Gastric twist after sleeve gastrectomy is an increasingly recognized cause of obstructive symptoms and dysphagia. Endoscopic dilation (ED) has been traditionally used, while lumen-apposing metal stents (LAMS) and fully covered self-expandable metal stents (FC-SEMS) have emerged as alternative options. This study compared the efficacy and safety of LAMS, FC-SEMS, and ED for the treatment of post-sleeve gastric twist.

Single-center retrospective cohort including all consecutive patients with symptomatic gastric twist after sleeve gastrectomy treated with LAMS (16×30 mm), FC-SEMS (22 mm × 110 mm), or pneumatic dilation between January 2012 and August 2025. Technical success (TS) was defined as completion of the planned procedure. Clinical success (CS) was defined as improvement of ≥1 level in the Mellow–Pinkas Dysphagia Score. Recurrence was defined as dysphagia score 3–4 and/or inability to maintain a satisfactory luminal caliber within 4 weeks after CS. Adverse events (AEs) were classified according to AGREE, and recurrence-free survival (RFS) was assessed by Kaplan–Meier analysis. Group comparisons were performed using Kruskal–Wallis and χ²/Fisher’s exact tests.

Overall, 151 patients were included (LAMS 97; ED 31; FC-SEMS 23). Baseline characteristics showed some differences in age, BMI, smoking, prior complications, and dysphagia severity across groups. TS was achieved in all patients (LAMS 96.9% with three immediate FC-SEMS crossovers, ED 100%, FC-SEMS 100%). CS was comparable (79.8% LAMS, 90.3% ED, 82.6% FC-SEMS; P=0.4091). Among patients with CS, recurrence occurred in 16.0% after LAMS, 39.3% after ED, and 31.6% after FC-SEMS (P=0.0324). RFS did not differ significantly by treatment at Kaplan–Meier analysis (log-rank P=0.1490). LAMS required fewer procedures (median 1 vs 2 with ED; P<0.000001) and shorter hospital stay (0 vs 2 days; P<0.000001). AEs were numerically lower with LAMS (13.4% vs 25.8% ED vs 30.4% FC-SEMS; P=0.0849), predominantly late migrations.

In post-sleeve gastric twist, LAMS achieved comparable clinical success with fewer procedures, shorter hospitalization, and a lower crude recurrence and AE rate compared with ED and FC-SEMS, supporting its role as an attractive first-line endoscopic option.