Efficacy and Safety of Gastric Per-Oral Endoscopic Myotomy (G-POEM): A Systematic Review and Meta-Analysis.

BACKGROUND: Gastric per-oral endoscopic myotomy (G-POEM) is an innovative treatment that has become increasingly utilized for patients with refractory gastroparesis. The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of G-POEM for the treatment of gastroparesis. METHODS: Individualized search strategies were developed through February 2021 in accordance with the PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions and mean difference preprocedure and postprocedure with rates estimated using random effects models. Measured outcomes included technical success, clinical success, improvement in gastroparesis cardinal symptom index (GCSI), change in gastric emptying rate, alterations in impedance planimetry (functional lumen imaging probe [FLIP]) assessment, and adverse events. RESULTS: A total of 20 studies (n=797 patients; 67.41% female) were included. The mean age was 48.92±11.61 y, with an average duration of 4.24±1.11 y since gastroparesis diagnosis. Technical success was 98.47% [(95% CI: 97.14, 99.19);I2=0.00] with a mean myotomy length of 3.78±1.16 cm. In terms of clinical success, mean preprocedure GCSI scores were 3.38±0.37 and improved significantly postprocedure [weighted mean difference -1.56 (95% CI: -1.89 to -1.24); I2=82.53; P<0.001]. Gastric retention after 4 hours demonstrated ~50% improvement (preprocedure 43.08±9.24% versus postprocedure 22.97±10.19%; P<0.001). FLIP assessment with 40 mL and 50 mL balloons demonstrated a significant increase in diameter, distensibility index, and cross-sectional area postprocedure (all P<0.05). Procedure-associated adverse events occurred among 10.92% [(95% CI 5.09 to 19.32); I2=82.85] of patients. CONCLUSION: G-POEM appears safe and highly effective for the treatment of patients with refractory gastroparesis regardless of symptom predominance or etiology.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy for the palliation of gastric outlet obstruction in patients with peritoneal carcinomatosis.

BACKGROUND : Gastric outlet obstruction (GOO) with peritoneal carcinomatosis presents a technical challenge. Surgical gastrojejunostomy (SGJ) or enteral stenting have been the standard of care; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a favorable alternative. Few data exist that compare these techniques in the setting of peritoneal carcinomatosis. METHODS : This single-center retrospective cohort study included 25 EUS-GE and 27 SGJ consecutive patients. Baseline demographics, cancer diagnosis and stage, clinical and technical success, adverse events, and obstruction recurrence data were collected. The primary outcome was the technical success comparison; secondary outcome was the adverse event rate comparison. Rates were compared with standard statistical tests. RESULTS : Mean age, obstruction location, and symptoms were similar between the groups. The EUS-GE group had more advanced disease (clinical stage 4, 100 % vs. 67 %; P = 0.006) and higher American Society of Anesthesiologists classification (class 3-4, 92 % vs. 50 %; P = 0.004). The technical success rate was 100 % in both groups (P > 0.99) and the adverse event rate was lower for EUS-GE (8 % vs. 41 %; P = 0.01). Clinical success was 88 % for EUS-GE and 85 % for SGJ (P > 0.99) and recurrent obstruction was lower with EUS-GE (28 % vs. 41 %; P = 0.13). The EUS-GE group had shorter procedure duration, length of stay, and time to chemotherapy resumption than the SGJ group. CONCLUSIONS : Although the EUS-GE group was older, with more comorbidity and advanced stages, the technical success rate was similar to SGJ and it had significantly fewer adverse events. EUS-GE is a safe and effective option for the management of malignant GOO with peritoneal carcinomatosis.

Effect of Endoscopic Bariatric and Metabolic Therapies on Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis.

BACKGROUND & AIMS: Weight loss via lifestyle intervention remains the mainstay of treatment for nonalcoholic fatty liver disease (NAFLD). Endoscopic bariatric and metabolic therapies (EBMTs) have recently been developed as an alternative treatment option for obesity. This study aimed to assess the effect of FDA-approved EBMTs on NAFLD. METHODS: We searched MEDLINE, EMBASE, Web of Science and Cochrane Central through December 2020 for studies that assessed changes in liver outcomes following EBMT. Primary Outcomes: Liver fibrosis. SECONDARY OUTCOMES: Liver biochemistry, steatosis, NAFLD histological changes and insulin sensitivity. The Grading of Recommendations, Assessment, Development, and Evidence (GRADE) approach was conducted to assess quality of evidence. RESULTS: Of 4994 potential studies, 18 studies with 863 patients were included. Average weight loss was 14.5% of initial weight at a 6-month follow-up. Primary outcomes: Following EBMT, liver fibrosis significantly reduced by standardized mean difference (SMD) of 0.7 (95% CI, 0.1, 1.3; P = .02). SECONDARY OUTCOMES: There were significant improvements in other NAFLD surrogates including alanine aminotransferase (-9.0 U/L; 95% CI, -11.6, -6.4; P < .0001), hepatic steatosis (SMD: -1.0; 95% CI, -1.2, -0.8; P < .0001) and histologic NAFLD activity score (-2.50; 95% CI, -3.5, -1.5; P < .0001). Other metabolic parameters including insulin resistance and waist circumference also significantly improved. The overall quality of the evidence for primary outcomes was low to very low. CONCLUSIONS: EBMTs appear effective at treating NAFLD with significant improvement in liver fibrosis. Given the worsening NAFLD pandemic and limitations of currently available therapies, EBMTs should be further investigated as a potential treatment option for this patient population.

Endoscopic revision of gastrojejunal anastomosis for the treatment of dumping syndrome in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis.

BACKGROUND: Dumping syndrome is a known complication of Roux-en-Y gastric bypass (RYGB). Recently, endoscopic gastrojejunal anastomosis (GJA) revision has been employed as a treatment option. The primary aim of this study was to perform a systematic review and meta-analysis for the role of endoscopic GJA revision in patients with RYGB for the treatment of dumping syndrome. METHODS: Search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception through December 2020 in accordance with PRISMA and MOOSE guidelines. Pooled proportions with rates estimated using random effects models were used. Outcomes included pooled technical success, clinical success, adverse events, and rate of reintervention. Heterogeneity was assessed with I2 statistics and publication bias by funnel plot using Egger and Begg tests. RESULTS: Six studies (n = 263 patients; 60.25% female) were included (1 prospective and 5 retrospective). Mean age was 46.27 ± 2.54 years. Average patient weight was 95.59 ± 4.78 kg, BMI of 41.43 ± 3.07 kg/m2, and pre-procedure GJA size of 32.23 ± 8.68 mm. Pooled technical and clinical success was 98.15% and 89.5%. Among studies reporting Sigstad scores, endoscopic GJA revision resulted in a significant improvement [mean Sigstad score difference of - 9.96 (95% CI, - 19.951 to - 0.975); P < 0.03]. Mean procedure time was 37.12 ± 10.40 min with an intra-procedural adverse event rate of 2.42%. Over a mean follow-up of 8.03 ± 6.87 months, post-procedure adverse events occurred in 2.96% of patients with a reintervention rate of 11.54%. CONCLUSION: This systematic review and meta-analysis suggests that endoscopic GJA revision appears an effective and safe treatment for dumping syndrome.

Endoscopic Approaches to Obesity Management.

The field of endoscopic bariatric and metabolic therapy has rapidly evolved from offering endoscopic treatment of weight regain following bariatric surgery to providing primary weight loss options as alternatives to pharmacologic and surgical interventions. Gastric devices and remodeling procedures were initially designed to work through a mechanism of volume restriction, leading to earlier satiety and reduced caloric intake. As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease. This review considers gastric devices and techniques including space-occupying intragastric balloons, aspiration therapy, endoscopic tissue suturing, and plication interventions, followed by a review of small bowel interventions including endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically delivered devices to create incisionless anastomoses.

Optimizing outcomes for EUS-guided gastroenterostomy: results of a Standardized Clinical Assessment and Management Plan (with video).

BACKGROUND AND AIMS: EUS-guided gastroenterostomy (EUS-GE) has emerged as an option for managing malignant gastric outlet obstruction (GOO). However, there is currently no standardized technique, and outcomes are variable with inconsistencies both within and across centers. The present study aims to develop and assess outcomes of a Standardized Clinical and Assessment Management Plan (SCAMP) for EUS-GE. METHODS: A SCAMP was created by a multidisciplinary team to develop and optimize a systematic approach for EUS-GE. This is a single-center, prospective cohort study on patients undergoing EUS-GE for GOO, using the developed SCAMP. Baseline demographics, cancer diagnosis and stage, Eastern Cooperative Oncology Group (ECOG) performance score, clinical and technical success, adverse events (AEs), and obstruction recurrence were collected. Primary outcomes included technical and clinical success. Obstruction-free and overall survival were calculated and compared with Kaplan-Meier analysis. RESULTS: Fifty patients underwent EUS-GE in accordance with the SCAMP. Mean age was 67 years, 54% were women, and pancreatic cancer represented the largest cancer type (51%). Technical success was 100% and clinical success 92%. AEs occurred in 2 patients (4%). Recurrent obstruction occurred in 16%, related to distal small-bowel obstruction from carcinomatosis. Estimated mean obstruction-free survival was 217 days. Median overall survival was 230 days among patients with ECOG scores 0 to 2 and 82 days for ECOG scores ≥3 (P = .008). CONCLUSIONS: The standardized technique used was associated with high technical and clinical success and low rates of AEs, morbidity and procedure-related mortality. Adopting a similar uniform systematic approach may improve procedural outcomes and dissemination.

Endoscopic full-thickness resection of colorectal lesions: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) is a novel endoscopic technique for the resection of GI lesions not amenable to standard endoscopic therapy. The primary aim of this study was to perform a systematic review and meta-analysis to evaluate EFTR for the resection of colorectal lesions. METHODS: Individualized searches were developed through October 2020 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Random-effects models were used to determine pooled technical success, margin-negative (R0) resection, adverse events, procedure duration, and rate of recurrence at follow-up. Subgroup analysis was used to assess the impact of specific procedure techniques and regression analyses to determine influence of lesion size. Heterogeneity was assessed with I2 statistics and publication bias by funnel plots using Egger and Begg tests. RESULTS: Fourteen studies (1936 subjects; 39.6% women) were included. Most EFTR lesions were located in the colon (75.8%) with the remaining in the rectum. Mean procedure duration was 45.4 ± 11.4 minutes. Pooled technical success was 87.6% (95% confidence interval [CI], 85.1-89.8; I2 = 33), R0 resection rate was 78.8% (95% CI, 75.7-81.5; I2 = 33), procedure-associated adverse events occurred in 12.2% (95% CI, 9.3-15.9; I2 = 61), and recurrence rate was 12.6% (95% CI, 11.1-14.4; I2 = 0) over an average weighted follow-up of 20.1 ± 3.8 weeks. Regression analyses revealed significantly lower R0 resection (odds ratio, .3; 95% CI, .2-.6; I2 = 61; P = .0003) and higher overall procedure-associated adverse event rates (odds ratio, 3.5; 95% CI, 1.8-7.2; I2 = 55; P = .0004) for lesions >20 mm. CONCLUSIONS: EFTR overall appears to be an effective modality with high technical success and R0 resection rate with a relatively low risk of adverse events and recurrence, with greatest success when lesions are <20 mm.

Endoscopic simulators: training the next generation.

PURPOSE OF REVIEW: To provide a review of current evidence evaluating endoscopic simulators as teaching platforms in gastroenterology training, with emphasis on upper gastrointestinal anatomy. RECENT FINDINGS: Endoscopic simulators have leveraged mechanical, virtual reality and ex-vivo or live animal platforms to deliver training in both general and therapeutic endoscopy. Simulators have demonstrated their greatest utility in training novice endoscopists. Intermediate and expert endoscopists may additionally benefit from simulator exposure when learning advanced therapeutic techniques including large tissue resection or natural orifice transluminal endoscopic surgery. SUMMARY: Simulator-based learning offers promise to complement conventional endoscopic training modalities for novice trainees. Nevertheless, additional evidence demonstrating a clear benefit is required for simulators to become an integral part of gastroenterology training. As novel advanced endoscopic therapies are developed, endoscopic simulators may assume a larger role in training prior to clinical practice.

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison.

BACKGROUND AND AIMS: An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period. METHODS: This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons. RESULTS: Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years. CONCLUSIONS: Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Morbid Obesity Increases 30-Day Readmission and Morbidity in Clostridiodes difficile Infection.

BACKGROUND: Readmission for patients hospitalized with Clostridioides difficile infections (CDIs) carries high morbidity, mortality, and burden on healthcare resources. This study aims to determine if morbid obesity is risk factor for 30-day readmission in patients hospitalized with CDI. METHODS: This retrospective cohort study used the 2014 National Readmission Database. Included patients had a principal diagnosis of CDI and excluded if younger than 18 years of age or admitted during the month of December. Readmissions to any hospital for non-trauma diagnoses within 30 days of the index admission were included. The primary outcome was 30-day all cause readmission. Secondary outcomes were (1) in-hospital mortality; (2) morbidity, initiation of dialysis, or total parenteral nutrition; and (3) resource utilization during index admissions. RESULTS: A total of 91,265 subjects were included in this study, 4388 of whom were morbidly obese. Morbid obesity was associated with significantly higher odds of readmission and was associated with higher adjusted mean total hospitalization charges and costs, higher odds of PMV, and acute renal failure requiring dialysis in individuals that develop CDI. CONCLUSIONS: Morbid obesity is an independent risk factor for 30-day readmission in patients hospitalized for CDI. Morbidly obese patients admitted for CDI experienced higher morbidity and increased resource utilization.

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass.

INTRODUCTION: Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard. METHODS: Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF. RESULTS: One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities. CONCLUSIONS: Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.

Quantification of gastric sleeve stenosis using endoscopic parameters and image analysis.

BACKGROUND AND AIMS: Sleeve gastrectomy has quickly become the most commonly performed bariatric surgery. In light of its increasing popularity, the prevalence of gastric sleeve stenosis (GSS) continues to rise. Management with serial pneumatic dilation is highly successful but underused because of a lack of quantitative diagnostic criteria. We aimed to develop quantifiable endoscopic criteria to characterize GSS based on the (1) ratio of narrowest to widest gastric lumen diameter, (2) endoscope angulation/trajectory required for passage, and (3) presence of bilious fluid pooling in the proximal sleeve and compare it with endoluminal functional lumen imaging probe (EndoFLIP) diameter and distensibility indices (DIs) and endoscopic documentation of gastric lumen morphology. METHODS: We retrospectively reviewed a prospectively maintained database of patients undergoing endoscopy to assess for GSS. Endoscopic images were reviewed in a blinded fashion by 2 bariatric endoscopists. The narrowest and widest part of the gastric lumen diameters were noted on each image, in addition to a hypothetical trajectory required for endoscope passage. Using image processing software, we calculated the the ratio of diameters (ie, narrowest divided by widest) and angle of endoscope trajectory. The presence of bilious fluid pooling in the proximal gastric lumen was noted. These values were then compared with EndoFLIP parameters and endoscopic documentation of gastric lumen morphology. RESULTS: Thirty patients met inclusion criteria, and 26 (87%) were found to have a stenosis on endoscopy. Of those, 9 (35%) were characterized as mild, 11 (42%) as moderate, and 6 (23%) as severe. There was no difference in demographic information between patients with and without stenosis. In patients with stenosis, mean EndoFLIP diameters and DIs were 12.9 ± 3.9 mm and 11.0 ± 6.8 mm2/mm Hg, respectively. In patients without stenosis, mean EndoFLIP diameters and DIs were 19.9 ± 2.9 mm and 21.5 ± 1.0 mm2/mm Hg, respectively. Patients with stenosis had significantly lower diameter ratios compared with those without stenosis (.27 ± .14 vs .48 ± .77, P = .01). Diameter ratios were also inversely related to severity of sleeve stenosis (ß = -.08, P = .01). Patients with stenosis were also more likely to have fluid pooling (96.2% vs 25%, P < .001). There was no significant difference in the trajectory of endoscope passage between the 2 groups. CONCLUSIONS: Endoscopic criteria for diagnosis of GSS are lacking. Our data suggest the ratio between the narrowest and widest gastric lumen diameters and presence of pooled fluid is associated with diagnosis of stenosis by EndoFLIP and gastric lumen morphology. Future studies to validate these criteria are needed.

Small Intestinal Bacterial Overgrowth: Clinical Presentation in Patients with Roux-en-Y Gastric Bypass.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is defined by an increased number of bacteria measured via exhaled hydrogen and/or methane gas following the ingestion of glucose. This condition is prevalent following abdominal surgery, including Roux-en-Y gastric bypass (RYGB), and associated with a variety of non-specific abdominal symptoms, often requiring an extensive diagnostic work-up. AIM: To assess the frequency that individuals with RYGB anatomy are diagnosed with SIBO and if they are more likely to report specific gastrointestinal (GI) symptoms compared to individuals with native anatomy. METHODS: This large matched cohort study evaluated patients with GI symptoms who underwent a glucose breath test (GBT) for SIBO evaluation, utilizing 1:2 matching between RYGB and native anatomy. Patients with positive GBT were included in univariate and multivariate analyses to distinguish the presence of ten specific GI symptoms between RYGB and native anatomy. RESULTS: A total of 17,973 patients were included, where 271 patients with RYGB were matched to 573 patients with native anatomy that underwent GBT. Patients with RYGB anatomy and a positive GBT (199; 73.4%) as compared to those with native anatomy and a positive GBT (209; 36%) more often reported nausea, vomiting, bloating, and diarrhea. There were no differences between the two groups in the report of heartburn, regurgitation, chest pain, gas, or constipation. CONCLUSIONS: SIBO is common in patients with RYGB and more commonly report nausea, vomiting, bloating, and diarrhea. The results of this study suggest that the report of these symptoms in RYGB should prompt early evaluation for SIBO.

Evidence of Duodenal Epithelial Barrier Impairment and Increased Pyroptosis in Patients With Functional Dyspepsia on Confocal Laser Endomicroscopy and "Ex Vivo" Mucosa Analysis.

INTRODUCTION: Duodenal epithelial barrier impairment and immune activation may play a role in the pathogenesis of functional dyspepsia (FD). This study was aimed to evaluate the duodenal epithelium of patients with FD and healthy individuals for detectable microscopic structural abnormalities. METHODS: This is a prospective study using esophagogastroduodenoscopy enhanced with duodenal confocal laser endomicroscopy (CLE) and mucosal biopsies in patients with FD (n = 16) and healthy controls (n = 18). Blinded CLE images analysis evaluated the density of epithelial gaps (cell extrusion zones), a validated endoscopic measure of the intestinal barrier status. Analyses of the biopsied duodenal mucosa included standard histology, quantification of mucosal immune cells/cytokines, and immunohistochemistry for inflammatory epithelial cell death called pyroptosis. Transepithelial electrical resistance (TEER) was measured using Ussing chambers. Epithelial cell-to-cell adhesion proteins expression was assessed by real-time polymerase chain reaction. RESULTS: Patients with FD had significantly higher epithelial gap density on CLE in the distal duodenum than that of controls (P = 0.002). These mucosal abnormalities corresponded to significant changes in the duodenal biopsy samples of patients with FD, compared with controls, including impaired mucosal integrity by TEER (P = 0.009) and increased number of epithelial cells undergoing pyroptosis (P = 0.04). Reduced TEER inversely correlated with the severity of certain dyspeptic symptoms. Furthermore, patients with FD demonstrated altered duodenal expression of claudin-1 and interleukin-6. No differences in standard histology were found between the groups. DISCUSSION: This is the first report of duodenal CLE abnormalities in patients with FD, corroborated by biopsy findings of epithelial barrier impairment and increased cell death, implicating that duodenal barrier disruption is a pathogenesis factor in FD and introducing CLE a potential diagnostic biomarker in FD.

Endoscopic Repair of Large Gastric Perforation Following Pneumatic Dilation of Sleeve Gastrectomy Stenosis.

Sleeve gastrectomy has become the most commonly performed bariatric surgery in the USA (English et al.in Surg Obes Relat Dis. 14(3):259-63, 2018). Despite the rising popularity of this procedure, gastric stenosis is a known complication with an incidence of up to 4% (Rebibo et al. in Obes Surg. 26(5):995-1001, 2016). Endoscopic pneumatic balloon dilation is increasingly utilized to treat this condition and to ameliorate symptoms of nausea, vomiting, reflux, and/or dysphagia (Dhorepatil et al. in BMC Surg. 18(1):52, 2018). Pneumatic balloon dilation does carry a risk of gastric perforation of up to 3% in the limited literature to date (Donatelli et al. in Surg Obes Relat Dis. 13(6):943-50, 2017), historically requiring immediate surgical consultation for repair (Donatelli et al. Surg Obes Relat Dis. 13(6):943-50, 2017). In this case series, two cases of gastric perforation during pneumatic dilation for gastric sleeve stenosis were repaired successfully endoscopically with use of an endoscopic suturing system, resulting in correction of gastric defect and elimination of symptoms.