Technical Challenges and Device Malfunction During Endoscopic Sleeve Gastroplasty for Revision of Laparoscopic Sleeve Gastrectomy. Our short title is Device Malfunction During Endoscopic Sleeve Gastroplasty. The authors are Dean Ehrlich, Adarsh Thakkar, Ali Reza Sadarat, Stephen Kim, Raman Muthusamy, and Danny Issa. These are our disclosures. A 38-year-old male who had undergone laparoscopic sleeve gastrectomy five years ago and lost 148 pounds presented to the clinic with weight regain of 45 pounds. Past medical history included hypertension, diabetes, and obstructive sleep apnea. A barium upper GI series showed a significantly dilated gastric pouch, likely secondary to dehiscence and poor compliance with dietary changes. We planned to move forward with endoscopic sleeve gastroplasty for volume reduction and weight loss. The procedure was performed using a double-channel endoscope. The patient was placed in left lateral and underwent general anesthesia. The endoscope was inserted into the stomach. There was evidence of a prior sleeve gastrectomy with severely enlarged gastric body. Two parallel anterior and posterior suture placement sites were mapped using argon plasma coagulation, starting from the incisor and extending to the GE junction. A tissue screw helix device was used to capture the muscularis propria. The overstitch device was used to allow the needle to capture a full thickness bite. Significant fibrosis, secondary to the prior surgery, was encountered. This introduced a challenge to obtain full thickness sutures. However, this was overcome by carefully choosing the suturing sites and the use of a tissue helix. During the cinching process, the T-tag could not disconnect from the suture. This is a common problem with the endoscopic suturing device. Here's how to troubleshoot the problem. One, you must immediately recognize the problem. The cinching device is unable to detach from the suture. Number two, stop pulling. Pulling may result in a perforation. Number three, you can wrap a Kelly clamp around the wire and apply slow steady pressure under endoscopic visualization. Number four, clear communication with the technician is crucial throughout. Attach the clamp to the wire and begin turning the clamp in a 360 degree motion, bringing it towards the endoscope. Continue turning the clamp and by doing so, apply pressure. You should be communicating clearly with the technician throughout this process. Once you are fully at the endoscope with the clamp, apply a gentle steady pressure. The T-tag was successfully deployed and no deep injury occurred. Following the completion of the suturing, the stitch was tightened to approximate the opposing gastric walls, creating a narrowed sleeve. A second layer of two sutures was placed for reinforcement. The final outcome was a reduction in the gastric volume. The patient was discharged home on the same day. No immediate or late adverse events were seen. At one month and five month follow-up, the patient had lost 28 pounds and 40 pounds respectively. The clinical implications of this case are the following. Number one, extensive fibrosis along the prior staple line can be overcome by careful selection of suturing sites and using a tissue helix. Number two, a T-tag malfunction or misdeployment has been reported as a common problem during endoscopic suturing and should be recognized by endoscopists. Number three, continuous pulling of the T-tag before addressing the malfunction can result in perforation. Number four, understand how to troubleshoot this malfunction and achieve successful completion of the procedure. In conclusion, this video demonstrates the successful endoscopic sleeve gastroplasty for the revision of an enlarged gastric body following laparoscopic sleeve gastrectomy. A device malfunction was quickly recognized and addressed.

Device Malfunction

Endoscopic Sleeve Gastroplasty

Weight Regain

Double-Channel Endoscope

Fibrosis