Endoscopic septotomy staple line released due to an unusual cause of dysphagia after sleeve gastrectomy. Disclosures. Complications of sleeve gastrectomy include leaks, fistulas and obstruction causing dysphagia. Severe dysphagia after a sleeve is usually caused by a tight or angulated sleeve that often requires re-operation. We describe two unusual cases of severe dysphagia caused by diverticulization of the gastric fundus just proximal to a sleeve staple line. We present the first report of endoscopic therapy for this condition via endoscopic tunnel-assisted septotomy staple line release which promptly and completely relieved the patient's severe dysphagia. Case number 1. 56-year-old woman had a post-lapse sleeve in 2001 followed by a RU-Y gastric bypass in 2020. Immediately after the surgery she was unable to tolerate liquids, she would regurgitate liquids within 20 minutes of ingestion and was TPN dependent. Initially she was thought to have a GJ anastomotic stricture but she did not respond to standard stenting and dilation. She developed bacteremia on TPN that cheated her knee requiring drainage. She was hostilized at an outside hostel for nearly 3 months prior to being admitted to a hostel 2 weeks after discharge. On barium we can see retention in the diverticulum of contrast. So here on endoscopy you also see dilation of the fundus in the form of a diverticulum and this is the pathway from the residual sleeve into the gastric GJ of the RU-Y bypass conversion. So we can see how food is easily diverted by this septum into the ever enlarging fundus. So given its appearance that it looks identical to a Zenker diverticulum we were prompted to use the same technique to perform a septotomy. Our Z-POEM technique also involves starting the tunnel at the apex of the septum and this is what we are doing here performing a septotomy using a multifunctional knife that can inject and cut at the same time and also with coagulating current such as forced coagulation we can get small vessels and then larger vessels can be coagulated using a hot forceps as shown here. And then we continue the dissection with the forceps in case there are other big vessels in this vicinity that we need to coagulate with the forceps and once we get to the staple line we switch to a safer hook knife which also allows easier removal of the staples. In this case we removed 5-6 staple lines from the residual sleeve staple line that had been left on the conversion to RU-Y gastric bypass. The septum has softened up after the 3-4 cm septotomy and the diverticulum appears more shallow so at this point we deem the septotomy complete and we close the tunnel opening with a running suture which achieves more secure closure particularly given how thick the mucosa is here compared to clips. So our intent with the septotomy is to make the diverticulum more shallow and also the septum much shorter and less robust so that the food will follow the pathway to the gastrojects as shown here instead of being diverted into the fundus and this is the end result. And now this shows the pre-procedure barium, the retention of the liquid barium into a diverticulum that intermittently squirts small amounts of barium into the jejunum and 7 months later on the barium we can see much smoother passage of the contrast with the esophagus and the diverticulum straight into the jejunum. Case number 2, 54 year old woman with severe heartburn, dysphagia and regurgitation to sodium liquid starting one year after lap sleeve in 2017 with symptoms getting worse in the past 6 months. The esophagram shows the dilated tortuous esophagus with delayed emptying into a large gastric fundus or diverticulum, HRM consistent with ineffective motility and endoscopy reveals a gastric diverticulum again as shown here, again the appearance is very similar to a patient's problems are probably caused by this thick septum caused by a high staple line on the sleeve that diverts food into the gastric fundus and causes obstruction to the point of having dilated the esophagus to an akalasia level of dilation and sigmoidization with a patchy cellulitis causing constant regurgitation and reflux of gastric fundus into the esophagus. So here we again started the septotum with a tunnel at the apex and now we switch again to the hook knife which is safer for any peritoneal structures that may be lying in the close vicinity and also allows easier removal of the staples and in this case we remove approximately 20 centimeters since this is an intact sleeve over a 3 to 4 centimeter septotomy as shown here and now we proceed to the final portion of the septotomy, we keep checking the pathway to the distal stomach and again we deem that an adequate weakening of the septum has been achieved to number one make the gastric diverticulum or fundus more shallow and the pathway to the distal stomach unobstructed and you can see here after suturing the pathway to the distal stomach now is not obstructed by the septum and the fundus is very shallow. On the pre-procedure bar you can see an akalasia like esophagus with regurgitation between this big diverticular fundus and the esophagus and a patchy cellulitis and on the gastrographin on post-operative day one you can see now no retention of contrast into the diverticulum and the contrast readily passes into the distal stomach. On follow-up case number one procedure 65 minutes no adverse events discharge at 48 hours and at 7 months complete the resolution of symptoms and gain 10 pounds. On case number two procedure 100 minutes no adverse events discharge at 72 hours at 4 months complete the resolution of symptoms gain 20 pounds. In conclusion we presented two cases of severe dysphagia secondary to diverticular dilation of the gastric fundus proximal to sleeve staple line. We described a novel and highly effective endoscopic therapy for this condition that completely resolved the patient's symptoms and this technique is an important addition to the armamentarium of endoscopic resection techniques that have been described to treat post-sleeve refractory fistulas and tight sleeves. Thank you.

severe dysphagia

sleeve gastrectomy

diverticulization

endoscopic therapy

tunnel-assisted septotomy staple line release