Background/Objectives: The management of refractory pancreatic duct (PD) and cystic duct leaks may represent an endoscopic challenge. Standard endoscopic therapy involves pancreatic/biliary sphincterotomy and stenting during endoscopic retrograde cholangiopancreatography (ERCP). After conservative (fasting, parenteral nutrition, and use of somatostatin analogs) or conventional endoscopic treatments fail, a surgical approach is usually required, leading to higher mortality due to several technical complications. Previous evidence of the endoscopic use of N-butyl-2-cyanoacylate (NBCA) for treating pancreaticobiliary leaks is reported, although the evidence is scarce. Methods: Six patients with pancreaticobiliary leaks (three IT pancreatic leaks and three Class A sec. Strasberg post-cholecystectomy biliary leaks) refractory to previous treatment were treated with the endoscopic topical application of NBCA. All our patients gave informed consent. The procedures were all performed between December 2017 and February 2025 at a tertiary referral center for biliopancreatic endoscopy. Results: Therapeutic success, as shown both endoscopically and radiologically, was 100%, and no procedural complication was reported. In one patient with biliary leak, standard cannulation of the cystic duct stump with the guidewire was unsuccessful, requiring a peroral cholangioscopy (SpyGlass System DSII) to directly visualize the leakage site, allowing a precise closure of the wall defect with NBCA. Conclusions: NBCA injection could represent a safe and effective endoscopic option in refractory PD of the tail of the pancreas and cystic duct leaks. Larger and further studies are necessary to confirm these results.

A 54-year-old man complaining of massive rectal bleeding and severe anemia was referred to our endoscopic center by the surgical unit. He had undergone stapled hemorrhoidectomy with Longo’s technique 3 weeks before, and had received topical steroid and mesalamine therapy for 1 week without clinical improvement. Rectosigmoidoscopy was scheduled and performed, showing a 3-cm dehiscence caused by impaired or delayed wound healing at the dentate line ([Fig. 1]). During the same procedure, 3 ml of the novel hemostatic gel Purastat was applied to obtain formation of a synthetic clot covering the entire dehiscence area. No bleeding or other complications were observed during or after the procedure ([Fig. 2]). Four weeks later, the patient underwent scheduled follow-up rectosigmoidoscopy, which showed scarring of the area with complete mucosal healing ([Fig. 3]). No bleeding, tenesmus, or other symptoms were reported by the patient ([Video 1]). Video 1 Endoscopic application of a novel hemostatic gel to treat wound dehiscence after stapled hemorrhoidectomy. Wound dehiscence is an early complication of stapled hemorrhoidectomy, with a prevalence of 3 %–5 %; it has been attributed to malfunctioning staplers and surgical inexperience, and surgical revision is often required [1]. Purastat is an uncolored, fully synthetic, viscous peptide hydrogel that self-assembles into fibers forming a sort of extracellular matrix; this matrix then acts as a mechanical barrier on the bleeding source, providing a hemostatic effect [2]. In addition to the known hemostatic effect, it has been hypothesized that the similarity of the 3 D nanostructure of activated Purastat to the natural extracellular matrix scaffold material favors cell and tissue proliferative processes, leading to more effective mucosal healing [3]. This treatment may become a valid alternative to revision surgery in patients with wound dehiscence following stapled hemorrhoidectomy. Endoscopy_UCTN_Code_CCL_1AD_2AJ Article published online: 17 March 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 55-year-old woman who complained of colicky pain, constipation, and abdominal fullness was referred to our endoscopy center by the surgical unit. The patient had undergone elective sigmoidectomy for diverticular disease 5 weeks previously and had received 1 week of polyethylene glycol (PEG)-based laxatives and antispasmodic therapy without clinical improvement. As a colorectal anastomotic stricture was suspected, rectoscopy was scheduled and performed, showing a thick septum that was partially occluding the colorectal anastomosis, which appeared to be freely passable with a gastroscope ([Fig. 1] a). During the same procedure, an endoscopic septotomy was performed using a single-use Triangle Tip electrosurgical knife ([Fig. 1] b). A minimal amount of intraprocedural bleeding occurred and was treated by the application of through-the-scope clips ([Fig. 2]). No other complications were observed ([Video 1]). The patient returned 4 weeks later to undergo a follow-up rectoscopy, which showed the septotomy scarring and a wide anastomotic lumen. No bleeding, tenesmus, or constipation were reported by the patient over the next weeks. Anastomotic stricture/stenosis is a common complication after colorectal anastomosis [1] but, to the best of our knowledge, we here report for the first time endoscopic septotomy for the treatment of a colorectal anastomotic septum. This treatment may become a valid alternative to revisional surgery for this rare colorectal anastomotic complication after elective laparoscopic sigmoidectomy. Endoscopy_UCTN_Code_TTT_1AQ_2AF Article published online: 28 May 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany