Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Table 1 Endoscopic closure techniques

Endoscopic techniques	Indications/advantages	Not indicated/disadvantages	Authors experience
Cap-mounted clips	(1) Acute/ early/ late/ chronic; (2) Small orifices (< 20 mm); and (3) Safe	(1) Orifices > 20 mm; (2) Need for external drainage; and (3) Variable efficacy	(1) Acute/ early/ late/ chronic; (2) Safe; (3) < 10 mm: > efficacy; (4) > 10mm: very low efficacy; (5) Combined therapy improves its efficacy; and (6) Can be removed when fails to close the defect (not easy to remove)
Glues/ tissue sealants	(1) Acute/ early/ late/ chronic; (2) Diameter < 10 mm; (3) Low drainage (< 200 ml/24 h); and (4) Safe	(1) Multiple sessions are usually required; (2) Need for external drainage; and (3) Variable efficacy	(1) Late/ chronic; (2) Low efficacy; (3) Safe; (4) Helpful as an adjunctive therapy; (5) Never use it as a single therapy; (6) Multiple sessions; (7) Cytology brushing or APC is useful to loosen granulation tissue before application; (8) Delivery via endoscopic or percutaneous access; and (9) High cost (tissue sealants)
Endoscopic suturing	(1) Acute/ early/ late/ chronic; (2) High technical success; and (3) Safe	(1) Need for external drainage; (2) Low efficacy (need for robust and healthy tissue for primary closure); (3) Challenging: Previous experience with the device is needed; and (4) High costs (most countries)	(1) Very poor long-term clinical success; (2) Helpful for other devices fixation; (3) Not recommended for chronic defects; and (4) High cost

APC: Argon plasma coagulation.