SET THE TABLE WITH THE NAPKIN RING AND HOLDER: NOVEL ENDOSCOPIC MULTI-STENT TECHNIQUE FOR COMPLICATIONS FROM WEIGHT LOSS SURGERY

A 61 year-old female had a laparoscopic sleeve gastrectomy complicated by post-procedure vomiting and barium swallow demonstrated no passage of contrast at the GE junction. Endoscopy was notable for a high-grade angulation with redundant tissue at the proximal stomach but was able to pass into the proximal duodenum. Contrast outlined the sharp angulation and the narrowed proximal stomach measured 2 cm in length. Three overlapping 15 mm x 10 mm double lumen apposing metal stents (LAMS), (AXIOS, Boston Scientific Corp, Marlborough, MA, USA) were interlocked to traverse the stricture. Then a fully covered 18 mm x 100 mm through the scope esophageal stent (Niti-S, TaeWoong Medical, Gimpo, South Korea) was placed within the interlocking stents. The smaller diameter of the LAMS served to fix the intervening esophageal stent in position. Then contrast freely passed into the proximal duodenum.

Our patient reported symptom relief and immediate barium swallow was normal. At one-month follow up, she described symptoms of recurrent gastric outlet obstruction from consuming a hamburger. Repeat endoscopy demonstrated a proximally migrated esophageal stent within the LAMS. The esophageal stent was simply replaced with another one and the patient had no further complaints. All stents were subsequently removed at 4 months. She remains symptom free and has not required any further interventions.

We describe a rescue technique for complications of dysphagia after a sleeve gastrectomy. Increasing obesity rates have led to an increase in weight loss surgeries and the sleeve gastrectomy is one of the most common one performed. Dyspahgia complications are often secondary to stricture, stenosis, angulation and redundant mucosa. In this case our method prevented the need for repeat surgery. This technique may also be used to optimize the patient prior to revision surgery or a rescue Roux-en-Y gastric bypass.