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A 52-year-old female with history of Roux-en-Y gastric bypass underwent resection of a huge cystic tumor of the pancreas. Postoperatively an amylase-rich retroperitoneal fluid collection was noted. The patient was referred for doubleballoon endoscopic retrograde cholangiopancreatography (ERCP) for a suspected pancreatic duct leak. The patient had anemia, anasarca, and severe malnutrition (albumin level of 1.8g/dl – normal range 3.5 to 4.6g/dl; hemoglobin 9g/dl – normal range 11.5 to 14.5). During endoscopy performed under general anesthesia, it became evident that the jejunal esophageal anastomosis was disrupted, communicating with a large pleuroperitoneal abscess. At this time a change in plans became mandatory. First, a direct, double-balloon enteroscopy (DPE) jejunostomy was performed to secure nutritional support (▶Fig. 1, ▶Video 1). Second, a Guardus overtube (STERIS Endoscopy, Mentor, Ohio, USA) was inserted per-orally into the abscess cavity and the therapeutic gastroscope was passed numerous times to remove copious amounts of pus and food using extraction devices. Third, the disrupted bowel was re-anastomosed endoscopically using a fully covered self-expanding metal stent (FCSEMS) (Cook Medical, Bloomington, Indiana, USA). In order to prevent stent migration, an over-thescope clip was used to anchor the FCSEMS in the esophagus. And finally, percutaneous assisted transprosthetic endoscopic therapy with sponge insertion was used to drain the abscessed cavity (▶Fig. 1, ▶Video 1). Several sponge exchanges were performed through the stent to finally collapse the cavity. The E-Videos

Extreme endoscopy: direct jejunostomy, re-anastomosis of bowel, percutaneous assisted transprosthetic endoscopic drainage in Roux-en-Y gastric bypass