Persistent Abdominal Pain After Endoscopic Sleeve Gastroplasty: A Multicenter Case Series and Hypothesis-Generating Management Framework.

Abstract

Introduction: Endoscopic sleeve gastroplasty (ESG) is an established minimally invasive treatment for patients with obesity, with a favorable safety profile. Although transient abdominal pain is common in the early post-ESG period, persistent pain remains poorly characterized. We aimed to describe the clinical presentation, diagnostic evaluation, management strategies, and outcomes of patients with persistent abdominal pain after ESG, and to propose a pragmatic management pathway.

Methods: We conducted a retrospective multicenter case series across six expert bariatric endoscopy centers. Patients with abdominal pain lasting more than 15 days after ESG were identified. Demographic, procedural, diagnostic, therapeutic, and follow-up data were collected.

Results: Among 4,350 ESG procedures, nine patients developed persistent abdominal pain (0.21%; 95% CI, 0.09-0.39%). Mean baseline BMI was 33.7 ± 1.4 kg/m². The median interval from the 15-day post-ESG threshold to documented pain treatment was 21 days [IQR, 1-52.5]. Laboratory testing, radiologic evaluation, and endoscopy excluded major complications; one gastric wall hematoma was identified on CT. Suspected mechanisms included excessive plication-related tension (55.6%), possible extra-gastric tissue capture or adhesions (33.3%), and gastric wall hematoma (11.1%). Conservative management (mainly nutritional reset and conventional analgesia) improved symptoms in 77.8% of cases. Mean numerical pain score decreased from 4.9 ± 1.8 to 1.2 ± 1.2. Two refractory cases required complete and selective endoscopic suture release.

Conclusions: Persistent abdominal pain after ESG is uncommon but clinically relevant. A stepwise strategy prioritizing exclusion of serious adverse events, conservative management, and selective endoscopic suture release in refractory cases may be appropriate. Prospective validation is required.