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Sleeve gastrectomy leak: endoscopic management through a customized long bariatric stent

      A 28-year-old woman, body mass index 35 kg/m2, underwent laparoscopic sleeve gastrectomy, without drain placement. Twelve days later, she experienced abdominal pain with radiation to her left shoulder, fever, and leukocytosis. The patient was admitted with a clinical diagnosis of gastric leak. Endoscopy showed a leak orifice below the gastroesophageal junction (GEJ), allowing passage to a perigastric cavity, with a small amount of purulent fluid and debris (Figs. 1A and B). This cavity was endoscopically washed with saline solution until the return of fluid was clear. The stomach had an axis deviation to the right, creating a stricture at the level of the incisura angularis, with difficult endoscope passage. A customized metallic bariatric stent (totally covered nitinol stent, 200 mm × 28 mm × 30 mm, Expand Stent, Plastimed S.R.L., Buenos Aires, Argentina) was placed, with the patient under general anesthesia (Fig. 1C; Video 1, available online at www.videogie.org). The stent was placed 3 cm above the GEJ, with the distal end on the duodenum, by use of a guidewire, under radioscopic guidance (Fig. 1D). No sutures, clips, or other fixation methods were used. Antibiotic agents already prescribed for sepsis control by the surgical team were maintained. For 3 days the patient experienced thoracic pain, moderate nausea, and biliary vomiting as a result of the stent diameter and position in the duodenum. A control radiograph showed the stent in a proper position.
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      Figure 1A, Endoscopic view of perigastric cavity and septum below the GEJ. B, Radiographic view of stomach with flow of contrast medium through leak orifice. C, Totally covered nitinol stent, 200 mm × 28 mm × 30 mm. D, Radioscopic control: stent positioned 3 cm above GEJ, in a transpyloric manner. E, Stent removal: proximal suture grasped by raptor forceps, with removal under radiologic control. F, Radiographic control after stent removal, showing resolution of axis deviation and closure of leak orifice. GEJ, gastroesophageal junction.
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