Gastric Torsion following Sleeve Gastrectomy: A rare case and surgical management by Gustavo Adolfo Frontado Boada in Journal of Clinical Case Reports Medical Images and Health Sciences

 Gastric Torsion following Sleeve Gastrectomy: A rare case and surgical management by Gustavo Adolfo Frontado Boada in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

Gastric torsion is a rare but potentially life-threatening complication that can occur following sleeve gastrectomy, characterized by the rotation of the stomach along its axis. This case report presents the clinical presentation, diagnostic approach, surgical management, and postoperative outcomes of a patient who developed gastric torsion after previous sleeve gastrectomy. Early recognition and prompt surgical intervention are crucial in effectively managing this uncommon complication.

Keywords: Gastric torsion, Sleeve gastrectomy, Postoperative complication, Clinical presentation, surgical management.

Introduction

The increasing global prevalence of obesity has led to a higher demand for effective treatment options, with bariatric surgery emerging as a successful intervention for obesity and its associated comorbidities (8,9). Among various bariatric procedures, sleeve gastrectomy (SG) has gained widespread popularity, surpassing the Roux-en-Y gastric bypass (RYGB) as the most frequently performed bariatric surgery worldwide (3).

Although recent randomized controlled trials have indicated inferior long-term results for SG compared to RYGB, proponents of SG argue that its technical simplicity and lower risk of postoperative complications outweigh potential differences in long-term outcomes (5,7).

Nevertheless, like any surgical procedure, SG is not without potential complications. One such complication is gastric torsion, which can occur in individuals with laxity in gastric anatomical fixations, a history of prior abdominal operations (increasing the likelihood of peritoneal adhesions), or increased mobility of the stomach due to the release of the greater curvature from the greater omentum during SG (4).

Additionally, scar tissue formation, adhesions along the gastric tube, or incorrect technique, including improper sleeve configuration, can contribute to an increased risk of gastric rotation or twisting. These factors, combined with anatomical vulnerabilities, can lead to gastric torsion and result in varying degrees of obstruction, compromised blood supply, and potential ischemic damage to gastric tissue (4,6).

Case Report

A 39-year-old female with a preoperative body mass index (BMI) of 33 kg/m² underwent SG in another hospital as a primary weight loss procedure. The surgery was uneventful, and the patient was discharged on the third postoperative day. One month later, the patient presented to the emergency department of a peripheral hospital with repetitive vomiting, occurring approximately 15 times per day, along with persistent nausea. She was unable to tolerate any oral intake, including food and fluids.

Upon examination, the patient appeared dehydrated. Her vital signs were stable, but she exhibited signs of malnutrition and overall weakness. The abdomen was slightly distended and diffusely tender, with presence of bowel sounds. Laboratory analysis revealed leukopenia, iron deficiency anemia, as well as a deficiency in vitamin A. Initially, the patient was admitted to a peripheral hospital for further diagnostics and nutritional support. An upper gastrointestinal endoscopy and a barium swallow study of the upper gastrointestinal tract were performed, both of which revealed gastric torsion following the sleeve gastrectomy (Fig. 1).

Consequently, the patient was transferred to our center for further treatment. A laparoscopic revision was performed. Intraoperatively, a visible clockwise torsion of the proximal portion along the longitudinal axis of the gastric sleeve was observed, resulting from extensive and inflammatory adhesions to the pancreas (Fig. 2).

Despite the challenges, a 10 mm calibration tube was advanced by the anesthesia team with extensive manipulation using atraumatic forceps, allowing it to pass through the area into the duodenum. Subsequently, meticulous adhesiolysis was performed between the pancreas and gastric sleeve to completely free the sleeve while avoiding pancreatic injury. Laparoscopic scissors were predominantly used for the dissection. The gastric sleeve appeared relatively narrow overall. But, after releasing the torsion, a 12 mm calibration tube was easily advanced into the duodenum without any instrument manipulation, indicating the absence of remaining stenosis.

To prevent further adhesion and stabilize the gastric sleeve, available gastrosplenic ligament tissue was placed between the pancreas and the posterior wall of the gastric sleeve. Using a continuous suture with VicrylÒ 2-0, the gastrosplenic ligament was fixed longitudinally to the posterior wall of the gastric sleeve (Fig 3). Additional portions of the ligament were then fixed along the greater curvature using a continuous suture. This ensured a smooth, unobstructed course for the gastric sleeve without any torsion or constriction.

Postoperatively, the patient was closely monitored in the surgical peripheral ward, receiving appropriate intravenous fluids and analgesics. Over the course of five days, the patient's clinical condition improved rapidly, and she was able to tolerate oral intake. Follow-up imaging studies confirmed the patency of the gastric conduit and adequate gastric emptying.

Discussion

Gastric torsion is a rare complication following sleeve gastrectomy, with limited reports in the literature. The exact etiology of gastric torsion remains unclear, but factors such as anatomical variations, excessive gastric mobility, adhesions, improper sleeve configuration, and abnormal gastric motility have been suggested as potential contributing factors (4,6).

Various studies have reported the incidence of gastric torsion following sleeve gastrectomy, ranging from 1.23% to 2.5%. Clinical presentation can vary, from subacute symptoms and distention to acute-onset severe abdominal pain. Imaging studies, such as abdominal X-rays, contrast studies, or upper gastrointestinal endoscopy, can aid in the prompt diagnosis. In some cases, endoscopic treatments like balloon dilation or stents may be helpful, but surgical exploration seems to be crucial for definitive diagnosis and treatment (1,8).

Surgical management of gastric torsion involves untwisting the stomach and assessing its viability. If the stomach is viable, simple detorsion in some cases could be sufficient. However, a continuous suture fixation of the sleeve to the free edge of the gastrocolic ligament is recommended to decrease the risk of recrudescence (6).  If ischemic changes are present, partial or total gastrectomy may be required, depending on the extent of necrosis. Reconstruction options include gastrojejunostomy, gastroplasty, esophagogastrostomy or esophagojejunostomy.

Conclusion

Gastric torsion is a rare but potentially serious complication following sleeve gastrectomy. Early recognition and timely surgical intervention are essential for optimizing patient outcomes. Bariatric surgeons should maintain a high index of suspicion for gastric torsion in patients presenting with acute abdominal pain, food intolerance, and distention after sleeve gastrectomy. Further research is needed to elucidate the risk factors, preventive measures, and long-term outcomes associated with this rare complication.

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