Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain

Upper endoscopy is an essential diagnostic and therapeutic tool in the evaluation of patients with gastrointestinal symptoms. Particularly in bariatric surgery patients, endoscopy is a valuable tool in the preoperative, intraoperative, and postoperative period. It is an increasingly important skill for surgeons managing surgical complications. We present a 48-year-old female who presented one year after undergoing a robotic-assisted sleeve gastrectomy and cholecystectomy with persistent epigastric pain and severe reflux symptoms. She had multiple emergency department visits following surgery, and prior computed tomography imaging was initially interpreted as normal without evidence of leak or obstruction, but on further review demonstrated a twisted configuration of the gastric sleeve. Upper endoscopy was performed using an Olympus GIF-HQ190 gastroscope, with the scope advanced under direct visualization through the esophagus, stomach, and into the second portion of the duodenum. Endoscopy revealed a widened hiatus consistent with a small hiatal hernia, as well as moderate luminal stenosis near the incisura with a spiral configuration of the staple line, consistent with a gastric sleeve twist. Proximal gastric dilation and bile reflux were also appreciated. This case highlights the importance of surgeon review of imaging studies and surgeon performed endoscopy in evaluating complex postoperative anatomy and underscores its role as a critical skill for surgeons involved in the long-term care of surgical patients.

Sleeve gastrectomy; bariatric surgery; gastrointestinal endoscopy; esophagogastroduodenoscopy; postoperative complications; gastric sleeve twist.

Sleeve gastrectomy is the most common bariatric procedure performed worldwide due to its technical simplicity and overall favorable outcomes.^1,2 Despite its widespread adoption, postoperative complications such as sleeve stricture, stenosis, kinking, and torsion may result in persistent or recurrent gastrointestinal symptoms such as nausea, vomiting, and reflux.^3,4

Furthermore, postoperative bariatric complications can often be challenging to diagnose. Upper endoscopy plays a crucial role in the evaluation of postoperative bariatric patients by allowing for the direct visualization of sleeve anatomy and detecting any luminal abnormalities. It is an increasingly important skill for surgeons involved in the management of bariatric patients, enabling timely identification and treatment of complications in both their own patients as well as those referred from other providers.

Gastric sleeve torsion or gastric twist both refer to a serious complication where the gastric sleeve rotates or twists on itself creating a functional obstruction. This case highlights the role of upper endoscopy in identifying a twisted gastric sleeve, an anatomic mechanical complication.

The patient is a 48-year-old woman with a history of morbid obesity (preoperative BMI 43 kg/m², current BMI 29.24 kg/m²), hypertension, hyperlipidemia, gastroesophageal reflux disease, hypothyroidism, and prior myocardial infarction, who underwent a robotic-assisted laparoscopic sleeve gastrectomy and cholecystectomy one-year prior to presentation. Her postoperative course has included persistent epigastric pain and severe reflux, prompting referral for endoscopic evaluation. Her most recent labs were within normal limits.

The patient appeared well and was in no apparent distress. Her abdominal examination revealed a soft and non-tender abdomen without palpable masses or the presence of any hernias.

Preoperative endoscopy demonstrated a small, 2-cm hiatal hernia. Postoperative computed tomography (CT) of the abdomen and pelvis with oral contrast revealed a twisted configuration of the gastric sleeve and the absence of obstruction or leak.

Figure 1. CT Abdomen and Pelvis. A) Axial view demonstrating sleeve gastrectomy staple line with an area of narrowing near the incisura (thick red arrow) as well as an air fluid level proximal to the narrowed area (thin red arrow). B) Sagittal view with obvious L-shaped bend (red arrow) near the incisura indicative of a gastric sleeve twist. 

Gastric sleeve twist represents a rotational deformity of the gastric conduit, resulting in functional obstruction rather than a fixed narrowing or stricture. It is a mechanical complication that can result from improper stapling, postoperative adhesions, or misalignment of the gastric conduit.^3,5 Gastric twist can be difficult to detect on imaging and is best diagnosed with direct endoscopic visualization.⁴ Without treatment, patient may experience persistent obstructive symptoms, reflux, impaired gastric emptying, and poor nutritional intake.^4,6

Management of patients with a suspected twisted gastric sleeve depends on the severity of the patient’s symptoms. A stepwise approach is typically utilized. Conservative management is typically considered for patients with mild or intermittent symptoms and includes proton pump inhibitors for reflux, antiemetics for nausea, and optimization of nutritional status.

For patients with moderate or progressive symptoms, endoscopic intervention may be attempted. For example, balloon dilation can be effective for patients with sleeve strictures but is not the treatment of choice for patients with a torsion, as the underlying issue is an anatomic rotation rather than narrowing. Moreover, endoscopic stenting of a sleeve gastrectomy can serve as a temporizing measure; however, stent migration, patient intolerance, and variable success rates limit its widespread use.^4,7

For patients with persistent severe symptoms, surgical revision is the definitive treatment—for example, conversion of the sleeve gastrectomy to a Roux-en-Y gastric bypass. Conversion effectively bypasses the obstructed segment and addresses the associated reflux.^3,6 Other surgical options may include sleeve revision or adhesiolysis, depending on the underlying mechanism of torsion and intraoperative findings.

Regardless, in all cases, upper endoscopy plays a crucial role in guiding management decisions and should be performed prior to any operative intervention. By differentiating between functional obstruction due to torsion and a fixed stenosis due to a stricture, endoscopy helps determine whether endoscopic intervention or surgical revision should be pursued.

The goal of treatment in this patient is to identify the underlying cause of persistent postoperative symptoms and guide the appropriate management. In patients presenting with epigastric pain and reflux following sleeve gastrectomy, it is essential to distinguish between functional and structural abnormalities, including stricture, torsion, and hiatal pathology.

Upper endoscopy provides direct visualization of the gastric sleeve and allows for dynamic assessment of luminal anatomy, making it the preferred diagnostic modality. In our case, endoscopy confirmed the presence of a twisted sleeve with an associated functional stenosis, as evidenced by a rotated staple line and bile reflux.

Accurate endoscopic diagnosis is critical, as management strategies differ depending on the underlying pathology. While fixed strictures may be amenable to endoscopic dilation, torsional deformities often require surgical revision.

Bariatric surgery patients often present with complex postoperative anatomy, which can make both diagnosis and management challenging. Gastric sleeve twist may be underrecognized, as symptoms can be nonspecific and imaging findings can be subtle.

Endoscopy in these patients requires meticulous technique, as areas of functional narrowing may increase the risk of perforation if excessive force is applied. Careful advancement and attention to luminal abnormalities are essential when navigating a twisted sleeve.

Surgeons managing bariatric patients should maintain a high index of suspicion for mechanical complications such as torsion in patients with persistent symptoms despite unremarkable imaging.

Gastric sleeve twist is an uncommon but clinically significant complication of sleeve gastrectomy characterized by a rotation or spiraling of the gastric tube. This results in a functional obstruction or stenosis, which differs fundamentally from a fixed fibrotic stricture.^3,4

In the case of our patient, endoscopy demonstrated the key findings of a twist or torsion, including rotation of the staple line and moderate narrowing without a complete obstruction. The luminal diameter measured approximately 1.5 cm on retroflexion, with resistance to scope advancement confirming a functional component.

Endoscopy is the preferred diagnostic modality in patients presenting with postoperative bariatric complications because it allows for direct visualization and dynamic assessment of gastric anatomy. Imaging may not detect rotational deformities, whereas endoscopy can clearly demonstrate the spiral configuration and differentiate torsion from true stenosis.^4,7 Additional findings such as bile reflux and prepyloric inflammation suggest impaired gastric emptying and stasis, which have been described in patients with sleeve dysfunction.⁸

Management depends on symptom severity. Endoscopic dilation may be attempted but is often less effective in torsional deformities compared to fixed strictures.⁴ Definitive management often includes surgical revision, most commonly conversion of the sleeve gastrectomy to a Roux-en-Y gastric bypass, which addresses both the obstruction and reflux.^3,6

In summary, although this is a relatively rare complication, a twisted gastric sleeve should be considered in patients with persistent epigastric pain and reflux following sleeve gastrectomy. 

• Standard adult gastroscope (e.g., Olympus GIF-HQ190).

Saamia Shaikh, DO, JD:

• Nothing to disclose.

Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.):

• Speaking/Teaching Honoraria:
  • Becton-Dickinson, Medtronic.
• Consultant:
  • Boston Scientific, Actuated Medical, Cook, Allergan, Mesh Suture Inc, Provation, Telabio.
• Royalties:
  • UpToDate (Wolters Kluwer), Springer.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.