Post written by Diogo Turiani Hourneaux de Moura, MD, MSc, PhD, from the Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA.

We present a case of a 22-year-old obese woman with a history of laparoscopic sleeve gastrectomy. The surgery was uncomplicated; however, the patient was slow in advancing her diet. For the first 2 weeks, she was able to tolerate a liquid diet without any symptoms. However, in the third week, when her diet was advanced to soft food, she began to experience severe nausea and vomiting. She underwent EGD, and stenosis at the level of the incisura was noted. An achalasia balloon (10 cm in length) dilation to 30 mm was performed. Unfortunately, because of her short 8-cm sleeve, her gastroesophageal junction was also dilated. After the procedure, the patient did not respond and continued to have difficulty with oral intake of any solid foods. An upper-GI series (barium swallow) demonstrated stenosis at the level of the incisura. She was referred for a repeat therapeutic endoscopy. Because the achalasia balloon was too long, the endoscopic tunneled stricturotomy technique was used.

This new endoscopic tunneled stricturotomy technique is performed in 4 steps: (1) identification of the precise location of stenosis; (2) submucosal injection approximately 3 to 5 cm before the stenotic area; (3) submucosal tunneling stricturotomy; and (4) closure. This procedure was technically successful and without adverse events. During follow-up, the patient tolerated an oral diet well, maintaining an 800- to 1000-calorie diet without recurrence of symptoms. An upper-GI series demonstrated significant improvement of the stenosis.

Laparoscopic sleeve gastrectomy is rapidly becoming the most commonly performed bariatric surgery. Despite clinical efficacy, adverse events including sleeve stenosis, have gradually increased due to its rapid adoption. Endoscopic treatment of sleeve stenosis with achalasia balloon dilation is commonly performed with satisfactory results. However, in some refractory cases or in patients for whom this technique is not indicated other options are needed. In this video, a new technique in the treatment of sleeve stenosis is demonstrated.

Endoscopic sleeve stricturotomy appears to be an interesting option for sleeve stenosis. This new technique can be used as a first approach or as a rescue therapy in cases where the endoscopic achalasia balloon dilation failed. This procedure appears feasible and safe; however, it should be performed by endoscopists with experience in both bariatric endoscopy and submucosal tunneling procedures (POEM/STER/ESD).

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