Post written by Syed Hamaad Rahman, DO, from Methodist Dallas Medical Center, Dallas, Texas, USA.

We describe the case of a 26-year-old woman who had undergone laparoscopic sleeve gastrectomy (LSG) and presented with severe intolerance of oral intake, reflux, and weight loss. She was found to have stenosis of the gastric sleeve with presence of a gastric diverticulum secondary to fundal sparing during her LSG. Treatment options were discussed at length with the patient, and it was decided to proceed with a modified gastric-peroral endoscopic myotomy (G-POEM) with sleeve release.

Our video highlights the step-by-step process of this novel procedure featuring submucosal tunneling down the length of the posterior gastric wall, followed by septotomy and myotomy down the length of the tunnel to release the sleeve. The procedure was a success with no adverse events, and our patient had complete resolution of symptoms, and her weight eventually normalized on follow-up.

One of the most common adverse events of LSG is gastric sleeve stenosis (GSS). Previously, pneumatic balloon dilation was thought to be the main treatment modality for GSS. In cases where pneumatic balloon dilation failed, conversion to Roux-en-Y gastric bypass was considered.

However, recent studies have shown modified G-POEM is a less invasive and effective alternative form of treatment, especially for patients with helical GSS, in which case it may actually be superior. Our case is unique because of the presence of the large gastric diverticulum, which was making a significant contribution toward the patient’s symptoms.

Modified G-POEM differs from conventional G-POEM, as it does not involve a pyloromyotomy. Submucosal tunneling and myotomy are performed across the length of the gastric body, sparing the antrum and pylorus.

For patients with GSS, especially those who are suspected to have helical GSS or failed pneumatic balloon dilation, modified G-POEM with sleeve release has been shown to be a minimally invasive, safe, and effective procedure. This may be a more appealing treatment option than conversion to Roux-en-Y gastric bypass, which is conventionally thought as second-line intervention after failure of balloon dilation.

We thank VideoGIE for the opportunity to present this case and hope that our video proves to be a valuable resource for other endoscopists.

Full-thickness myotomy down the length of the tunnel to relieve the stenosis.

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