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The article presents a case study of a 67-year-old woman who was presented to the emergency department with complaints of nausea, vomiting, abdominal pain, and distention three days post-intragastric balloon insertion. Topics discussed include risk factors associated with intragastric balloons, the difficulty in deciphering expected post-intragastric balloon insertion symptoms, and the use of intragastricballoons for weight loss.

Objectives: The global rise in overweight, obesity, and related diseases is undeniable; however, the pathogenesis of obesity and obesity-associated diseases is heterogeneous, with varied complications and a discordant response to treatment. Intriguingly, men have a shorter lifespan than women, despite being half as likely to be obese. This paradox suggests a potential gender disparity in the impact of obesity on mortality, with men potentially being more vulnerable to obesity-associated health risks., Methods: This retrospective study utilized Global Burden of Diseases data from 204 countries/territories to bridge the knowledge gap in understanding gender disparities in obesity-related mortality. Outcomes were obesity-associated mortality, years of life lost, years lived with disability, and disability-adjusted life years (DALYs)., Results: In 2019, the global overweight/obesity-related disease burden reached 160.2 million DALYs, with 5.02 million associated deaths. From 1990 to 2019, the age-standardized death rates increased in males (from 58.19 to 66.55 per 100,000 person-years, APC = 0.36%, 95% CI: 0.30 to 0.42%, P < 0.001), while females experienced a decrease in age-standardized death rates (from 59.31 to 58.14 per 100,000 person-years, APC = -0.22%, 95% CI: -0.29% to -0.14%, P < 0.001). Age-standardized DALYs increased more in males (1632.5 to 2070.34 per 100,000 years, APC = 0.74%, 95% CI: 0.70% to 0.78%, P < .001) compared to females (1618.26 to 1789.67 per 100,000 years, APC = 0.24%, 95% CI: 0.19% to 0.29%, P < 0.001). Disparities were more pronounced in countries with a higher socioeconomic status and predominantly affected younger populations., Conclusions: Overweight/obesity-related morbidity and mortality are higher among male sex. Identifying differences in pathogenesis, complications and treatment response is crucial to develop targeted interventions and equitable public health policies to combat this global burden., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background & Aims: There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process., Methods: A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus., Results: A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak., Conclusions: The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM., (Copyright © 2024. Published by Elsevier Inc.)

Background and Aim: Effective clinical event classification is essential for clinical research and quality improvement. The validation of artificial intelligence (AI) models like Generative Pre-trained Transformer 4 (GPT-4) for this task and comparison with conventional methods remains unexplored., Methods: We evaluated the performance of the GPT-4 model for classifying gastrointestinal (GI) bleeding episodes from 200 medical discharge summaries and compared the results with human review and an International Classification of Diseases (ICD) code-based system. The analysis included accuracy, sensitivity, and specificity evaluation, using ground truth determined by physician reviewers., Results: GPT-4 exhibited an accuracy of 94.4% in identifying GI bleeding occurrences, outperforming ICD codes (accuracy 63.5%, P < 0.001). GPT-4's accuracy was either slightly lower or statistically similar to individual human reviewers (Reviewer 1: 98.5%, P < 0.001; Reviewer 2: 90.8%, P = 0.170). For location classification, GPT-4 achieved accuracies of 81.7% and 83.5% for confirmed and probable GI bleeding locations, respectively, with figures that were either slightly lower or comparable with those of human reviewers. GPT-4 was highly efficient, analyzing the dataset in 12.7 min at a cost of 21.2 USD, whereas human reviewers required 8-9 h each., Conclusion: Our study indicates GPT-4 offers a reliable, cost-efficient, and faster alternative to current clinical event classification methods, outperforming the conventional ICD coding system and performing comparably to individual expert human reviewers. Its implementation could facilitate more accurate and granular clinical research and quality audits. Future research should explore scalability, prompt and model tuning, and ethical implications of high-performance AI models in clinical data processing., (© 2024 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Introduction: Symptom burden management is a major goal of pancreatic cancer care given that most patients are diagnosed late. Early palliative care is recommended in addition to concurrent active treatment; however, disparities exist. We sought to determine the factors associated with inpatient palliative treatment among pancreatic cancer patients and compare treatment outcomes in terms of mortality, discharge disposition and resource utilization., Methods: We conducted a retrospective study of 22,053 pancreatic cancers using the National Inpatient Sample (NIS) database (January - December 2020). Patient and hospital characteristics, mortality, discharge disposition, length of stay (LOS), hospital costs and charges were compared between pancreatic cancer patients based on palliative treatment. Multivariate regression was used to evaluate patient and hospital characteristics and outcomes associated with palliative treatment., Results: A total number of 3839 (17.4%) patients received palliative care. Patients who received palliative care were more likely to be older, Medicaid insured, and nonobese. Patients were less likely to receive palliative care if they are males, Medicare insured, had a lower Charlson comorbidity score, or treated in Urban nonteaching hospitals. Patients who received palliative care displayed higher odds of in-hospital mortality and prolonged LOS. The adjusted additional mean hospital cost and charges in patients who received palliative care were lower by $1459, and $4222 respectively., Conclusions: Inpatient palliative treatment in pancreatic cancer patients is associated with an older age, a higher comorbidity burden, non-obesity, insurance status and urban teaching hospitals. Our study suggests that inpatient palliative treatment decreased hospital resource utilization without prolonging survival., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose of Review: The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications., Recent Findings: The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB., Summary: Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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: Disclosure 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., (Copyright © 2024 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. Published by Elsevier Inc. All rights reserved.)

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

Objective: We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts., Background and Aims: Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results., Methods: An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data., Results: Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity., Conclusions: PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines., Competing Interests: A.D.S. has received an honorarium from Foundation Medicine Inc. M.N.N. and Y.E.N. own intellectual property related to the PancreaSeq technology and receive royalties from University of Pittsburgh. R.H.H. has the potential to receive royalty payments from Thrive Earlier Detection for the GNAS invention in an arrangement reviewed and approved by the Johns Hopkins University in accordance with its conflict-of-interest policies. The remaining authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of these endoluminal bariatric and metabolic procedures., Recent Findings: The landscape of endoluminal devices and techniques for treating obesity has expanded significantly, with FDA-approved therapies currently available to patients with a body mass index values as high as 50 kg/m 2 . Although notable advancements have been made in this area, there is a need for further emphasis to be placed on the metabolic improvements resulting from these therapies, in addition to the conventional focus on weight loss outcomes. Some of these procedures are now FDA approved for the treatment of metabolic disease as opposed to weight loss. To achieve the most favorable results, it is imperative that all endoluminal interventions are combined with a moderately intensive diet and lifestyle program lasting at least 12 months., Summary: Endoluminal metabolic and bariatric therapy represents a bridge between lifestyle counseling, pharmaceutical interventions, and the most efficacious treatment for obesity, bariatric surgery. By virtue of its minimally invasive approach, this therapy may be an appealing option for patients who are ineligible for, or averse to, bariatric surgery and who have experienced suboptimal outcomes or unable to afford medical treatments. Furthermore, these interventions may be particularly beneficial in the early stages of obesity., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and study aims A single-operator, articulating, through-the-scope (TTS) traction device was recently developed to facilitate endoscopic submucosal dissection (ESD). Clinical data on the performance of this device are limited. We report an initial multicenter experience with ESD using this articulating TTS traction device. Patients and methods Retrospective analysis on all consecutive patients who underwent ESD using this traction device (T-ESD) at five centers between August 2021 and December 2022. Endpoints included: rates of en-bloc resection, R0 resection, curative resection, and adverse events. Results Thirty-six patients (median age 64.8 years; 47.2% women) underwent ESD (median lesion size 40 mm; interquartile range [IRQ]: 27.5-67.5) for lesions in the esophagus (n=2), stomach (n=8), sigmoid colon (n=6), and rectum (n=20). Submucosal fibrosis was encountered in one-third of the lesions (33.3%). Median ESD time was 104.6 minutes (IQR: 65-122). En-bloc, R0 and curative resection were achieved in 94.4%, 91.6%, and 97.2%, respectively. The single patient with non-curative resection of an invasive rectal adenocarcinoma underwent surgery. There were no cases of delayed bleeding or perforation. There was no recurrence on surveillance endoscopy (n=20) at a median of 6 months (IQR: 3.75-6). Conclusions This initial multicenter experience demonstrates high resection rates and excellent safety profile when performing ESD with this novel articulating TTS device. Dynamic real-time traction may lower the technical difficulty of ESD. Additional studies are needed to assess its cost-effectiveness and compare its usefulness with other traction devices and techniques during ESD., Competing Interests: Conflict of Interest D Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, Medtronic and Microtech. DYang receives research support from Microtech and 3D-Matrix. MK Hasan is a consultant for Boston Scientific and Olympus. PV Draganov is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. V Kumbhari is a consultant for Boston Scientific, Medtronic, FujiFilm, and has received research support from FujiFilm. M. Mizrahi is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. A. Schlachterman is a consultant for Fujifilm, Lumendi, Apollo Endosurgery, Olympus. All other authors have nothing to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and Aims: The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs)., Methods: The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality., Results: One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48)., Conclusions: The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background/aim: Training endoscopists to perform endoscopic retrograde cholangiopancreatography (ERCP) is critical to address the increasing patient population with pancreatobiliary diseases. Concerns remain about ERCP safety and success involving trainees. We compared the technical success and immediate adverse events between ERCP with and without trainee involvement., Methods: Retrospective analysis of 28,271 ERCP procedures in a national sample of the United States over 12 years. Demographics, procedure and fluoroscopy time, visualization and cannulation of main structures, adverse events, and technical success rates were compared between ERCP with and without trainees. Categorical variables were compared using Pearson's chi-square test and continuous variables using a standard t-test. Univariate and multivariate regressions were performed adjusting for age, gender, ethnicity, US region, ASA class and clinical setting., Results: Approximately 49.5% of ERCPs had a trainee involved. The ampulla was visualized in 97.4% with trainee vs. 97.3% without trainee involvement (P = 0.858). The common bile duct was visualized and cannulated in 90.4% with trainees vs. 91.7% without trainees involved (P < 0.001). The ERCP was incomplete in 5.9% of cases with trainees vs. 6.4% without trainees involved (P = 0.207). Trainee participation added 8.7 min to average procedure time (aOR: 1.02, P < 0.001) and 2.0 min to fluoroscopy time (aOR: 1.00, P = 0.796). Adverse events (aOR: 0.89, P = 0.704) and technical success (aOR: 0.83, P = 0.571) were similar in both groups., Conclusions: Trainee involvement leads to increased procedure duration but is not associated with increased immediate adverse events, or technical failure. Our study supports ERCP safety and success with trainee participation., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: We conducted this study to compare the weight loss outcome of intragastric balloons (IGBs) in conjunction with pharmacotherapy vs IGB and intensive lifestyle changes alone., Methods: This was a multicenter, non-randomized, retrospective study involving 4 academic hospitals. Patients underwent IGB placement with or without concomitant anti-obesity pharmacotherapy. The primary outcome was percent total weight loss (TBWL) after IGB placement at 6 and 12 months., Results: This study included 102 patients, with 23 patients (mean age 46.6 years, 82.6% female) treated with IGB/pharmacotherapy and 79 patients (mean age 46.0 years, 88.6% female) treated with IGB/lifestyle modifications. Patients had a 100% follow-up rate at 6 and 12 months. At 6 months following IGB placement, both groups achieved a similar %TBWL. At 12 months, %TBWL was greater in the IGB/pharmacotherapy group (12.6% ± 1.2 vs 9.7% ± 0.7, P = .04). 65.2% of patients achieved ≥10% TBWL at 12 months in the IGB/pharmacotherapy group, compared to 38.0% in the IGB/lifestyle group ( P < .05). The proportion of patients that achieved ≥15% weight loss at 12 months was also significantly different between the IGB/pharmacotherapy and IGB/lifestyle groups (30.4% vs 20.3%, P < .05)., Discussion: IGB with concomitant use of pharmacotherapy did not improve weight loss while the IGB was in place compared to IGB and lifestyle changes. However, patients receiving IGB with pharmacotherapy did have greater weight loss and diminished weight regain after balloon removal compared to those receiving just IGB and lifestyle changes.

Prosthetic valve endocarditis (PVE) remains a serious condition with a high mortality rate. Precise identification of the PVE-associated pathogen/s and their virulence is essential for successful therapy and patient survival. The commonly described PVE-associated pathogens are staphylococci, streptococci, and enterococci, with Staphylococcus aureus being the most frequently diagnosed species. Furthermore, multi-drug resistance pathogens are increasing in prevalence and continue to pose new challenges mandating a personalized approach. Blood cultures in combination with echocardiography are the most common methods to diagnose PVE, often being the only indication, it exists. In many cases, the diagnostic strategy recommended in the clinical guidelines does not identify the precise microbial agent, and frequently, false-negative blood cultures are reported. Despite the fact that blood culture findings are not always a good indicator of the actual PVE agent in the valve tissue, only a minority of re-operated prostheses are subjected to microbiological diagnostic evaluation. In this review, we focus on the diversity and the complete spectrum of PVE-associated bacterial, fungal, and viral pathogens in blood and prosthetic heart valve, their possible virulence potential, and their challenges in making a microbial diagnosis. We are curious to understand if the unacceptable high mortality of PVE is associated with the high number of negative microbial findings in connection with a possible PVE. Herein, we discuss the possibilities and limits of the diagnostic methods conventionally used and make recommendations for enhanced pathogen identification. We also show possible virulence factors of the most common PVE-associated pathogens and their clinical effects. Based on blood culture, molecular biological diagnostics, and specific valve examination, better derivations for the antibiotic therapy as well as possible preventive intervention can be established in the future., Competing Interests: Conflict of interest: There is no conflicts of interest of the authors who worked on this publication., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.