Vivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at the Johns Hopkins Medical Institutions in Baltimore, Maryland, USA presents this VideoGIE case, “Novel technique for the management of staple line leaks after sleeve gastrectomy.”
A 32-year-old male presented for management of late proximal staple line leaks following sleeve gastrectomy (SG). The patient was initially treated with a percutaneous drain and insertion of an esophageal fully covered self-expandable metallic stent (CSEMS) for 4 weeks. However, the 2 leak sites persisted and each were closed with individual over-the-scope clips. Two partially overlapping FCSEMSs were then inserted such that they extended from the distal esophagus to the duodenum. The proximal FCSEMS was secured to the esophagus with endoscopic sutures. Additionally, the 2 fully CSEMSs were secured to each other using endoscopic sutures. At 8 weeks the sutures were cut and the fully CSEMS removed one at a time with no evidence of residual leak. The percutaneous drain was removed and the patient remains asymptomatic.
There is a desperate need for a sleeve customized metallic stent to manage proximal gastric leaks post SG. The ideal stent should be removable yet not migrate, provide good esophageal wall apposition and be long enough such that it crossed the pylorus. Unfortunately, such a stent does not currently exist in the USA. Currently, we use partially or fully CSEMSs though these stents have a maximum length of 15cm.
This video demonstrates a method of suturing 2 stents together to effectively function as a single long stent. Care must be taken when suturing the stents together to avoid moving the stent during the suturing process. Although the costs of using 2 stents is high, we believe that it will likely increase the chances of leak closure.
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