INTRODUCTION: Gastric leaks following laparoscopic sleeve gastrectomy (LSG) are a feared complication, occurring in 2.4 % of cases in the proximal portion ( >90%). LSG is more prone to a leak due to a long staple line and high intraluminal pressure, sealed between an intact pylorus and lower esophageal sphincter and less likely to close spontaneously. There are no standardized guidelines for management of this or other forms of anastomotic leaks. We present a case that failed to respond to initial attempt to close with a luminal stenting, which led to multiple techniques to include endoscopic vacuum therapy (EVT), pneumatic dilation of the sleeve, and pylori Botox injection that ultimately achieved success. CASE DESCRIPTION/METHODS: 51 year old female with a recent history of laparoscopic sleeve gastrectomy complicated by a proximal leak detected 4 weeks post op. She initially underwent endoscopic closure with an Ovesco placement over the defect of the sleeve leak and stent placement across the sleeve. UGI immediately following the procedure revealed no leak. Subsequent imaging two weeks following the procedure revealed a leak, requiring the stent removal. The endoscopic exam revealed a large proximal sleeve defect leading to a large purulent cavity (3 × 4 cm) with multiple sinus openings. She underwent endoscopic vacuum therapy (14 sessions) every 3-4 days, leading to the complete sealing of the cavity and reduction of the cavity. There was a 1 × 1 cm persistent sealed cavity with diffuse granulation tissue, requiring a placement of a double pigtail stent. After functional stenosis was noted under fluoroscopy, not allowing contrast to freely flow downstream, Botox injection of the pylorus and pneumatic dilation of the sleeve (to 30 mm, 3 sessions) were performed, to relieve the pressure gradient. UGI series confirmed the completely sealed nature of the cavity and smooth contrast flow distally to the small intestine. Pigtail stent was left indefinitely to allow natural healing. DISCUSSION: Multiple endoscopic techniques have been implemented to close LSG leaks. The new paradigm has focused on optimizing pressure gradients to allow internal drainage with closure of the cavity by secondary intention. Our case described an initial failed closure that ultimately achieved success with a variety of techniques to include internal drain placement and Botox and dilation. This subject would benefit from further study to determine optimal initial or stepwise approach.