Eduardo Guimarães Hourneaux De Moura1, Diogo Turiani Hourneaux de Moura1,2, Christiano Makoto Sakai1, Vitor Sagae1, Antonio Coutinho Madruga Neto1, Christopher C Thompson3. 1. Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, São Paulo, SP, Brazil. 2. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1404, Boston, MA, 02115, USA. 3. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn 1404, Boston, MA, 02115, USA. cthompson@hms.harvard.edu.
Abstract
INTRODUCTION: Laparoscopic sleeve gastrectomy is becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events have gradually increase due to its rapid adoption. Sleeve stenosis is the second most common adverse event, occurring in 0.7 to 4% of patients undergoing laparoscopic sleeve gastrectomy (LSG). Endoscopic management with pneumatic balloon dilation (PBD) or stent placement is commonly performed, with a success rate of up to 88%. Recently, Moura et al. (VideoGIE 4(2):68-71, 2018) described a new technique, named as endoscopic tunneled stricturotomy. In this video, we demonstrated the evolution of this technique including full-thickness dissection with staple line disruption. METHODS: A 28-year-old woman with a BMI of 35.3 kg/m2 who underwent LSG, presented with dysphagia to solid food. An upper GI series showed a stenosis at the level of the incisura angularis. The patient was then referred for endoscopic evaluation. RESULTS: She underwent three endoscopic PBD in an attempt to treat the stenosis. Unfortunately, her symptoms did not improve. After failed PBD treatment, an endoscopic tunneled stricturotomy with full-thickness dissection was performed. The procedure is performed in 6 steps: (1) identification of the stenosis, (2) submucosal injection 3-5 cm before the stenosis, (3) incision, (4) submucosal tunneling, (5) stricturotomy with full-thickness dissection, and (6) mucosal closure. During follow-up, the patient maintained a 1200-cal diet, without recurrence of symptoms. CONCLUSION: Endoscopic tunneled stricturotomy with full-thickness dissection is feasible and appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure may be an option after conventional treatment failure or may be considered as a primary alternative.
INTRODUCTION: Laparoscopic sleeve gastrectomy is becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events have gradually increase due to its rapid adoption. Sleeve stenosis is the second most common adverse event, occurring in 0.7 to 4% of patients undergoing laparoscopic sleeve gastrectomy (LSG). Endoscopic management with pneumatic balloon dilation (PBD) or stent placement is commonly performed, with a success rate of up to 88%. Recently, Moura et al. (VideoGIE 4(2):68-71, 2018) described a new technique, named as endoscopic tunneled stricturotomy. In this video, we demonstrated the evolution of this technique including full-thickness dissection with staple line disruption. METHODS: A 28-year-old woman with a BMI of 35.3 kg/m2 who underwent LSG, presented with dysphagia to solid food. An upper GI series showed a stenosis at the level of the incisura angularis. The patient was then referred for endoscopic evaluation. RESULTS: She underwent three endoscopic PBD in an attempt to treat the stenosis. Unfortunately, her symptoms did not improve. After failed PBD treatment, an endoscopic tunneled stricturotomy with full-thickness dissection was performed. The procedure is performed in 6 steps: (1) identification of the stenosis, (2) submucosal injection 3-5 cm before the stenosis, (3) incision, (4) submucosal tunneling, (5) stricturotomy with full-thickness dissection, and (6) mucosal closure. During follow-up, the patient maintained a 1200-cal diet, without recurrence of symptoms. CONCLUSION: Endoscopic tunneled stricturotomy with full-thickness dissection is feasible and appears to be safe and effective in the management of stenosis after sleeve gastrectomy. This procedure may be an option after conventional treatment failure or may be considered as a primary alternative.
Authors: Ossamu Okazaki; Wanderley M Bernardo; Vitor O Brunaldi; Cesar C de Clemente Junior; Maurício K Minata; Diogo T H de Moura; Thiago F de Souza; Josemberg Marins Campos; Marco Aurélio Santo; Eduardo G H de Moura Journal: Obes Surg Date: 2018-06 Impact factor: 4.129