Post written by Diogo Turiani Hourneaux de Moura, MD, MSc, PhD, from the Endoscopy Unit, Gastrointestinal Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

In this video, we present a case of a large esophageal perforation that occurred after a bariatric stent placement for the treatment of post-sleeve leak. The perforation was successfully treated with endoscopic vacuum therapy.

A 55-year-old morbidly obese woman underwent SG and experienced a gastric leak on the seventh postoperative day. She was in clinically stable condition and was referred to our endoscopy unit for SEMS placement. We opted for a fully covered bariatric stent (28 mm x 24 cm), which completely occluded the leak at the proximal corpus. Ten days later, the drain output increased and became darkish. An endoscopic reassessment identified a large perforation at the distal part of the esophagus where the proximal edge of the self-expandable metal stent (SEMS) was anchored. The patient underwent emergency surgery. Intraoperatively, both the esophageal perforation and the gastric fistula were identified. We repaired both defects and placed mediastinal and peritoneal drains. Ten days later, we removed the stent and observed complete dehiscence of the esophageal perforation with a mediastinal drain into the orifice. We removed the drain from the orifice and placed the vacuum system, with sponge system exchanges every 3 to 5 days. Nine vacuum system exchanges and 50 days were needed to completely close the esophageal perforation. Moreover, treatment of the gastric leak entailed the removal of surgical staples and 2 septotomies. Control endoscopy and upper-GI series showed no signs of leaks. The patient was discharged 3 months after the SG with normal oral nutritional intake and no symptoms.

This video demonstrated a rare adverse event related to SEMS use, suggesting that this new large bariatric stent should be used with caution. The appropriate management of patients with transmural defects requires a multidisciplinary team. Due to an increase in the number of complications related to bariatric surgeries, more non-invasive endoscopic treatment modalities have been developed to treat the complications associated with these surgeries. The variety of endoscopic approaches and devices is transforming endoscopy as the first-line approach for therapy of transmural defects. The best treatment approach is based on local expertise, device availability, and expert opinion.

By watching this video, endoscopists can understand that when determining the appropriate endoscopic approach for closure of luminal defects, certain fundamental principles should be considered. Undrained collections should be drained. Additionally, several features must be considered to optimize outcomes, including defect size, shape of margin, viability of the surrounding tissue, and location of the wall defect. This video, demonstrated techniques used in the management of endoscopic closure of transmural defects, including the endoscopic vacuum therapy as a salvage procedure after complication after SEMS placement.

Recognition of perforations and leaks are essential for choosing the best treatment modality. Endoscopic closure is the most commonly used therapeutic procedure used in the treatment of an iatrogenic perforation. Endoscopic techniques have been shown to be highly effective in reducing morbidity and mortality in the treatment of all gastrointestinal wall defects.

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