Post written by Allison R. Schulman, MD, MPH, from the Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.

The case described here is a 71-year-old woman with a history of laparoscopic sleeve gastrectomy performed 1 year prior who presented with nausea, vomiting, reflux, and inability to tolerate oral intake. Index endoscopy demonstrated severe stenosis at the level of the incisura. Dilation with a hydrostatic balloon followed by a pneumatic balloon was performed. With the balloon inflated less than 1minute, the gastric mucosa was noted to have a severely discolored appearance, which rapidly extended proximally. The balloon was immediately deflated, and a large 5-cm x 3-cm perforation was visualized on the lesser curvature side of the gastric wall, opposite the suture line. Endoscopic suturing using a running stitch was performed distally to proximally with successful closure.

With the increasing popularity of sleeve gastrectomy, the prevalence of sleeve stenosis continues to rise. This diagnosis is typically made by endoscopy or upper gastrointestinal series, and endoscopic dilation with a pneumatic balloon is the primary mode of management. However, perforation rates are not insignificant. Here I demonstrate that endoscopic suturing for closure of a large perforation is a technically feasible and effective treatment negating the need for surgical revision.

The appearance of severely discolored gastric mucosa which rapidly extends proximally may signify impending perforation, and the pneumatic balloon should be deflated immediately. Endoscopic suturing may be an effective alternative to surgery if the patient is hemodynamically stable.

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