EndoVAC therapy is a potentially useful adjunct to conventional treatments of a subset of upper gastrointestinal leaks and perforations when there is a contained cavity <8 cm. It appears less effective in an uncontained perforation or chronically established tract. It has clear advantages of being easily applied with readily available equipment and disposables.

This report describes three cases of significant lower gastro-intestinal haemorrhage caused by a bleeding Meckel's diverticulum. In the first two cases a pre-operative technetium-pertechnetate or Meckel's scan was negative or inconclusive, and in the third case no Meckel's scan was carried out. The diagnosis was established at laparoscopy in all three cases and in each case the diverticulum was excised extracorporeally.

No abstract

A 73-year-old woman presented with iron deficiency anemia and melena. Biochemical parameters revealed a hemoglobin of 77 g/L and urea 8.5 mmol/L with normal renal indices. She was transfused with 2 units of red blood cells. Gastroscopy revealed a bread clip embedded in D1 (showing the date Friday, 13 April;• " Fig. 1), pinching the distal and proximal duodenal roof fold and dangling like an earring. Attempts to remove the clip by crushing with grasping forceps, cutting with a needle-knife device, and snapping with snare were unsuccessful. A gastric band cutter (Endotherapeutics, Sydney, Australia) was employed endoscopically. The cutting wire was threaded between the bread clip and the duodenum (• " Fig. 2), and the free end was retrieved and locked into the racheting device, forming a loop. Tightening of the loop resulted in the wire snapping the clip, which was then retrieved orally (• " Fig. 3). Only 21 cases of bread clip ingestion have been reported since 1975. Most cases present as small-bowel perforation requiring bowel resection [1]. Bread clips are made of plastic and are therefore nondegradable. With an aging population, we postulate that such cases will be increasingly seen [2]. The shape of the clip results in a traplike effect, which prevents easy removal once it is embedded [3]. Endoscopic removal of embedded foreign bodies can require taking a unique approach. This is the first reported case of the use of a gastric band cutter to divide an embedded foreign body followed by successful retrieval. Endoscopy_UCTN_Code_TTT_1AO_2ALCompeting interests: None This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Objectives: To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables. Summary of Background Data: Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. Methods: From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. Results: A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (k ¼ 0.85, P < 0.001). There were 59 patients, (training: 30, validation: 29). Age 42.5 AE 10.8 versus 38.9 AE 10.0 years (P ¼ 0.187); female 65.5% versus 80.0% (P ¼ 0.211), weight 127.4 AE 31.3 versus 141.0 AE 47.9 kg, (P ¼ 0.203). In the training group, there was a trend toward longer hospital stays as grading increased (I ¼ 10.5 d; II ¼ 24 d; III ¼ 66.5 d; IV ¼ 72 d; P ¼ 0.005). Risk of salvage resection increased (risk ratio grade 4 ¼ 9; P ¼ 0.043) as did complication severity (P ¼ 0.027).Findings were reproduced in the validation group: risk of salvage resection (P ¼ 0.007), hospital stay (P ¼ 0.001), complications (P ¼ 0.016). Conclusion:We have developed and validated a classification system, based on protocolized CT imaging that predicts a step-wise increased risk of salvage resection, complication severity, and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions.