Obesity Surgery

https://doi.org/10.1007/s11695-020-04641-x

ORIGINAL CONTRIBUTIONS

Role of Endoscopic Stent Insertion on Management of Gastric Twist

after Sleeve Gastrectomy
Mohamed Ibrahim Hassan 1 1 1
& Mohamed Shaaban Khalifa & Mohamed Attia Elsayed & Yasser Mohamed ElGhamrini
1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose The effectiveness of endoscopic management of twisting of the gastric pouch after sleeve gastrectomy.
Methods This was a retrospective study on Ain Shams University Hospital. Patients who had obstructive symptoms and
diagnosed with twist after gastric sleeve were included in this study.
Results From May 2017 to January 2019, 860 patients underwent LSG as a definitive procedure. Thirty-two (3.7%) patients
developed symptoms of gastric obstruction. Twenty-two (2.5%) patients diagnosed with sleeve axial twist were included in this
study after excluding 11 patients with sleeve stricture. A total of 72% (16 out of 22) of patients were female, with a mean age of
41. The mean time of presentation was 40 days (20–60 days) after surgery. Gastrografin contrast study was positive in 14 (63%)
patients. 3D contrast CT was positive in 100% of cases. The timing of endoscopic intervention was 40 ± 20 days (20–60) after
surgery. Endoscopic treatment was successful in 20 patients (91%). Recovery was uneventful in 19 patients; 1 patient had
esophageal stricture at the upper end of the stent, which necessitated a session of dilation. The success of endoscopic intervention
was 91% with complete relief of symptoms and correction of the gastric pouch axis. Endoscopic intervention failed in only 2
patients (9%) who necessitated laparoscopic exploration after stent removal.
Conclusion Gastric pouch twisting is a rare complication; however, it has a rising incidence. Endoscopic stent insertion is highly
effective on the management of twisting after SG and it should be tried before any further surgical intervention.

Keywords Sleeve . Gastrectomy . Twist . Dilation

Introduction Materials and Methods

Laparoscopic sleeve gastrectomy becomes a very poplar sole
bariatric procedure after it had been considered the first step of
two-staged duodenal switch operation [1].
Laparoscopic sleeve gastrectomy has many complica-
tions as gastric fistula in 2.5% of cases, bleeding in 5%
of cases, and gastric stenosis in 0.69 to 3.5% of cases [2].
Gastric stenosis is classified as either functional or organic
[3]. Functional stenosis is also called gastric twist. Gastric
twist can be classified according to the time of diagnosis
into intraoperative diagnosis, early postoperative, and de-
layed postoperative diagnosis [4].
* Mohamed Ibrahim Hassan
Dr.mohamedibrahim35@yahoo.com
1
Faculty of Medicine, Ain Shams University, Cairo, Egypt
This was a retrospective study on Ain Shams University
Hospital. Patients who had obstructive symptoms and diag-
nosed with twist after gastric sleeve were included in this
study. Informed consent was obtained; all the possible com-
plications and the possibility of endoscopic failure were ex-
plained to the patients.
Surgical Technique
We are using a 4-port technique. Division starts 5 cm from the
pylorus. We are using 5–7 stapler cartilages. Equal traction of
the anterior and posterior wall of the stomach was ensured to
avoid gastric twist. The free movement of the 36 bougies was
assessed with every firing to avoid stricture or twist (Fig. 1).
We are doing both the methylene blue test and air bubble leak
test. All the cases had been done laparoscopically by our ex-
pert team.

Fig. 1 a, b Show equal traction at
the equator of the stomach during
staple firing to avoid twisting. c, d
Show uniform non-twisted staple
line
Patients’ Evaluation
Patients who had developed symptoms of gastric obstruction
as repeated non-bilious vomiting and intolerance of fluids and
semi-solid foods were evaluated routinely by Gastrografin
study which showed cessation of the dye at the upper part of
the gastric pouch (Fig. 2).
Three-dimensional contrast CT was done for all patients to
confirm the diagnosis (Fig. 3).
The method used for evaluation of the remnant stom-
ach size and shape is the 3D CT gastric volumetry and
gastrography. The main principle is to distend the stomach
with around 150 cc of oral contrast on average. Scanning
the patient in multiple positions, e.g., prone and left lat-
eral position, in addition to a supine position is sometimes
required in order to achieve the proper filling of oral con-
trast of all aspects of the remnant stomach. It is very
helpful in cases of gastric leak and twist in one or multi-
ple points as well as to measure the exact dimension of
the strictured point. Afterward, 3D post processing soft-
ware has to be applied to get the 3D image which will get
the surgeon the exact idea of the shape of the remnant
stomach; leaking point exact location and its diameter;
twisted axis and dimension; volume of the sleeve stom-
ach; and exact dimension of the stricture—stenosis at
mid-body or incisors if any. Finally, sometimes CT virtual
gastroscopy is added to delineate any kind of gastric rugal
thickening that might indicate gastritis status in the proper
clinical context.
The patients with symptoms of gastric obstruction and
were confirmed by contrast study were sent to do upper GI
endoscopy. The patients with stricture of the gastric sleeve
were excluded from the study.
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The medical records were reviewed and the data of the
operative details, timing of presentation, imaging results, site
of stenosis, and management options were collected.
The timing of the intervention, stent diameter, stent migra-
tion, stenting duration, and timing from stent placement until
resolution of symptoms were recorded with follow-up for
12 months after stent removal.
Endoscopic Procedure
The patients with symptoms of gastric obstruction and were
confirmed by contrast study underwent upper GI endoscopy.
Endoscopy in all cases had shown dilation of the proximal
lumen followed by narrowed and tortuous short segment
which necessitated marked manipulation of the scope to reach
the antrum denoting twist of the gastric pouch. They had been
treated with insertion of fully covered, 23-cm self-expandable
ultra-long, wide and flexible Mega stent (Taewoong Medical,
Gimpo, Korea) endoscopic stents (Fig. 4). Informed consent
was obtained from all individual participants included in the
study.
The proximal part of the stent was located near the middle
of the esophagus while the distal part was located at the an-
trum facing the pylorus. A contrast study was performed after
stent insertion to ensure proper management of the gastric
twist.
Results
The study involved 860 patients who underwent LSG as a
definitive bariatric procedure. Seventy-nine percent were fe-
male with a mean age of 39.7 ± 14 years (range 23–49 years)
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Fig. 2 a–c Gastrografin study

shows cessation of the dye at the
upper part of the gastric pouch. d
Shows trickling of the dye after
injection under pressure to
overcome the twisted part

and a mean body mass index of 48.6 ± 14 kg/m2 (range 41–
59 kg/m2). Sleeve gastrectomy was performed along 36-Fr
boogies (Table 1).
Thirty-two (3.7%) patients developed symptoms of gastric
obstruction (early satiety, epigastric fullness, nausea, repeated
non-bilious vomiting, and epigastric pain). Twenty-two
(2.5%) patients diagnosed with sleeve axial twist were
included in this study after excluding 11 patients with sleeve
stricture (Table 2). Seventy-two percent (16 out of 22) patients
were female, with a mean age of 41. The mean time of pre-
sentation was 40 days (20–60 days) after surgery.
Gastrografin contrast study was positive in 14 (63%) pa-
tients which was used as the first diagnostic step. 3D contrast
CT was done in all patients to confirm the diagnosis and as

Fig. 3 Three-dimensional CT
study shows marked twisting of
the gastric pouch

Fig. 4 a Gastrografin study of the
twisted gastric pouch. b After
insertion of Mega stent. c After
removal of the stent
positive in 100% of cases. Gastric twist was confirmed in 3
axes in 15 patients. Timing of the endoscopic intervention was
40 ± 20 days (20–60) after surgery. Endoscopic treatment was
successful in 20 patients (91%).
Twenty patients were successfully managed by endoscopic
stenting. Stent migration had occurred in 4 patients that ne-
cessitated 1–2 sessions of repositioning. Recurrent attacks of
chest pain and epigastric pain had occurred in 6 patients after
stent insertion that were controlled by analgesics.
The stents had been removed after 45 days. The patients were
kept on oral fluids starting from the second day of its insertion up
to 2 weeks then kept on semi-solid diet until its removal.
Recovery was uneventful in 19 patients; only 1 patient had
esophageal stricture at the upper end of the stent, which ne-
cessitated one session of dilation using Savary dilators.
The success of endoscopic intervention was 91% with
complete relief of symptoms and correction of the gastric
pouch axis with a follow-up for 12 months. Endoscopic inter-
vention had failed in only 2 patients of which 9% necessitated
laparoscopic exploration after stent removal. The exploration
had shown marked twist at the incisura and fibrous adhesion
between the twisted part and the inferior surface of the liver
that prevents proper correction of the gastric axis and causes
re-twist after stent removal. The adhesions were released
Table 1 Total population characteristics
Age 39 ± 7 years
Female: male 79%:
Obstructive sleep apnea 4.5%
Diabetes mellitus 112 (13%)
Hypertension 440 (51%)
Body mass index (BMI) 47 ± 9
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carefully in this area and gastric bypass procedure was done
using the proximal gastric pouch.
Discussion
Twisting of the gastric sleeve could be classified according to
its presentation or diagnoses into intraoperative, early post-
operative (up to 4 weeks), and late post-operative (more than
4 weeks) [5]. The timing between the procedure and diagnosis
has been reported to occur in early post-operative period [6,
7]. In our study, it was 40 days (20–60 days) mainly when the
patients shift their diet from fluid to semi-solid or sold
ingredients.
Early presentation could be marked salivation and repeated
attacks of vomiting and late presentations are repeated
vomiting of undigested food and refractory reflux not
responding to different medications [8].
Twisting of the gastric sleeve could be due to improper
alignment of the stapler during firing with unequal traction
of the greater curve of the stomach which leads to twisting
of the gastric tube either anteriorly or posteriorly.
Delayed presentation could be due to marked adhesion,
over the gastric pouch through narrowing the incisura
Table 2 Complications of sleeve gastrectomy
Leak 6 (0.6%)
Organic stenosis 11 (1.16%)
Twisted sleeve 22 (2.5%)
Bleeding 10 (1.1%)
Endoscopic stenting 20 (91%) success rate
Migration of stent 20%
OBES SURG
angularis leading to the formation of mucosal valve-like flap
[9].Stenosis after sleeve gastrectomy was 3.7% which is sim-
ilar to the results of Parikh et al. [6]. Twisting was responsible
for 65% of our cases.
Upper endoscopy was a highly reliable tool for diagnosing
gastric twisting with a sensitivity of 100% through marked
manipulation of the scope to pass the twisted part; the same
was confirmed by Murcia et al. who found that the upper
endoscopy is highly valuable for diagnosis [10].
Gastrografin study was positive in 63%.
Endoscopic insertion of Mega stent was highly effective in
91% of cases. Only 2 cases had necessitated laparoscopic
intervention with conversion to Roux-en-Y gastric bypass.
Proper alignment of the stapler with equal traction at the
equator of the greater curve is very important to prevent ante-
rior or posterior twisting.
Reattachment of the greater omentum to the gastric pouch
is an additional option to prevent gastric twist [11].
Eubanks et al. [12] had used endoscopic stents to treat
gastric stenosis. In a 7-day period of stenting, six patients
had a success rate of 83%. The stents remained in place for
only 1 week as it caused pain and had to be removed.
However, they considered that the stent improved the chance
of the stenosis to be corrected compared with dilation.
Results in the literature are not consistent because of mi-
gration or poor tolerance of stents. Marquez et al. [13] assume
that these migrations were frequent due to the use of improper
stents that was originally planned for the management of
esophageal strictures.
In our study, we used fully covered Mega stents that were
highly selective for the management of gastric sleeve
complications.
Several published results show conflicting efficacy of bal-
loon dilation for the management of gastric stenosis after gas-
tric sleeve. Shnell et al. [14] showed a success rate of 43%
among patients who had endoscopic balloon dilation for GSS.
Our explanation for such a rate is that most of the cases had
gastric twist rather than stricture so more than 50% of cases
had poor compliance for balloon dilation.
Endoscopic stent insertion for twisting of gastric sleeve is
less invasive than other surgical options as conversion to gas-
tric bypass or fixation of the twisted angle laparoscopically,
such interventions, had various complications compared with
the endoscopic management.
The limitation of our study is the need to assess the role of
endoscopic stenting in a greater number of patients. 3D CT
volumetric study needs an expert radiologist to interpret twist-
ing of the gastric pouch and differentiate between twist and
stricture of the gastric sleeve. The availability and the cost of
endoscopic Mega stent are other limitations of our study.
All procedures performed in studies involving human par-
ticipants were in accordance with the ethical standards of the
institutional and/or national research committee and with the
1964 Helsinki declaration and its later amendments or com-
parable ethical standards.
Conclusion
Laparoscopic sleeve gastrectomy is highly effective and wide-
spread in weight loss operation; however, it needs experience
to prevent complications.
Gastric pouch twisting is a rare complication; however, it
has a rising incidence.
Non-operative endoscopic stent insertion is highly effec-
tive on the management of such twisting after SG and it
should be tried before any further surgical intervention.
Compliance with Ethical Standards
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Conflict of Interest The authors declare that they have no conflict of
interest.
Informed Consent Informed consent was obtained from all individuals
who participated in the study.
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