Abstract Background The growing popularity of intragastric balloons (IGBs) as a non-surgical intervention for obesity has led to a subset of patients presenting for definitive bariatric surgery after multiple balloon placements. While gastric sleeve (sleeve gastrectomy) remains a preferred option for such patients, prior balloon interventions may significantly alter gastric wall integrity and thickness, posing unique intraoperative challenges. This presentation describes a rare but critical complication: stapler failure due to excessive gastric wall thickness during sleeve gastrectomy following repeated balloon therapy. Case presentation A 28-year-old female with a BMI of 38 presented for surgical intervention after undergoing three separate gastric balloon treatments over five years. Each balloon remained in place for approximately six months. The patient hid this history for fear of surgeon not accepting further surgeries. Intraoperatively, during standard stapling along the greater curvature, 2 of the staple firings failed to completely transect and seal the gastric wall. On inspection, the gastric wall in that region appeared markedly thickened and fibrotic, likely secondary to prior balloon-induced chronic inflammation and scarring. The stapler left an incomplete transection line without adequate staple formation or tissue compression. Immediate intraoperative assessment was conducted to manage the incomplete staple line. The stapled segment was reinforced and re-transected and the defect was sutured. The procedure was completed successfully with no further complications. Postoperative recovery was uneventful, and contrast study on postoperative day 1 showed no leak or obstruction. At 6-month follow-up, the patient had achieved 26% total weight loss with no complications. Discussion This case highlights an important technical consideration in patients with a history of multiple gastric balloons. Chronic pressure and repeated stretching from balloon inflation can lead to gastric wall fibrosis and hypertrophy, significantly altering the mechanical properties of the stomach. Standard staplers may be insufficient to safely and effectively compress and transect such tissue, increasing the risk of incomplete sealing, misfires, or staple line leaks. Conclusion Sleeve gastrectomy following repeated gastric balloon treatments presents unique technical challenges due to increased gastric wall thickness and fibrosis. Intraoperative stapler failure, while rare, can occur and demands prompt recognition and correction. Awareness of this potential complication and preparedness to adapt the technique are key to ensuring safe surgical outcomes. Video Component: The lecture will include intraoperative footage illustrating the staple misfire, tissue characteristics, and corrective technique used to manage the complication, providing a visual guide for bariatric surgeons facing similar scenarios.
Islam Abdelkhalek (Thu,) studied this question.