Endoscopic approach to complex gastric tube stricture after laparoscopic sleeve gastroplasty: a case report

As bariatric surgery becomes more prevalent, endoscopists commonly face adverse events now that this minimally invasive treatment has little morbidity and great efficacy [1]. Gastric tube stricture is one of the most common adverse events, occurring in 0.1 to 3.9 % of patients [2] [3]. Mechanical stricture (gastric sleeve) and axis deviation are the entities that can cause obstruction [2].

Endoscopic treatment often includes pneumatic balloon dilation and/or self-expandable metal stent (SEMS) placement with great success rates [3] [4]. Recently, endoscopic tunneled stricturotomy has been adopted as a promising technique [5].

We present a case ([Video 1]) of a 55-year-old woman with morbid obesity (body mass index of 43.9 kg/m²). She underwent a laparoscopic sleeve gastrectomy and developed progressive dysphagia in the follow-up. Upper gastrointestinal (GI) endoscopy and contrast X-ray image revealed gastric tube stricture and axis deviation.

Video 1 Complex strictures after gastrointestinal surgery are challenging for endoscopic management. In this case report with video, we highlight different therapeutic endoscopic options that might be used in these cases.

An endoscopic tunneled stricturotomy with full-thickness dissection was performed 6 months after the surgery, although without technical or clinical success.

A new endoscopic approach was performed with pneumatic balloon dilation (30 mm) followed by placement of a 23 × 105-mm partially covered esophageal SEMS (PCSEMS) ([Fig. 1]). To avoid stent migration, a nasoenteral feed tube with suture threads was fixed to the stent using metallic clips ([Fig. 2]). After this procedure, the patient improved clinically and tolerated a soft oral diet well.

Fig. 1 Fluoroscopic aspect after the first endoscopic stent placement.

Fig. 2 Self-expandable metal stent (SEMS) fixed to the nasoenteric catheter by suture threads and metallic clips to avoid stent migration.

At 18 days after placement, intense tissue hyperplasia in the proximal and distal portions of the stent (uncovered areas) made removal impossible ([Fig. 3]). So a 23 × 155-mm fully covered esophageal stent (FCSEMS) was placed over the first stent (stent-in-stent technique) ([Fig. 4]). After 1 week, the patient presented good acceptance of a soft oral diet and both stents were removed endoscopically without complications ([Fig. 5]).

Fig. 3 Tissue hyperplasia in the proximal stent end (uncovered area), precluding its removal.

Fig. 4 Fluoroscopic aspect of the stent-in-stent technique.

Fig. 5 Stricture area after the removal of both stents.

Currently (2.5 months after the last procedure), the patient remains with a good soft oral diet intake and stable weight. She is satisfied with the improvement in her quality of life and no further endoscopic intervention is necessary.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Deslauriers V, Beauchamp A, Garofalo F. et al. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surgical Endoscopy 2018; 32: 601-609
• 2 Ogra R, Kini GP. Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand. Obesity Surgery 2015; 25: 242-248
• 3 Okazaki O, Bernardo WM, Brunaldi VO. et al. Efficacy and safety of stents in the treatment of fistula after bariatric surgery: a systematic review and meta-analysis. Obesity Surgery 2018; 28: 1788-1796
• 4 Agnihotri A, Barola S, Hill C. et al. An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy. Obesity Surgery 2017; 27: 2628-2636
• 5 de Moura EGH, de Moura DTH, Sakai CM. et al. Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis. Obesity Surgery 2019; 29: 2711-2712

Publication History

Article published online:
17 December 2020