Post written by Jessica Yu, MD, from the Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
We present a case of a 45-year-old woman who presented with a leak and peri-gastric fluid collection 6 weeks after a vertical sleeve gastrectomy (VSG). This was initially treated with percutaneous drainage and placement of a single fully covered self-expandable metal stent (FCSEMS). However, her course was complicated by FCSEMS migration and ongoing leak prompting FCSEMS removal. In order to treat her leak but address the subsequent risk of migration of additional FCSEMSs, the decision was made to place overlapping FCSEMSs. The overlapping FCSEMSs were affixed to each other utilizing a novel suture fixation technique. Additionally, the proximal aspect of the proximal FCSEMS was sutured to the esophageal wall. Interim imaging at 1 month showed resolution of the fluid collection and no evidence of a leak. The patient subsequently developed hematemesis. On repeat EGD, the distal end of the distal FCSEMS was noted to be causing ulceration in the gastric antrum. The FCSEMSs were removed but remained affixed to each other at the time of removal. The gastric leak was subsequently resolved with a short period of enteral tube feeding following stent removal.
Placement of FCSEMSs is an effective method of treating early leak after VSG. Even with stent fixation of a single FCSEMS, migration remains a risk. Our video highlights a novel method for affixing overlapping FCSEMSs together as a potential way to treat acute leaks following VSG, while reducing the risk of stent migration, stent intussusception, or stent migration, using equipment readily available in many endoscopy units.
We hope that other endoscopists consider this technique in future cases in which overlapping FCSEMSs are indicated for the treatment of acute leaks following VSG.
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