Endoscopic Evaluation of a Twisted Gastric Sleeve Causing Severe Reflux and Epigastric Pain
Saamia Shaikh, DO, JD; Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.)
Penn State Health Milton S. Hershey Medical Center

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. This article presents 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.