Post-surgical complications such as leaks & fistulas are the source of considerable morbidity & mortality. Transcutaneous radiological interventions & resource intensive Endo-Vac have variable & limited success in managing these patients. We have previously tested a minimally invasive novel approach of Endoscopic Negative Intracavitary Pressure (Endo-NIP) as proof of principle and found it to be effective in resistant leaks and fistula. Endo-NIP approach drains the cavity towards the luminal side instead of trans-cutaneous drains, an alternate to Endo-Vac, it uses simplified placement, ability to irrigate the cavity, as well as no requirement for frequent exchanges or expensive accessories. To examine the efficacy, safety and the factors that predict the success of Endo-NIP in a large series of patients with resistant leaks who failed, or were not candidates for conventional management. Forty-four patients (mean age 54.8 years; 68.1% male) underwent Endo-NIP for resistant leaks who failed, or were not candidates for conventional management. In a location and size dependent manner, Endo-NIP was approached either via a natural orifice (trans-nasal or trans-anal) or an existing prosthetic device (gastrostomy or jejunostomy feeding tubes). The cavity was disinfected endoscopically followed by the placement of variable length and diameter locking loop drains over a guide wire to create NIP, either through standard wall suction or low-cost portable alternatives. Periodic monitoring via contrast injection through loop drain allowed a low-cost follow-up to decide conclusion of management by removal of the Endo-NIP drain. The demographic, clinical, and imaging data was analyzed in a descriptive manner to outline the results of the study. On an average, patient had 4 failed procedures prior to EndoNIP and had leak/fistula for a mean of 56 days. 19 (43%) patients had EndoNIP with prosthesis (PEG/PEJ). In 22 (50%) patients, the drain size was 16Fr. In 29/44 patients (65.9%) Endo-NIP was successful with complete resolution of symptoms at a mean of 137.4 days with 430.4 days of mean follow-up. For 12 patients (27%) Endo-NIP had a partial response and provided a successful endoscopic bridge to surgery leading to a complete surgical response and 3(6.8%) had no response. Out of 23 patients with an upper GI defect, 17 (73.9%) responded compared to 12/21 (57.1% p<0.05). Other factors such as IBD, smoking, history of malignancy, chronicity of leak/fistula, type of approach and drain size were not statistically significant. Endo-NIP approach provides a definitive management strategy or optimizes nutrition & control of inflammation for a bridge to surgery and is a conceptually novel, promising alternative to conventional management of challenging and resistant leaks or fistulas.Figure 2Pelvic abscess: A) Concept drawing of pelvic abscess resulting from pouch leak. B) Endoscopic view of the rectal fistula. C) Fluoroscopic view of the fistula tract. D) Fluoroscopic view of the resolved fistula. E) Endoscopic view of the resolved fistula tract.View Large Image Figure ViewerDownload Hi-res image Download (PPT)