Full thickness endoscopic strictor autumn in the management of sleep gastrectomy stenosis associated with a complex fistula. Despite technical advancements, leaks and fistula incidents remain significant, affecting 1.9 to 5.3% of patients after laparoscopic sleep gastrectomy, occurring mostly at the level of van Gogh Hiss. For stable patients, endoscopy is now considered the first approach and a combination of therapies is usually required. In addition to treating the defect, it is crucial to address associated factors. In this video, we present the journey of treating a fistula associated with a downstream stenosis following laparoscopic sleep gastrectomy. We present a case of a 30-year-old man suffering from class 3 obesity. He underwent laparoscopic sleep gastrectomy and, in the 9th postoperative day, he started with fever, tachycardia and abdominal pain. The CT scan revealed a leak at the level of Van Gogh Hiss with an associated collection. Antibiotic therapy was started, associated with sterile drainage, and endoscopic evaluation performed at another institution. The endoscopic and fluoroscopy evaluation confirmed the leak and an associated infected collection. An intracavitary endoscopy vacuum therapy was placed for 3 weeks. Then, it was exchanged for a percutaneous vacuum therapy for 2 more weeks. There was reduction in cavity, abundant granulation tissue formation and infection control. However, a chronic gastrocutaneous fistula has emerged and the patient was then referred to our institution. At this moment, this was the endoscopic image that showed a chronic fistula with an epithelial tract and a percutaneous vacuum in place. In the first procedure conducted at our institution, we began by removing the percutaneous vacuum. Subsequently, we proceeded with an endoscopic evaluation, confirming the fistula's opening with signs of chronicity and an associated septum and sleeve stenosis. The proposed approach was to perform a septotomy to address associated condition with the fistula, the septum. Closing the fistula opening was done using the cardiac septal defect occluder. Additionally, incorporating the bariatric customized stent, besides treating the organ's stenosis, serves as an adjunctive therapy to the cardiac septal defect occluder for the closure of the fistula. Septotomy was performed using argon plasma coagulation. For the CSDL placement, we used a guide wire externalized through the skin and secured to the CSDL proximal flange. Traction on the guide wire was performed through the mouth and the floor was spin endoscopic controlled until a proper position was confirmed, with the proximal flange inside the stomach and the neck and the distal flange of the CSDL within the fistula's tract. There was no more controus sterilization, so the bariatric stent was placed. After proper placement and controus installation, the stenosis and torsion of the organ's axis are even more notable. To avoid migration, the stent was fixed using a cup-mounted clip. The patient went home with a plan of endoscopic evaluation after 4 weeks. He just expressed mild chest pain in the first days after the procedure. The stent was removed using a foreign body forceps. A residual septum can be seen. The fluoroscopy evaluation confirmed adequate closure of the fistula with an associated downstream stenosis. Septotomy was again performed using argon plasma coagulation, and this leaves the stent to be removed. Septotomy was again performed using argon plasma coagulation, and this leaves stenosis was dilated using a 30 mm pneumatic balloon. The patient persisted with symptoms despite the procedure, and he was refatory to further dilations. In this scenario, we proposed the treatment with endoscopic tunnel stereotomy, procedure conducted following 5 essential steps. First, we must identify the point of stenosis, easily seen at the transition from the body to the antrum. Then, submucosal injection and incision is done 2 to 5 cm above the stenosis. The third step involves the creation of submucosal tunnel, which should pass through the stenotic area. Then, full thickness stictorotomy can be safely performed. After finishing, a meticulous evaluation is conducted to confirm the absence of damage to the mucosa, and the device is withdrawn from the tunnel. Finally, the last step consists on mucosal closure, which can be done using clips or suture. This video compares the passage of the gastroscope before and after the procedure. The improvement is noticeable and the device passes smoothly, serving as a good parameter to assess technical success. Two days after the procedure, the patient was discharged from the hospital accepting auralic diet without complications. After six months, the patient persisted asymptomatic, accepting full diet. The CSDO was migrated spontaneously and it was removed during a routine endoscopic evaluation. There was no sign of fissile recurrence. And this slide summarizes the fissile evolution, from the first procedure until his last endoscopic evaluation, after cardiac septal defect occluder migration. Management of laparoscopic sleeve gastrectomy complications is complex, requiring a multidisciplinary team with experience. Using multiple endoscopic techniques is required during the treatment. Treating associated factors such as stenosis is essential for both treatment sources and preventing the recurrence of leaks and fissile, in addition to symptomatic control. Endoscopic tunneled full-frequency sectorotomy is a promising approach in treating post-laparoscopic sleeve gastrectomy stenosis. It should be considered as an alternative to surgical reintervention in repertory patients.

laparoscopic sleeve gastrectomy

fistulas

stenosis

endoscopic procedures

multidisciplinary team