Endoscopic sleeve gastroplasty (ESG) is a novel minimally invasive endoscopic bariatric technique used in the management of first- and second-degree obesity. It involves the placement of intragastric transmural sutures to perform a plicature along the greater curvature that reduces gastric volume and compliance, leading to significant weight loss. Although ESG is associated with a relatively low rate of adverse events compared to other bariatric procedures, there have been reports of the need for surgical intervention in the early post-operative period either due to bleeding or intra-abdominal infections. In this video, we present a case of successful laparoscopic management of an adverse event that has not commonly been described for endoscopic sleeve gastroplasty.

Endoscopic sleeve gastroplasty (ESG) is a novel minimally invasive bariatric technique performed with upper gastrointestinal endoscopy which has gained traction in the management of first- and second-degree obesity over the last decade [1]. ESG involves the placement of intragastric transmural sutures to perform a plicature along the greater curvature that creates concentric compression and therefore reduces gastric volume and compliance [2]. It has been shown to delay gastric emptying, induce early satiety, and significantly reduce body weight [3]. The procedure is indicated in in obese patients with Body Mass Index (BMI) less than 40 Kg/m2 and it is associated with approximate weight loss of 15 to 20% of baseline BMI at 1 Year after the intervention [4].Although the largest series of patients published suggest that ESG is a safe and effective procedure, with a relatively low morbidity and mortality compared to other bariatric procedures [5, 6], there have been reports of adverse events such as perigastric collections and gallbladder perforation that required surgical intervention as part of their management [5, 7].

There have been no reports of transmural gastric suturing involving the parietal peritoneum of the upper anterior abdominal wall and diaphragm. In addition, there is also a scarcity of literature reporting the role of laparoscopic surgery in management of adverse events after ESG.

We report the case of a 45-year-old obese female patient with no significant previous medical history, who had a poor response to lifestyle and dietary measure and who underwent ESG to manage second degree obesity (BMI 39 kg/m2). Intra-operatively there were no reported incidents and no significant blood loss, with a total duration of the intervention being 91 minutes. There was no perception of misplacement of sutures or of suture bites involving structures other than the gastric wall.

In the early post-operative period, the patient developed severe abdominal pain in the upper left quadrant, which radiated to the lower left chest and left shoulder, as well as nausea and shortness of breath. Abdominal palpation revealed severe tenderness with signs of peritoneal irritation.

An emergent thoraco-abdominal CT scan with oral contrast was performed, which revealed peri-gastric contrast spillage, with moderate pneumoperitoneum and moderate bilateral pneumothorax. Broad spectrum antibiotics were started and the patient was brought to the emergency operating room. Bilateral thoracic drains were put in place by a cardiothoracic surgeon. An exploratory laparoscopy was performed, which revealed transmural suture bites from the previously performed ESG involving the parietal peritoneum of the anterior abdominal wall and the left hemidiaphragm. All of the sutures were dissected with a laparoscopic advanced bipolar energy device and cut with scissors, followed by peritoneal lavage and placement of two abdominal drains. Upper gastrointestinal endoscopy was performed at the end of the laparoscopy, and methylene blue dye was instilled in the stomach. There was no evidence of dye leakage into the peritoneum and a naso-enteric tube was placed.

Video description

An emergent exploratory laparoscopy was performed, with the patient in a modified beach- chair position, under general anesthesia. Pneumoperitoneum was achieved with a supra- umbilical 10 mm trocar placed through direct visualization; CO2 was inflated into the abdominal cavity, with a target 12 mmHg pressure. 2 other trocars were placed: a 5 mm trocar in the upper right quadrant; a 12 mm trocar in the left flank.

Inspection of the abdominal cavity revealed perigastric localized peritonitis (Figure.1), with several transmural suture bites from the previously performed ESG involving the parietal peritoneum of the anterior abdominal wall and the left hemidiaphragm (Figure.2). A takedown of these suture bites was performed (Fig.3) with an advanced bipolar energy device (Ligasure, Ethicon) and sharp dissection, effectively freeing the anterior gastric wall from the involved parietal peritoneum. Access to the lesser sac was achieved with partial dissection of the gastro-colic ligament (Figure.4), revealing localized peritonitis but no evidence of extramural sutures involving the posterior gastric wall (Figure.5).

There were no evident perforations of the gastric wall (other than the places where the suture was extramural). At the end of the laparoscopy, upper gastrointestinal endoscopy was performed, revealing a partially distorted anatomy of the previous ESG, but without clear evidence of continuity into the peritoneum. Methylene blue dye was instilled through the upper endoscope, without spillage into the peritoneum. A naso-enteric tube was left in place for feeding.

The surgical intervention was concluded with peritoneal lavage (Figure.6), placement of 2 abdominal drains (in the left subhepatic and retro-gastric positions) and removal of pneumoperitoneum and trocars.

                       Figure 1: Localized peritonitis with transmural suture bites from the ESG involving the parietal peritoneum of the anterior abdominal wall.

                                                   Figure 2: Transmural suture bites from the ESG involving the parietal peritoneum of the left hemidiaphragm.

                                                                                                                Figure 3: Takedown of involved sutures.

                                                                                       Figure 4: Dissection of greater omentum (gastro-colic ligament).

                                                                                                                               Figure 5: Lesser sac inspection.

                                                                                                                             Figure 6: Peritoneal lavage.

Outcome

Intravenous broad-spectrum antibiotic was maintained and enteral tube feeding was resumed a day later. Four days later, oral feeding was resumed and the thoracic drains were removed. On Day 6, the abdominal drains were removed. The patient presented gradual clinical improvement and was discharged at day 15, without signs of persistent intra- abdominal infection. An upper gastrointestinal contrast study performed the day prior to discharge showed no evidence of contrast leakage outside the gastric lumen.

She remains asymptomatic after 2 years of follow-up. There was an initial weight loss of 21 kgs (97 to 76 kgs) corresponding to 22% of baseline BMI (BMI 39 to 30.4 kg/m2), with weight regain to 87 kgs (BMI 34.8 kg/m2). Upper endoscopy at 1 year follow-up revealed a partially undone gastroplasty; the patient preferred to have no further bariatric procedures in the meantime.

This case report highlights the importance of following the specific safety recommendations of ESG. A disregard to specific technical recommendations of ESG may turn a relatively safe procedure into a potentially harmful one. Carefully planned suture placement is paramount to this technique and placement of sutures near the gastric fundus should be avoided [8]. This case demonstrates the importance of allowing the tissue to come to the Overstitch® device (Apollo Endosurgery, Austin, Texas, United States) with the help of the helix and not the reverse. This prevents enclosure of extra-gastric tissue into the plicature, therefore preventing injury to other intra-abdominal organs.

There may also be some relevance to maintaining intra-gastric CO2 pressure in controlled intervals, as excessive pressure may lead to a more intimate contact between the gastric wall and the parietal peritoneum, increasing the risk of extra-mural suture bites enclosing extra-gastric tissue.

Like other bariatric surgery procedures, in the early post-interventional period of ESG there must be a high index of suspicion for even the mildest symptoms such as persistent or increasing abdominal pain, breathlessness, tachycardia, hypotension or fever presented by the patient, as these can be the earliest signs of an adverse event [9]. The timely diagnosis and treatment of adverse events and, when necessary, early re-intervention, are the most effective ways to prevent potentially catastrophic consequences for the patient [10].

In the case of re-operation and when technically feasible, laparoscopic surgery is a safe minimally invasive strategy with the benefits of earlier recovery from surgery, less bleeding, less postoperative pain and less surgical site infection without compromising the effective treatment of the mentioned complication [10]. Finally, this case illustrates how the synergy between endoscopy and laparoscopy can be of extreme importance in bariatric surgery, with each one complementing the other in the process of treating obesity and dealing with adverse events that may occur.

The authors have nothing to disclose.