Artificial Intelligence and ChatGPT in Abdominopelvic Surgery: A Systematic Review of Applications and Impact.

BACKGROUND/AIM: The integration of AI and natural language processing technologies, such as ChatGPT, into surgical practice has shown promising potential in enhancing various aspects of abdominopelvic surgical procedures. This systematic review aims to comprehensively evaluate the current state of research on the applications and impact of artificial intelligence (AI) and ChatGPT in abdominopelvic surgery summarizing existing literature towards providing a comprehensive overview of the diverse applications, effectiveness, challenges, and future directions of these innovative technologies. MATERIALS AND METHODS: A systematic search of major electronic databases, including PubMed, Google Scholar, Cochrane Library, Web of Science, was conducted from October to November 2023, to identify relevant studies. Inclusion criteria encompassed studies that investigated the utilization of AI and ChatGPT in abdominopelvic surgical settings, including, but not limited to preoperative planning, intraoperative decision-making, postoperative care, and patient communication. RESULTS: Fourteen studies met the inclusion criteria and were included in this review. The majority of the studies were analysing ChatGPT's data output and decision making while two studies reported patient and general surgery resident perception of the tool applied to clinical practice. Most studies reported a high accuracy of ChatGPT in data output and decision-making process, however with an unforgettable number of errors. CONCLUSION: This systematic review contributes to the current understanding of the role of AI and ChatGPT in abdominopelvic surgery, providing insight into their applications and impact on clinical practice. The synthesis of available evidence will inform future research directions, clinical guidelines, and development of these technologies to optimize their potential benefits in enhancing surgical care within the abdominopelvic domain.

The multidisciplinary management of locally advanced rectal cancer.

INTRODUCTION: The classic paradigm for the management of locally advanced rectal cancer (LARC) consists of (chemo)radiotherapy (C)RT), total mesorectal excision, and adjuvant chemotherapy (CHT). At present, due to the high rate of distant metastasis (up to 30%), the total neoadjuvant therapy (TNT) with the administration of systemic CHT in the neoadjuvant setting has gained acceptance as standard of care.Our aim is to critically review the current literature on LARC management and summarize the different approaches recently proposed to improve clinical outcomes. It represents a starting step to develop an effective strategy that ultimately could harmonize the standard of care in daily clinical practice. AREAS COVERED: Studies reporting the impact of TNT approaches were deemed eligible. De-escalation strategies, including non-operative management (NOM) after TNT, as well as RT omission or systemic therapy alone, were also investigated. EXPERT OPINION: The year 2020 has seen promising new data from randomized phase III trials in the field of LARC management. Nowadays, TNT strategy has been accepted as the primary treatment for LARC. The role of de-escalation strategies is still unknown. The goal is to achieve better survival outcomes with improving quality of life. Only selected patients are likely to benefit from NOM or immunotherapy alone.

Bariatric Surgery and New-Onset Substance Use Disorders: A Systematic review and Meta-analysis.

Increasing evidence suggests that bariatric surgery (BS) patients are at risk for substance abuse disorders (SUD). The purpose of this systematic review and meta-analysis was to determine the relationship between BS and the development of new-onset substance abuse disorder (SUDNO) in bariatric patients. On October 31, 2023, we reviewed the scientific literature following PRISMA guidelines. A total of 3242 studies were analyzed, 7 met the inclusion criteria. The pooled incidence of SUDNO was 4.28%. Patients' characteristics associated with SUDNO included preoperative mental disorders, high pre-BS BMI, and public health insurance. Surgical factors associated with new SUDNOs included severe complications in the peri- or postoperative period. The occurrence of SUDNOs is a non-negligeable complication after BS. Predisposing factors may be identified and preventive actions undertaken.

Analysis of Factors Related to Gastroesophageal Reflux After Gastric Bypass at 10-Year Follow-up: A Retrospective Single-institutional Study.

BACKGROUND/AIM: Long-term gastroesophageal reflux (GERD) after gastric bypass for obesity is underestimated. The present study aimed to evaluate the rate of treated GERD and the factors influencing it in a cohort of patients who underwent gastric bypass. PATIENTS AND METHODS: Patients who underwent one-anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) as a primary bariatric procedure between 2010 and 2011 at a French private referral center were included in the study. The primary endpoint was the 10-year prevalence of GERD. RESULTS: In total, 422 patients underwent RYGB and 334 underwent OAGB with a biliopancreatic limb of 150 cm. The mean age was 38.9±11.3 years, and 81.6% of patients were female; the mean preoperative body mass index was 42.8±5 kg/m2 Preoperative GERD was diagnosed in 40.8% of patients in the total cohort, 31.7% in the RYGB group versus 49.1% in the OAGB group (p<0.0001). At 10-year follow-up, the rate of GERD was 21.1%, with no difference between the two groups. Remission of preoperative GERD and de novo GERD were comparable between the two types of bypass. Surgery for GERD resistant to medical treatment was more frequent in the OAGB group. At multivariate analysis, factors significantly correlated with long-term GERD were: Preoperative GERD, total weight loss at 120 months <25%, glycemic imbalances and anastomotic ulcers. CONCLUSION: Identification and correction of modifiable factors may help reduce the incidence of long-term GERD.

Readmission and reoperation rates after laparoscopic bariatric surgery in an Italian center of excellence.

BACKGROUND: The aim of this study was to analyze short-term outcomes focusing on readmissions after laparoscopic bariatric metabolic surgery (BMS) in an Italian academic Bariatric Center of Excellence IFSO-European Chapter (EC). METHODS: This is a retrospective study based on the analysis of a prospectively maintained institutional database. Patients aged between 18 and 65 years who underwent primary BMS and/or revisional BMS (RBMS) between 2012 and 2021 were included. Primary endpoint was to analyze the readmission rate at 30 postoperative days. The secondary endpoint involved assessing the causes of readmission within 30 days of discharge, the rates, and types of reoperations and/or additional procedures related to the first surgery, and the outcomes of readmitted patients. RESULTS: A total of 2297 patients were included in the study. Among them, 2143 underwent primary surgery and 154 patients underwent RBMS. Eighty-two percent of the Enhanced Recovery after Surgery (ERAS) protocol items were applied starting from 2016. Within 30 days after discharge, 48 patients (2.09%) were readmitted. Overall readmission rate following primary and revisional BMS was 2.15%, respectively 1.30%. Ten readmitted patients (20.8%) had complications graded IIIb or more (Clavien-Dindo classification) and needed additional procedures. Mortality rate was 4.17% among readmitted patients. CONCLUSIONS: Only 2.09% of patients undergoing laparoscopic bariatric surgery were readmitted. Of these, 20.8% required additional procedures. Standardization of surgical techniques and perioperative protocols in a bariatric center of excellence resulted in a low readmission rate even in RBMS.

Stapled Anastomosis Versus Hand-Sewn Anastomosis With Mucosectomy for Ileal Pouch-Anal Anastomosis: A Systematic Review and Meta-analysis of Postoperative Outcomes, Functional Outcomes, and Oncological Safety.

PURPOSE: This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of ulcerative colitis and familial adenomatous polyposis. METHODS: This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines 2020 and AMSTAR 2 (Assessing the methodological quality of systematic reviews) guidelines. We included randomized clinical trials (RCTs) and controlled clinical trials (CCTs). Subgroup analysis was performed according to the indication for surgery. RESULTS: The bibliographic research yielded 31 trials: 3 RCTs, 5 prospective clinical trials, and 24 CCTs including 8872 patients: 4871 patients in the stapled group and 4038 in the hand-sewn group. Regarding postoperative outcomes, the stapled group had a lower rate of anastomotic stricture, small bowel obstruction, and ileal pouch failure. There were no differences between the 2 groups in terms of operative time, anastomotic leak, pelvic sepsis, pouchitis, or hospital stay. For functional outcomes, the stapled group was associated with greater outcomes in terms of seepage per day and by night, pad use, night incontinence, resting pressure, and squeeze pressure. There were no differences in stool Frequency per 24h, stool frequency at night, antidiarrheal medication, sexual impotence, or length of the high-pressure zone. There was no difference between the 2 groups in terms of dysplasia and neoplasia. CONCLUSIONS: Compared to hand-sewn anastomosis, stapled ileoanal anastomosis leads to a large reduction in anastomotic stricture, small bowel obstruction, ileal pouch failure, seepage by day and night, pad use, and night incontinence. This may ensure a higher resting pressure and squeeze pressure in manometry evaluation. PROTOCOL REGISTRATION: The protocol was registered at PROSPERO under CRD 42022379880.

Roux en Y gastric bypass and iterative intussusception at the jejuno-jejunal anastomosis: Conversion into one anastomosis gastric bypass (with video) - A case report.

INTRODUCTION: The aim of this article is to describe a rare complication of Roux en Y gastric bypass (RYGB): recurrent intestinal intussusception of the biliary limb, and an original treatment: the removal of the jejuno-jejunal anastomosis with conversion into "short limb" one anastomosis gastric bypass (OAGB). PRESENTATION OF CASE: A 25-year-old patient underwent RYGB fashioned with a 50 cm-length biliary loop and a 150 cm-length alimentary loop. She was hospitalized other 3 times in the following months for episodes of acute abdominal pain and excessive weight loss, with CT scans showing intussusception at the jejuno-jejunal anastomosis. Conversion from RYGB to OAGB with "short biliary limb" was performed. The patient at 60-month follow-up has no bile reflux and regained weight. DISCUSSION: Small bowel intussusception is a rare complication that can occur following Roux-en-Y gastric bypass (RYGB) surgery, leading to symptoms like acute or chronic abdominal pain. Treatment options reported in medical literature include resection and re-fashioning of the jejuno-jejunal anastomosis, simple reduction (with a risk of recurrence), and imbrication/plication of the jejuno-jejunal anastomosis. Given the rarity of this complication, there are no standardized recommendations, and the best treatment should be determined on a case-by-case basis, taking into consideration the patient's unique circumstances and the medical team's expertise. CONCLUSION: Intestinal intussusception at the jejuno-jejunal anastomosis responsible for chronic abdominal pain is a rare complication after RYGB. One of the possible treatments is conversion into OAGB.

Large and bleeding gastroduodenal artery aneurysm: Challenging diagnosis and treatment. A case report.

INTRODUCTION: Visceral artery aneurysms (VAA), including gastroduodenal artery aneurysms (GAA), are rare pathologies that can be challenging to diagnose due to their often-asymptomatic nature. VAA are usually correlated to atherosclerosis, fibro dysplasia, or hemodynamics changes, while pseudo aneurysms are mostly correlated to infection, inflammation, traumas, or iatrogenic lesions. PRESENTATION OF CASE: We report the case of an 82-years-old female presenting with abdominal pain and hematemesis. Upper gastrointestinal endoscopy retrieved a large duodenal mass and subsequent CT scans identified a large GAA with contrast extravasation. Endovascular procedure included selective arteriography, microcatheterization, and embolization. DISCUSSION: VAA are mostly located in the splenic and hepatic artery. Symptoms of VAA are related to pressure on neighboring organs. VAA rupture is associated with a high mortality risk (over 76 %) and presents with symptoms like acute abdominal pain, hematemesis, and hemodynamic shock. Diagnosis is often made through CT scans and angiography. Treatment options for VAAs and GAAs include both surgical and endovascular methods. Endovascular treatment is preferred, with a success rate of 89 %-98 %. CONCLUSION: This case provides an example of challenging diagnosis and treatment of a large and bleeding GAA.

Oncological Outcome After Laparoscopic 'No-touch' RAMPS Versus 'Touch' Left Pancreatectomy for Pancreatic Adenocarcinoma.

BACKGROUND/AIM: The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a "no-touch" technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aimed to evaluate the oncological outcomes of the laparoscopic "no touch" technique versus the "touch" technique. PATIENTS AND METHODS: From 2001 to 2020, we retrospectively analyzed 45 patients undergoing laparoscopic distal pancreatectomy (LDP) for PDAC in two centers. Factors associated with overall (OS), disease-free survival (DFS) and time to recurrence (TTR) were identified. RESULTS: The OS rates in the 'no-touch' and 'touch' groups were 95% vs. 78% (1-year OS); 50% vs. 50% (3-year OS), respectively (p=0.60). The DFS rates in the 'no-touch' and 'touch' groups were 72 % vs. 57% (1-year DFS); 32% vs. 28% (3-year DFS), respectively (p=0.11). The TTR rates in the 'no-touch' and 'touch' groups were 77% vs. 61% (1-year TTR); 54% vs. 30% (3-year TTR); 46% vs. 11% (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique [odds ratio (OR)=2.62, p=0.02] and lymphovascular emboli (OR=4.8; p=0.002). CONCLUSION: We advise the 'no-touch' technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the 'no-touch' technique in this setting although there could be oncological benefits.

Wandering spleen causing small bowel obstruction: Laparoscopic surgical treatment (with video).

INTRODUCTION: Wandering spleen (WS) is a clinical entity in which the spleen is not located in its normal anatomical site. Few cases have been reported, mainly in women of childbearing age. This condition can be congenital or acquired due to excessive elasticity of the spleen's suspensory ligaments. WS may cause acute complications requiring emergency surgery, especially related to the rotation of its vascular pedicle, leading to chronic or acute ischemia. The aim of the present case is to show a rare complication of WS, small bowel obstruction (SBO), and its management. PRESENTATION OF CASE: We report the case of a 40-year-old female presenting with abdominal pain, nausea, and vomiting. CT scan showed SBO caused by WS located in the pelvis with an enlarged spleen vascular pedicle (SVP). Laparoscopic exploration, splenectomy, small bowel resection and anastomosis were performed. DISCUSSION: WS may cause chronic or acute complications, mainly linked with enlargement and torsion of SVP, including acute ischemia and spleen necrosis, or compression of the near organs such as small intestine, stomach, pancreas. The diagnosis is based on physical examination, CT scan and blood exams. Generally, the WS's treatment is laparoscopic splenectomy or splenopexy. In case of vital spleen, splenopexy can be performed, in case of not vital spleen, splenectomy should be preferred. CONCLUSION: This case provides an excellent example of SBO related to WS. In the video, the management of this complex situation is shown. In these cases, splenectomy represents a valuable option.

Overall Survival Following Anastomotic Leakage After Surgery for Carcinoma of the Esophagus and Gastroesophageal Junction: A Systematic Review.

The effect of anastomotic leakage, in patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction, on overall survival (OS) is a debated and controversial topic. The aim of this systematic review was to clarify the impact of anastomotic leakage on long-term survival of patients with esophageal cancer undergoing esophagectomy. A systematic literature review was carried out from 2000 to 2022. We chose articles reporting data from patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction. Data regarding 1-, 3- and 5-year OS were analyzed. Twenty studies met the inclusion criteria, yielding a total of 9,279 patients. Analyzing data from selected studies, anastomotic leakage was found to be associated with decreased OS in 5,456 cases while in the remaining 3,823 it had no impact on long term survival (p<0.05). However, this result did not emerge from the other studies considered in the systematic review. Anastomotic leakage is a severe postoperative complication, which seems to have an impact on overall survival. However, the topic remains debated and not supported by all case series included in this systematic review.

Perforated Ulcer of the Gastrojejunal Anastomosis and Concomitant Internal Hernia After One Anastomosis Gastric Bypass.

PURPOSE: The management of concomitant complications after OAGB is challenging. We aim to show the surgical management of two concomitant complications after one anastomosis gastric bypass: internal hernia and anastomotic ulcer perforation. MATERIALS AND METHODS: We present the case of a 32-year-old woman with BMI of 51 kg/m2, who underwent OAGB. Three years later, she presented with intense and brutal epigastric pain. She was a heavy smoker. Her weight and BMI were 75 kg and 26 kg/m2, respectively. Clinical examination showed generalized peritonitis, computed tomography showed pneumoperitoneum, diffuse peritoneal effusion, and rotation of the superior mesenteric vessels indicative of an internal hernia. RESULTS: A generalized biliary peritonitis secondary to a perforated ulcer on the gastrojejunal anastomosis and internal hernia of the common loop into a large Petersen orifice were diagnosed. The internal hernia was reduced, and a perforation of the posterior surface of the gastrojejunal anastomosis was identified. Surgical treatment consisted in the placement of a Kehr's drain into the perforation, closure of the Petersen orifice, and lavage-drainage of the peritoneal cavity. The postoperative course was uneventful, and she was discharged on postoperative day 12. The Kehr's drain was removed 1 month after discharge. CONCLUSION: The combination of two different complications after OAGB can make the pre- and intra-operative judgment difficult and hamper the therapeutic approach. The initial reduction of the internal hernia made it possible to reduce the pressure in the surgical assembly and facilitated the treatment of the anastomotic perforation.

A Narrative Review on Bariatric ERAS.

Introduction: Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS. Methods: A literature search for studies published up to June 30, 2022, with no restrictions on language or publication period, was performed on Medline and Embase, using the keywords "ERAS" OR "enhanced recovery after surgery" AND "bariatric surgery" OR "metabolic surgery". Postoperative length of hospital stay LOS, overall and major morbidity and mortality, readmission rates, postoperative nausea or vomit PONV, opioids and antiemetics use, hospital costs, ERAS in specific health care settings, barriers to ERAS and further developments were analyzed. Results/Conclusions: The results were presented with a narrative review, using tabulation to summarize the results of meta-analyses and RCTs: 6 articles reporting guidelines, 5 metaanalyses, 9 randomized controlled trials, and 48 observational studies. ERAS protocols are feasible and safe in the setting of BMS, and associated to reduced LOS, PONV and postoperative pain, reduced opioid and antiemetic use and reduced costs. Postoperative mortality and readmission rates are similar between patients receiving standard care and those with ERAS protocols. Furthermore, increase of ERAS application may be useful in health care systems dealing with epidemic infectious diseases and implemented by technological advancements.

Endoscopic Kehr's T-Tube Placement to Treat Persistent Large Gastro-cutaneous Fistula After One Anastomosis Gastric Bypass: Video Demonstration.

BACKGROUND: We aim to show the endoscopic placement of a T-tube to treat a persistent large gastro-cutaneous fistula after OAGB. METHODS: We present the case of a 46-year-old woman with BMI of 48 kg/m2, who underwent OAGB and was re-operated on the 2nd postoperative day (POD) for leakage. Washing and drainage of the abdominal cavity was performed, and no fistulous orifice was identified. An upper gastrointestinal (GI) endoscopy was performed at POD 20 for the persistence of leakage of 150 ml/day by the drain and a gastric fistulous orifice of 2 cm was detected. RESULTS: At POD 22, under general anesthesia, upper GI endoscopy was performed and a T-tube was placed in the fistulous orifice with a "rendez-vous" technique (as demonstrated in the Video), placing the T branch in the digestive lumen pressed against the wall and the long part of the T exiting at the cutaneous orifice. The T-tube was clamped after 3 days and the patient could be gradually re-fed. The patient was discharged 8 days after the procedure, with perfect clinical tolerance and no complications. The ablation of the tube one was performed on POD 84. No relapse occurred during a follow-up of 48 months. CONCLUSION: Persistent large gastro-cutaneous fistulas with an orifice bigger than 1 cm in diameter are difficult to manage. The endoscopic placement of a T-tube seems a useful option, which may facilitate the healing of the fistula. Further studies are needed to better define the role of this procedure.

Postoperative Pancreatic Fistula: Is Minimally Invasive Surgery Better than Open? A Systematic Review and Meta-analysis.

BACKGROUND/AIM: Minimally invasive pancreaticoduodenectomy (PD) is gaining popularity. The aim of this study was to compare the incidence of postoperative pancreatic fistula (POPF) after minimally invasive versus open procedures. MATERIALS AND METHODS: Following the PRISMA statement, literature research was conducted focusing on papers comparing the incidence of POPF after open pancreaticoduodenectomy (OPD) versus minimally invasive pancreaticoduodenectomy (MIPD). RESULTS: Twenty-one papers were included in this meta-analysis, for a total of 4,448 patients. A total of 2,456 patients (55.2%) underwent OPD, while 1,992 (44.8%) underwent MIPD. Age, ASA score III patients, incidence of pancreatic ductal adenocarcinoma and duct diameter were significantly lower in the MIPD group. No statistically significant differences were found between the OPD and MIPD regarding the incidence of major complications (15.6% vs. 17.0%, respectively, p=0.55), mortality (3.7% vs. 2.4%, p=0.81), and POPF rate (14.3% vs. 12.9%, p=0.25). CONCLUSION: MIPD and OPD had comparable rates of postoperative complications, postoperative mortality, and POPF.

Ten-year outcome of one-anastomosis gastric bypass with a biliopancreatic limb of 150 cm versus Roux-en-Y gastric bypass: a single-institution series of 940 patients.

BACKGROUND: Long-term outcomes of one-anastomosis gastric bypass (OAGB) need to be compared with those of Roux-en-Y gastric bypass (RYGB). OBJECTIVE: The present study evaluates the long-term outcomes at 10-year follow-up of OAGB with a biliopancreatic limb of 150 cm versus RYGB. SETTING: Private practice, France. METHODS: Data of patients who underwent OAGB or RYGB as primary or secondary procedures between 2010 and 2011 at a referral center were collected prospectively and analyzed retrospectively. RESULTS: A total of 940 patients underwent OAGB (n = 405) or RYGB (n = 535). Operative time was significantly shorter in the OAGB group. Postoperative morbidity occurred in 17.2% of patients after RYGB versus 8.1% after OAGB (P ≤ .0001). Patients in the RYGB group had a significantly higher rate of kinking of the jejuno-jejunal anastomosis, stenosis of the gastrojejunal anastomosis, and dysphagia for early ulcers. At long term, no differences were found in the rate of severe malnutrition. Cumulated morbidity was significantly higher after RYGB, with higher incidence of internal hernia, anastomotic ulcer, blind-loop syndrome, and hypoglycemia. Conversion to RYGB and laparoscopic exploration for chronic pain were more frequent after OAGB. Surgery for weight regain was significantly more frequent after RYGB. Patients in the OAGB group had significantly lower weight, body mass index, and greater percentage excess, and total weight losses at 120 months. No significant differences were detected in co-morbidity outcomes. CONCLUSION: After 10 years, both RYGB and OAGB are effective procedures. However, OAGB is associated with shorter operative times and better results in short- and long-term morbidity and weight loss outcomes.

Treatment of Persistent Large Gastrocutaneous Fistulas After Bariatric Surgery: Preliminary Experience with Endoscopic Kehr's T-Tube Placement.

PURPOSE: Post-bariatric surgery gastrocutaneous fistula is a chronic leak with an incidence of 1.7 to 4.0% and no standardized management. A large gastrocutaneous fistula (LGCF) is not indicated for treatment with pigtail drains. We aimed to evaluate results of a novel treatment using endoscopic Kehr's T-tube placement. METHODS: Only patients with a postoperative LGCF duration of > 10 days and a flow rate of > 50 cc by external drainage after revisional surgery for sepsis were included. Endoscopic placement of Kehr's T-tube was performed. Patients had been reoperated with wash and drainage for severe sepsis after initial bariatric surgery in which no fistula had been discovered. Patients not reoperated, or with a fistula requiring intraoperative Kehr's T-tube placement, or a pigtail drain were excluded. Primary outcomes were endoscopic characteristics and results (LGCF closure rate, Kehr T-tube retention time, etc.). RESULTS: The study group included 12 women, 2 men; body mass index 43.1 ± 4.5 kg/m2. Interventions were SG (7), RYGB (2), OAGB (4), and SADI-S (1). Endoscopic assessment was carried out after a mean of 33.2 ± 44.3 days after the bariatric procedure. The mean fistula orifice diameter was 2.0 ± 0.9 cm. Kehr's T-tube was positioned at a mean 51.5 ± 54.8 days after the bariatric procedure. T-tube tolerance was excellent. Mean additional days: hospitalization, 34.4 ± 27.0; T-tube retention, 86.4 ± 73.1; fistula healing, 139.9 ± 111.5, LGCF closure rate, 92.9%. COMPLICATIONS: 1 pulmonary embolism, 2 T-tube migrations,1 drain-path bleed, 1 skin abscess. No mortality. CONCLUSIONS: Endoscopic Kehr's T-tube placement was successful in closing persistent post-bariatric surgery LGCF in 92.9% of patients.