After 20 years of evolving methods in managing Foregut leaks a couple of lessons have been learned. Unfortunately, the published literature provides no coherent guide as to how to approach these patients. While there is clear agreement that the clinical course of these leaks is frequently not benign, translating this knowledge into management algorithms is difficult because many surgeons have only sporadic exposure to these patients and reluctance to make early contact with high volume clinicians is prevalent. Treatment algorithms also vary between institutions depending less on patient factors than clinician preference. Despite these problems, Laparoscopic Sleeve Gastrectomy (LSG) leaks are a useful “model” for the study of the management of foregut leaks. These leaks can be classified in a way that allows clinicians to select treatments that treat the drivers of the leak as well as the associated sepsis. Therapy that fails to acknowledge the presence of a high-pressure lumen and/or a large unstable extra-luminal cavity will fail. Endoscopic, radiologic and surgical therapies are not binary choices and should be used synchronously. Failed therapy is a common occurrence and practitioners managing these patients should consult early with experienced clinician’s. Finally, surgery has the potential to both rescue or doom a patient who presents with a foregut leak. Surgical therapies beyond “lavage and drain” will sometimes be preferable however they are escalatory and can potentially create new problems without effectively treating the underlying condition. This presentation will discuss an “endoscopy first” approach to diagnosis and management of foregut leaks.