Endoluminal Rescue Management in a Complete Dehiscence of the Gastric Sleeve Suture Line

Background Leak is defined as a transmural defect with communication between the intra and extraluminal compartments and usually occurred in 1.9 to 5.3% of LSG (Burgos et al. in Obes Surg. 19:1672-1677, 2009; Aurora et al. in Surg Endosc. 26:1509-1515, 2012). Endoscopy has become the first-line therapy of post-bariatric leaks and fistulas, except in unstable patients where a surgical approach is preferred. In the case of defects greater than 2 cm, some authors suggest endoscopic vacuum therapy (EVT) or self-expanding metal stents (SEMS) (Oliveira et al. in World J Gastroenterol. 29:1173-1193, 2023). As for SEMS, migration is a major limitation, since it is responsible for up to one-third of cases needing re-intervention, thus increasing costs. Stent migration may be responsible for further AEs such as perforation or obstruction (Cereatti et al. in World J Gastroenterol. 26:4198-4217, 2020; Ko et al. in J VascIn-tervRadiol. 18:725-32, 2007). For these reasons, specifically designed SEMS have been developed for the management of leaks after bariatric surgery. The most used is the Niti-S-Beta stent (Taewoong Medical, Seoul, South Korea), a fully covered stent with a proximal flange and a double-bump in the proximal third to reduce migration (Cereatti et al. in World J Gastroenterol. 26:4198-4217, 2020). We would like to share our first experience of a challenging staple line leak treated with the apposition of a Niti-S-Beta stent.Method Prospectively collected data in our tertiary bariatric center was retrieved.Result A 32-year-old male with a BMI of 40 kg/m(2) without any comorbidities had an uneventful LSG in a center of northern Italy. On the third day post-operatively, he presented to our emergency with fever, abdominal pain, and laboratory tests showing neutrophilic leukocytosis and increased CRP and PCT values. A CT scan showed two communicant collections between the hepatic profile and the sutures. Given the patient's instability, laparoscopic drainages were placed. Subsequently, an EGD showed, downstream of the gastro-esophageal junction, a voluminous abscess cavity with the LSG's suture lines completely dehiscent in the absence of clear intestinal continuity. After various attempts, it was possible to find the antropyloric region. We measured the distance between the duodenal bulb and the distal esophagus by the withdrawal of the endoscope, and we placed over-the-wire a Niti-S-Beta stent (18 cm x 24 mm). Unfortunately, part of the stent kinked at the level of the dehiscence, preventing proper deployment. To address this issue, we used a foreign body forceps in order to maintain the guidewire in tension and the endoscope to create a force parallel to the stent to stiffen the delivery system. The stent was released with the proximal end in the third portion of the esophagus and the distal end in the duodenum. We also placed a nasojejunal feeding tube with the distal end beyond the Treitz (Video). We observed a rapid resolution of the symptoms and a reduction of WBC, PCR, and PCT. A CT scan, 5 days after the procedure, showed the correct positioning of the prosthesis and the stability of the collections. We removed the stent after 3 weeks, and post-removal EGD showed reconstitution of intestinal continuity with the formation of a neo-stomach characterized by granulation tissue and healthy gastric mucosa. The patient was discharged in excellent clinical condition and without discomfort upon resuming oral feeding. Conclusion Our experience confirms that, even in the case of a complete dehiscence of the sutures post-LSG, the possibility of placing an enteral metal stent can be considered, sparing the patient a re-surgery with a high risk of mortality.