Gastro-gastric anastomosis guided by endoscopic ultrasound: a promising treatment for gastric twists after Sleeve Gastrectomy (with video)?

Aims Post-sleeve gastrectomy (LSG) gastric strictures are less frequent than fistulas but have a major nutritional impact. Gastric twist results from the rotation of the post-sleeve stomach around its longitudinal axis, inducing a functional gastric stenosis responsible for major digestive discomfort, sometimes leading to severe undernutrition. The endoscopic management of twist is complex, with little clinical benefit. The high recurrence rate implies surgery in over 50% of cases. We therefore wished to study the safety and efficacy of a EUS-guided gastro-gastric anastomosis (GGA) between the upstream and downstream stomach in the management of gastric twist post sleeve gastrectomy.

Methods We present the efficacy and safety results of 6 cases performed in the department with two videos, managed by GGA for symptomatic post-LSG twist. The procedure steps were as follows: a nasocavitary drain was placed in the stomach downstream from the twist, for saline filling with a pump; then 20x10 mm Hot-Axios stent is released between the 2 parts of the stomach, after direct puncture for completing GGA. Patients were left fasting on the evening of the operation, then gradually resumed eating on Day 1 after medical examination. The main objective was to assess the efficacy of the treatment defined by the improvement in the GOOSS score of at least 1 point. Secondary objectives were weight gain by analysis of variations in weight and BMI, quality of life measured by the GLQLI score, and complications according to the AGREE classification.

Results Seven patients were included between October 24, 2023 and August 29, 2024, aged 31 to 61 years, operated on by sleeve gastrectomy 4 months to 10 years prior to referral. Median initial GOOSS was assessed at 0.5, time from first symptoms to surgery was 7.5 days. Efficacy results were analyzed with a median follow-up time of 120 days. Clinical success was achieved in 83% of patients, and no complications occurred during or after the procedure. Patients were hospitalized after the procedure for 48 hours. The mean GOOSS at 1 month was 2.5, so clinical efficacy was achieved in 5 out of 6 patients. All patients but one still have the stent in place at the end of follow-up. One underwent an incision of the mucosal bridge (video) to restore a normal gastric anatomy, which should be the second step of the whole management.

Conclusions Our series brings together the first cases of management of gastric twist by gastro-gastric anastomosis performed under EUS, demonstrating a high mid-term efficacy rate (83%) in such complex situation, without any severe adverse event

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
27 March 2025