Well, there are several different types of bariatric surgery, and I thought it'd be nice just to show you kind of the main ones here, and the top is the sleeve gastrectomy, where you have a long staple line and a good portion of the stomach is removed. On the bottom left is the gastric bypass, where now, in addition to that one long staple line, you have a couple of anastomoses. You have the gastrojejunal anastomosis and the jejunal jejunal, and then we have a long limb bypass on the right, and you can see the blue and yellow represents the food and then the various fluids, pancreatic biliary secretions that are mixing with it, and that has to do with the mechanism of action, but there's also unique variants to each one of those surgeries, and we'll touch on those a little bit as we go, but the main complications are very similar. The anastomotic ulcers are typically seen with the gastric bypass and the longer limb bypasses, and really, since the complications are the same, we'll focus more on gastric bypass since that's what's more common, and then we'll get on to stenoses, which can be seen in both gastric bypass and sleeve gastrectomy, leaks in fistula, and then weight regain. So ulcers can occur in up to 20% of patients in some series. It's most common in the first three months post-operatively, and they can develop at any time. Etiology can be acid production in the pouch. Pouches do produce acid. You can have a fistula between the pouch and the remnant stomach. Always need to look for that, do an upper GI series, NSAIDs, H. pylori, foreign body reaction, or microvascular ischemia due to tobacco or diabetes. In diagnosis, of course, typically made by EGP, but you do have to think about the mechanism of action here for these. So you might want to check a pouch pH if they're on PPIs already. If you're looking for H. pylori, remember to use either serology or fecal antigen because of breath tests and biopsies aren't good enough in this setting, and then when you treat them, you want to use a soluble PPI, open capsule PPI, sulforaphate's useful as well, and make sure you remove any contributory factors such as tobacco. So this is something else you can do to treat these, and it's ulcer over-sewing, and you can see up above here, this is a perforated ulcer that we sutured closed. So first we went out and lavaged the area, cleaned it up. It actually had ascites as well because it had decompensated cirrhosis, but this patient did very well afterwards. They got off their CBVHD and they were able to go home, and this is over-sewing an ulcer bed, basically advancing a flap over the ulcer, sewing from distal to proximal with a couple of interrupted sutures. So this is a series of 11 patients that were cast with marginal ulceration, and you can see they over-sewed in seven of these, and a couple also had covered stents placed over them, and abdominal pain improved substantially after this, technical success 100%, and ulcer healing was seen in 90% of these patients in the lab first advance. So if you have ulcers that aren't healing, this is a nice way to deal with it. Keep it in mind. It is very useful, especially as more and more of us are suturing. Moving on to stenosis. Oops, we've got to go backwards. So this is a case. This is a little laggy. Yeah, I'm sorry. It's funny, right? It's a 30. So the video, what's playing here is a stenosis, okay, and this patient was a 35-year-old female, three years post-gastric bypass with this anastomotic stricture. She had five sessions of balloon dilatation and was not responding, sent it to the surgeons for revision. They said, give it one more shot. So after dilating, we saw all the suture material. This is very common, right? If they over-sewed their anastomosis, you're going to find this, and the sutures were preventing the balloon from dilating the scar tissue. So we then injected some saline, and on follow-up exam, you can see it looked much better, and we did it one more time, removed remaining suture, and they did great. Sometimes just a more aggressive approach is needed. You don't want to just keep dilating larger balloons necessarily, because that can cause problems. But remove any foreign material. This is typically a good idea. You can also do a needle-in-the-life incision if you need. She had durable symptom improvement. So stenosis, fairly common. The best treatment here, balloon dilation, successful in up to 93% of cases. Two to three sessions are often required. Tell them about that in advance. Say we're going to go in a stepwise fashion. We don't want to perforate you or have you gain weight. Just let them know. You don't want to exceed 15 millimeters in the first dilation. Again, the perforation rate is 3% to 5%, so it's not insignificant. If you have a perforation, you can use aluminum-opposing metal stent to cover that area. That's probably the best way to treat it. Remove any foreign bodies. Do a physical revision only when necessary, because that's a big surgery. And don't over-dilate. Here's another case, a 54-year-old male with gastric bypass, chronic stenosis, resistant to multiple attempted balloon dilations, epigastric pain, and this is what the upper GI looks like. If you look at this carefully, always look at your imaging, it kind of looks like there might be something there, right? It's really laggy. Something right in there. And you can see on the upper endoscopy, it's clearly stenosed. And what we're doing here is we're putting aluminum-opposing metal stent in, because this patient, you can see right there, that white, that's a band, right? So what they have and what you see on the upper GI is a FOBI ring or a sialastic band, and that band will prevent you from being able to dilate it. So after leaving that stent in just four to eight weeks, it will cause erosion of the band inter-aluminally, and you can cut it and remove it. That's a FOBI capella procedure. Keep an eye out for it, more common on the West Coast, but we still see a good bit of it. We just did this a few weeks ago. And it's much better to do it this way than have them go to surgery. It's a big surgery. Trying to advance the slide. There we go. Next we have a 32-year-old female with gastric bypass and postprandial emesis excess weight loss. It's not doing well here, but the upper endoscopy showed that the anastomosis was normal. Symptoms didn't resolve despite dilation. They also had a normal motility study. So what do we see here? You see a very long blind limb, right? So this is something called a candy cane syndrome. It's more and more common as we look for it, and we're doing an EUS because a good way to treat this, I don't know why that skipped back, but a good way to treat this is to use another aluminum opposing metal stent here. So here what we're doing is taking a stent and going from the blind portion of the root limb into the main root limb, release the distal flange into that, and we release the proximal flange and we connect. And this is a phenomenal way to treat this. Much better than revision surgery. You can see the stent right there. And it's just another trick to have up your sleeve for these patients. Try to advance that slide. There we are. You also see stenosis in sleeve gastrectomy. This is very common as well. Usually down at the incisora, it's seen up to 4% of patients. It can be related to them using a small bougie or twisting the sleeve as they're stapling. Symptoms are what you'd expect. And what I'm showing here is a pneumatic balloon dilation. So there are other options to treat this as well, but you can start if it's proximal stenosis, you can use a hydrostatic balloon. However, if it's down in the incisora and you're at least six weeks out from surgery, you should use a pneumatic balloon, 30 millimeter. Don't go larger than that to begin with. And I always recommend using the one with a sphingomanometer bulb. It takes you up to a 20 PSI and you don't really want to go above that. And here you see, I like to do it with an endoscope and look through the balloon. And you want to keep an eye on this because you can totally open up the staple line. It's rare. It happened to me just a few weeks ago though. So you got to be careful and you just watch it. If that pale area, you want to see it kind of a small ring, maybe even a wide white ring. But if it spreads faster or larger than that, you want to be careful and not continue with the dilation. And so this is a meta-analysis looking at 18 studies, 426 patients that underwent balloon dilation, average 1.8 sessions, overall success rate was 76%. So this is very effective. And it's something that's very helpful. It's better than making the patients have a gastric bypass or conversion procedure. And 17% of people ultimately needed surgery in that series, but it's a lot that avoided it. Moving on to leaks and fistula. These can be categorized by chronicity, etiology, location, and severity. And there's, you know, different sites. This is important to know for gastric bypass because you can't just assume it's an anastomosis. You have to see where that leak is, or you could run into problems, right? So type, here's the different types and locations. And type one to two is up in that pouch along the staple line or at the anastomosis, 80% are there. Type four down at the JJ anastomosis, this is a 30 to 40% mortality rate because people stent the pouch, high five, we treated it, and the leaks down at the JJ and they ignore that. So that's a problem. So you can go down there and clip that or take care of the actual leak. And you can see here, the other ones are more rare. There we go. So proximal, so for a sleeve gastrectomy, the staple line leak is typically at the top. And that's oftentimes due to stenosis of the lower sleeve down at the incisor as well. Mortality rate is still 9% when it's pretty substantial, but there it is. And here we are, the different ways of treating these. So you can use exclusion techniques using a covered stent. That's a good way to treat these. If it's acute, if it's chronic, it's not going to do anything. You can actually close them with hemo clips or, you know, a cap mounted clip or maybe a suturing device. That's fine for acute ones as well. If it's chronic, it's not going to work. Then there's occlusive devices. Now the ones on the left are for acute leaks and the ones on the right are for more chronic things. So you can use septal occluders, sorts of plugs and fibrin sealants. You can also do internal drainage if it's a chronic leak with a cavity, such as pigtails and vacuum-assisted closure devices. All right. So just looking at covered stents. So covered stents are very effective. This is an old meta-analysis showing that success rate's 88% if it's an acute leak and gastric bypass. That's good. I'm going to keep moving. So that's good for acute leaks. There's a cap mounted clip and this was a nice series, multi-center retrospective led by the Hopkins Group. You can see here leaks. There are 32 patients with leaks and there was a 80% success rate in treating those leaks. Those are acute leaks. The fistula, if you look at chronic ones, it's only 45% successful. You can see here we're grabbing tissue using this twin grasper, pulling it into the clip and then we're going to release the clip. So I think that, and we like doing this with fluoro so we can confirm that it's sealed. You can leave a wire through it as well to make sure you keep it centered because the main problem is if you're not centered, you're going to still have a persistent leak. And so that's a pretty easy way to treat these. But again, it has to be acute. Don't try this in a chronic leak, it's just not going to work. Trying to advance that. There we go. And then pigtails are another, a very effective way to drain chronic leaks and fluid collections. We've known this since we've used them for treating walled off necrosis. And you can see here success rates very high, as high as 98% when you have a nice chronic walled off collection. So good for chronic leaks. And then this is something that's a little newer, but we do use a lot of these now for chronic leaks. This is a use of a cardiac septal occluder. Again, this is off label. This is not their indication, but we're loading it into an OASIS delivery catheter there. And then we use a pediatric biopsy forceps through it. We just have to cut it. There's no delivery system that's available that's long enough to go through an endoscope. You can see in the bottom video, we're actually placing it and we're just pushing it out the OASIS system with a pediatric forceps, and then we'll be able to position it. So this is a series of 43 patients, 31 had sleeve gastrectomy, 12 had gastric bypass. And you can see most of them had failed prior endoscopic treatment, a hundred percent technical success rate and 90% clinical success rate. And that success rate was actually oddly associated with the chronicity. The more chronic the fistula, the more likely it was it would be successful. So you don't want to use these in acute ones, it's kind of expensive too, but for chronic ones, it's good for chronic leaks. And then finally, vacuum therapy. This is another one for really just recalcitrant ones that are just really difficult. This is a phenomenal way. The only problem is with this, it's kind of quirky, you have to make it yourself, right? So you put the tube in the nose, you pull it out the mouth, you sew the sponge on, you go down and drive it down where you want to put it. But if you have something that's not healing with any other means, this thing works. It's quite amazing. I think they're going to have this at the hands-on sessions here for the ASC as well. So we have over 80% success rate in fistula that just aren't otherwise healing. It's chronic. So again, main things you're thinking about when you're, how do we treat these leaks? It's chronicity. If it's acute, you want to cover it, clip it or suture it. And if it's chronic, you want to drain it, plug it or use vacuum therapy. And then you can consider other things as well. If it's down at the JJ, you can't put an esophageal stent in, that makes sense. You could clip it if it's acute, et cetera. So you think about the location and the size as well. And finally, weight regain. So this is a study we did when Barb and I were together back at the Brigham. And basically we showed that the larger the anastomosis was, the more weight was regained. So that's relevant, right? So we know that big outlets will benefit from being closed. Can we advance that please? Thanks. And this is just a regression that showed that. Please advance. And this was the first multicenter randomized sham control trial using the old barred endosynch so it's no longer available. And what they showed was patients in both the treatment and sham group lost weight for the first six weeks. And then the sham group gained their weight back where the treatment group kept it off. Now, it wasn't a lot of weight, it was 3.5% total weight loss, but it was providing us level one evidence to show that it worked. Next slide, please. And you can see here, it does, the new device delivers much more weight loss, the OverStitch, which is approved for this now, and delivers 8.8% total weight loss at five years. And we have a 10-year abstract here at this DDW, so stop by and check it out. But this is a very good procedure and it offers great solution for people to weight gain after gastric bypass. Next slide. And you can see here, this is the newer way we're doing it. We're incorporating third space into bariatrics for better weight loss results. And what we're doing is using a T-type knife that can inject fluid under high pressure to perform a modified ESD circumferentially around the gastrodegenal anastomosis. And this is much better. It's a better way to prepare the tissue than just APC alone. 8.8% weight loss is great, but you can see here using this technique, we're getting 12% total weight loss. And that does great from an insurance coverage standpoint. So it doesn't take that long to do it. You can do these in well under an hour. It's also an easier type of ESD, if you will, than you would, like, say, colon ESD. It's much easier than that. Then we ablate the intervening mucosa using APC. That's 70 watts forced in the end-firing probe. And then we got conclusions, I guess. So that's a very effective procedure. So in conclusion, marginal ulcerations, you want to use open capsule PPIs for absorption. You want to remove any contributory factors and remove any foreign material as well. For stenosis, you want to, again, remove foreign material whenever possible. And you can do a myotomy if needed. There's tunnel stricturotomy techniques as well. For leaks in fistula, anatomic features are important, and you got to consider chronicity to help you guide therapy. And for weight regain, endoscopic management is optimal, and you got to learn the right techniques and keep improving. And finally, many surgical complications are amenable to endoscopic therapy. May seem aggressive, but they're less invasive than surgical alternatives. So please, you know, try to continue building your skillset so you can offer these to patients. Thank you very much.

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