Advertisement

Endoscopic closure of a large perforation during pneumatic dilation of a sleeve gastrectomy stricture

Open AccessPublished:May 07, 2019DOI:https://doi.org/10.1016/j.vgie.2019.03.016
      Stenosis after sleeve gastrectomy classically occurs at the incisura, with a reported incidence of up to 7%.
      • Rebibo L.
      • Hakim S.
      • Dhahri A.
      • et al.
      Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management.
      With the increasing popularity of sleeve gastrectomy, the prevalence of this adverse event continues to rise. Symptoms of obstruction can occur depending on the severity of the narrowing. This diagnosis is typically made by endoscopy or upper-GI series. Endoscopic dilation with a pneumatic balloon is the primary mode of management; however, perforation rates are not insignificant.
      • Manos T.
      • Nedelcu M.
      • Cotirlet A.
      • et al.
      How to treat stenosis after sleeve gastrectomy?.
      • Jirapinyo P.
      • Abidi W.M.
      • Thompson C.C.
      Systematic treatment of sleeve gastrectomy stenosis with hydrostatic and pneumatic balloon dilation is safe and effective.
      • Schulman A.R.
      • Thompson C.C.
      Complications of bariatric surgery: what you can expect to see in your GI practice.
      • Parikh A.
      • Alley J.B.
      • Peterson R.M.
      • et al.
      Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.
      Here, we demonstrate pneumatic dilation complicated by a large gastric perforation that was successfully closed by endoscopic suturing (Video 1, available online at www.VideoGIE.org).
      A 71-year-old woman with a history of laparoscopic sleeve gastrectomy performed 1 year earlier presented with nausea, vomiting, reflux, and inability to tolerate oral intake. Index endoscopy demonstrated severe stenosis at the level of the incisura (Fig. 1). Dilation with a hydrostatic balloon followed by a pneumatic balloon was performed (Fig. 2). With the balloon inflated less than 1 minute, the gastric mucosa was noted to have a severely discolored appearance, which rapidly extended proximally (Fig. 3). This was a sign of impending perforation.
      Figure thumbnail gr1
      Figure 1Severe stenosis at the level of the incisura.
      Figure thumbnail gr2
      Figure 2Pneumatic dilation of sleeve stricture.
      Figure thumbnail gr3
      Figure 3Rapid extension proximally of severely discolored mucosa during pneumatic dilation.
      The balloon was immediately deflated, and a large 5-cm × 3-cm perforation was visualized on the lesser curvature side of the gastric wall, opposite the suture line (Fig. 4). Endoscopic suturing with a running stitch was performed in a distal-to-proximal direction, with successful closure. An upper-GI contrast study demonstrated no evidence of active or ongoing leak (Fig. 5).
      Figure thumbnail gr4
      Figure 4Large perforation visualized on the lesser curvature side of the gastric wall, opposite the suture line.
      Figure thumbnail gr5
      Figure 5Upper-GI series demonstrating no evidence of active or ongoing leak.
      In conclusion, endoscopic suturing for closure of a large gastric perforation after pneumatic dilation of a sleeve gastrectomy stricture is a novel, technically feasible, and effective treatment negating the need for surgical revision.

      Disclosure

      Dr Schulman is a consultant for Apollo Endosurgery, Boston Scientific, and MicroTech.

      Supplementary data

      References

        • Rebibo L.
        • Hakim S.
        • Dhahri A.
        • et al.
        Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management.
        Obes Surg. 2016; 26: 995-1001
        • Manos T.
        • Nedelcu M.
        • Cotirlet A.
        • et al.
        How to treat stenosis after sleeve gastrectomy?.
        Surg Obes Relat Dis. 2017; 13: 150-154
        • Jirapinyo P.
        • Abidi W.M.
        • Thompson C.C.
        Systematic treatment of sleeve gastrectomy stenosis with hydrostatic and pneumatic balloon dilation is safe and effective.
        Gastroenterology. 2018; 154: S-1276
        • Schulman A.R.
        • Thompson C.C.
        Complications of bariatric surgery: what you can expect to see in your GI practice.
        Am J Gastroenterol. 2017; 112: 1640-1655
        • Parikh A.
        • Alley J.B.
        • Peterson R.M.
        • et al.
        Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.
        Surg Endosc. 2012; 26: 738-746