A bump in the road, paving the way for a new endoscopic sleeve technique. Disclosures are as follows. A 48-year-old female with a history of thyroid cancer, status post resection, celiac disease, and obesity with a BMI of 39.5 was referred for weight management. After failure of lifestyle therapy, we recommended endoscopic sleeve gastroplasty. The patient presented for her procedure, however, a large submucosal-appearing lesion was noted bulging from the greater curvature of the stomach. Plans for ESG were aborted, and the patient was rescheduled for an EUS. EUS noted several anechoic lesions, the largest of which measured over 6 centimeters. Given unclear origin and etiology, sampling was deferred. A CT scan was obtained and noted numerous cysts scattered throughout the liver with the attenuation of water, consistent with benign hepatic cysts. In order to safely facilitate ESG, the need was recognized to drain the hepatic cysts and relieve the compression of the gastric wall. Given concern for the potential of endoscopic transgastric intervention of a sterile cystic environment, the case was reviewed at our multidisciplinary conference with multiple hepatobiliary surgeons with plan to proceed. The procedure began with upper endoscopy, which again noted the deformity along the greater curvature of the stomach caused by compression from the hepatic cysts. An echoendoscope was advanced into the stomach, and the lesions were identified under sonography. Prior to needle puncture, Doppler imaging was used to confirm the lack of significant vascular structures. A 19-gauge FNA needle was then used to puncture the cavity, and 50 cc's of clear fluid was aspirated. The cyst could be seen collapsing on sonography, and on endoscopy, the previously noted bulge was no longer present. Attention was then turned to the ESG. A novel suturing pattern, referred to here as the cable technique, was used in order to facilitate foreshortening of the stomach, as well as to minimize the use of the grasping device after having decompressed the liver cyst. In order to create these cables, the first series of stitches is placed along the posterior gastric wall. Two sutures are used, each with running placement of three stitches, in order to raise and foreshorten the gastric tissue in short segments while minimizing excessive tension. This is then repeated along the greater curvature, ultimately leading to the creation of two full-thickness cables. A triangulated suture pattern is then created with full-thickness stitches from the anterior wall, utilizing the previously created cables along the greater curvature and posterior walls. To begin the procedure, argon plasma coagulation is used to mark the stomach along the greater curvature, the anterior wall, and posterior wall, extending from the incisora up to the cardia to guide subsequent suture placement. An endoscopic suturing system was mounted on a dual-channel therapeutic endoscope. A grasping device is used to take the first stitch on the posterior wall. Using the same suture, two more stitches are placed in a running pattern along the posterior wall. The suture is cinched, creating the first cable or ridge along the posterior wall. A second suture was used to place another three running stitches, to further create the cable along the posterior wall. The suture was tightly cinched, thereby creating another ridge, with noticeable foreshortening of the gastric lumen. A cable was then created along the greater curvature of the stomach, using two sutures with three bites each. These were similarly cinched in standard fashion. Starting with a full thickness stitch along the anterior wall, a triangulated suture pattern was created utilizing the previously created cables along the greater curvature and posterior walls. The pattern allowed for minimized use of the grasping device, taking advantage of the raised ridges or cables to ease with stitch placement. Each suture was successfully cinched, thereby creating a narrowed gastric lumen. This pattern was repeated proximally from the incisora up to the GE junction, leaving a small fundic pouch. Reinforcement sutures were placed in a Z configuration at the proximal end of the suture line, while leaving the fundus intact. The sutures were tightly cinched in standard fashion. Second look endoscopy was performed, which demonstrated a narrow gastric tubular appearing lumen. The patient tolerated the procedure without any adverse events. She was discharged the same day from endoscopy. She had been administered IV antibiotics during the transgastric cis drainage, and she was discharged with one week of oral antibiotics, and has been doing well. In conclusion, the use of a novel suturing pattern with the cable technique provided a safe and effective way to perform endoscopic sleep gastroplasty following same-session transgastric liver cis drainage. This technique led to considerable foreshortening of the gastric lumen, ease of stitch placement, and improved efficiency compared to other suture patterns, making it an appealing approach for future study.

endoscopic sleeve technique

obesity

endoscopic sleeve gastroplasty

submucosal lesion

cable technique