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.
Endoscopy_UCTN_Code_TTT_1AO_2AH
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
