1% ± 9.3% vs 7.5% ± 3.3% TWL, respectively; P =.036). On regression analysis, ESD remained a significant predictor of percent of TWL at 12 months after controlling for age, sex, body mass index, weight regain, and years from RYGB (β = 5.99, P =.02). Combining endoscopic tissue dissection with suturing provides greater and more durable weight loss for patients with weight regain after RYGB. [ABSTRACT FROM AUTHOR]

Primary obesity surgery endoluminal (POSE) is a primary endoscopic bariatric therapy focusing on gastric remodeling. The original POSE procedure involved placement of full-thickness plications in the fundus. Here we aim to assess the feasibility, safety, and efficacy of a novel POSE procedure that involves plications of only the gastric body to reduce the width and length of the stomach. This was a pilot study of patients who underwent a distal POSE procedure with gastric body plications for the treatment of obesity. Outcomes included technical success rate, serious adverse event (AE) rate, and efficacy of this novel POSE procedure at inducing weight loss and improving obesity-related comorbidities. Ten patients (6 women, age 52 ± 20 years) underwent a distal POSE procedure. Baseline body mass index was 38.1 ± 6.2 kg/m2. The technical success rate was 100%. An average of 21 ± 4 plications were placed per case (6 ± 2 for distal belt, 10 ± 3 for suspenders, 4 ± 2 for proximal belt, and 3 ± 1 for fillers). The gastroesophageal junction was pulled distally by 3.0 ± 1.6 cm. The gastric body was shortened by 11.0 ± 5.1 cm, representing a 59% reduction. The serious AE rate was 0%. At 6 months, patients experienced 15.0% ± 7.1% total weight loss (TWL). All patients achieved at least 5% TWL, and 8 patients (80%) achieved at least 25% excess weight loss. Hypertension, diabetes, GERD, and obstructive sleep apnea improved after the procedure. This novel POSE procedure, focusing on gastric body plication and sparing the fundus, is technically feasible and appears to be safe and effective for the treatment of obesity. [ABSTRACT FROM AUTHOR]

Argon plasma coagulation (APC) of gastrojejunal anastomosis (GJA) is effective in treating weight regain after Roux-en-Y gastric bypass (RYGB). This study aims to compare the efficacy of different APC settings for treating weight regain. This was a single-center retrospective study of patients who had undergone RYGB and then underwent APC from 2014 to 2018 for weight regain. Patients receiving only low-dose APC (45-55 W) or high-dose APC (70-80 W) were compared. The primary outcome was the difference in percentage total weight loss (% TWL) between the groups at 6 and 12 months after the last treatment. Secondary outcomes were technical success, adverse events (AEs), and predictors of weight loss at 12 months. Two hundred seventeen patients met the inclusion criteria and underwent 411 APC sessions. Of these, 116 (53.5%) patients underwent 267 low-dose APC sessions (2.4 ± 1.5 sessions/patient) and 101 (46.5%) patients underwent 144 high-dose APC sessions (1.4 ± 0.7 sessions/patient). Follow-up rates were 82.9% and 75.3% at 6 and 12 months. At 6 months, the low- and high-dose groups experienced 7.3% ± 6.6% and 8.1% ± 7.4% TWL, respectively (P =.41). At 12 months, the low- and high-dose groups experienced 5.1% ± 8.5% and 9.7% ± 10.0% TWL, respectively (P =.008). Technical success was 100%. The overall AE rate was 8.0%; the most common AE was GJA stenosis (4.6%). The GJA stenosis rate was similar for the low- and high-dose groups (3.0% vs 7.6%, P =.06). High-dose APC remained a significant predictor of greater weight loss at 1 year after controlling for confounders. APC is effective at treating weight regain after RYGB, and higher-watt APC was associated with greater weight loss. [ABSTRACT FROM AUTHOR]

Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe. This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe. Three hundred thirty-one RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index was 40 ± 9 kg/m2. Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5% ± 8.5%, 6.9% ± 10.1%, and 8.8% ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single purse-string, interrupted, double purse-string, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. Some patients (39.3%) had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (β =.43, P =.01) and an additional endoscopic weight loss procedure (β = 8.52, P =.01) were predictors of percentage of TWL at 5 years. TORe appears to be safe, effective, and durable at treating weight regain after RYGB. [ABSTRACT FROM AUTHOR]

Weight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR. We hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms. Single tertiary care referral center. This was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ2 and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations. Forty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P =.02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P =.003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P =.03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet. Dysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR. • Dysphagia is a risk factor for weight regain in patients who have had Roux-en-Y gastric bypass (RYGB), a finding which could be due to conversion of regular dietary intake to relatively calorie-dense liquid and soft foods. • Dysphagia in post-RYGB patients can be caused by primary motility disorders of the esophagus, for which high-resolution esophageal manometry (HRM) is the most accurate test. • HRM may be underutilized in the workup of upper GI symptoms in post-RYGB patients. • Identification of pre- or post-RYGB patients with esophageal motility disorders has the potential to improve the long-term weight loss outcomes of RYGB. [ABSTRACT FROM AUTHOR]

Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition. This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold. A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ±.3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ±.95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities. This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload. Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P <.0001). The perforation rate was higher in the ESD group (60% vs 30%, P =.18). Total procedure time (34.1 vs 88.6 min, P =.001) and dissection time (27.8 vs 79.4 minutes, P =.002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P =.01). RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads. [ABSTRACT FROM AUTHOR]

The management of laparoscopic sleeve gastrectomy leaks remains a challenge. This can be treated with placement of self-expandable metal stents, which are most effective in the acute and early settings. However, migration is a frequent adverse event (AE). Novel, fully covered stents with a larger proximal flare to limit migration designed specifically to treat postsleeve leaks were recently introduced. The aim of this study was to evaluate the safety and efficacy of a novel stent specifically designed for postsleeve leaks treatment. Multicenter retrospective study. This is a multicenter study, including patients with acute and early post laparoscopic sleeve gastrectomy leaks, treated with a large bariatric stent. The outcomes include technical success, clinical success, and safety profile. A multivariable regression was performed to assess predictors of success. Thirty-seven patients were included (10 acute and 27 early leaks), with 30 stents in the postpyloric (POST) and 7 in the prepyloric position. Technical success was 100%. Mean stent dwell time was 29.08 days. Clinical success was achieved in 78.37%. Leak duration, leak size, and stent dwell time did not correlate with clinical success. During follow-up, 8 patients had stent migration (21.62%) and all were in a POST position. AE poststent removal were also evaluated (prepyloric: 57.14% vs POST: 33.3%, P =.45). There was no difference between prepyloric and POST position in the severe AE analysis. This novel, large-caliber, fully covered stent specifically designed for sleeve leaks appears to be effective at treating acute and early leaks. However, the large flanges and long stent length do not appear to reduce migration rate and may be associated with higher overall severe AE rates. Avoiding placement in the POST position may help mitigate migration risk; however, owing to the risk profile this stent should be used with caution. - Despite satisfactory clinical results associated with bariatric surgery in the treatment of obesity, the number of complications has increased due to broad adoption of the procedure - A novel large-caliber fully-covered stent specifically designed for sleeve leaks appears to be effective at treating acute and early leaks - The large flanges and long stent length of this novel large-caliber fully-covered stent specifically designed for sleeve leaks do not appear to reduce migration rate - Post-pyloric POST position is associated with a higher incidence of migration and should be avoided. [ABSTRACT FROM AUTHOR]

Background and Aims The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. Methods Two 30-mm circular lesions were created in an ex vivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. Results Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P <.001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P <.001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P <.001). Conclusions The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States. Graphical abstract [ABSTRACT FROM AUTHOR]

Bariatric endoscopy has emerged as an alternative treatment modality for obesity and its related comorbidities. The field includes a wide range of procedures from endoscopic treatment for complications of bariatric surgery to performing primary endoscopic procedures for weight loss. Additionally, knowledge of adjunctive lifestyle therapy and pharmacotherapy are also critical to ensuring successful outcomes. This article reviews specific goals, resources, and specific steps for acquisition of specific cognitive and technical skills in bariatric endoscopic procedures. [ABSTRACT FROM AUTHOR]

Obesity is a worsening pandemic with numerous related comorbid illnesses. Conservative management including lifestyle modification and medications have limited efficacy. In contradistinction, bariatric surgery is effective, however, with substantial cost and non-negligible morbidity and mortality. As such, a small percentage of eligible patients undergo surgery. Over the past decade, endoscopic bariatric and metabolic therapies have been introduced as a less invasive option for the treatment of obesity and its related comorbid illnesses. This article reviews major endoscopic bariatric and metabolic therapies, their surgical analogues, and proposed mechanisms of action. Clinical trial data for each device also are discussed. [ABSTRACT FROM AUTHOR]

Background and Aims Transjugular intrahepatic portosystemic shunting involves the creation of a low-resistance channel between the portal vein (PV) and the hepatic vein (HV), and is routinely performed under angiography. The aims were to evaluate (1) safety and technical feasibility; (2) procedural duration; and (3) subjective workload assessment of EUS-guided intrahepatic portosystemic shunt (EIPS). Methods Five Yorkshire pigs were used in the study. The HV or inferior vena cava (IVC) was identified using a linear-array echoendoscope and accessed with a 19-G FNA needle preloaded with a digital pressure wire. Mean pressure was recorded. The needle was advanced into the PV, where pressure measurements were again taken, and ultimately exchanged over a guidewire. A lumen-apposing metal stent was deployed under EUS and fluoroscopic guidance, with distal and proximal ends positioned inside the PV and HV (IVC), respectively. Dilation was performed, and pressure measurements repeated. The National Aeronautics and Space Administration (NASA) Task Load Index (TLI) was scored. Animals survived 2 weeks before necropsy. Results EIPS was successful in 5 out of 5 pigs. Mean time required for EUS identification, needle access, pressure measurement, and stent placement was 43 (31-55) minutes. NASA TLI scores revealed moderate workload. Mean baseline pressure measurements were PV 7.0 (5-9) and HV/IVC 5.0 (3-7) mm Hg and PV 6.3 (5-7) and HV/IVC 6.0 (4-7) mm Hg after. All animals survived 2 weeks. No bleeding was seen on necropsy. Conclusions This study demonstrates the technical feasibility of EIPS using LAMS, with direct portal pressure measurement, in a survival model. In addition, the procedure was performed quickly with moderate technical demand. [ABSTRACT FROM AUTHOR]