Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach

Introduction

The Cascade stomach (CS), also known as the “cup and spill” stomach, is a relatively rare anatomical-functional gastric deformity characterized by dorsal folding of the gastric fundus toward the corpus, resulting in the formation of two distinct chambers or biloculated stomach —an upper loculus formed by out-pouching of the fundus and a narrower lower loculus comprising parts of the corpus.^1,2 CS may be congenital or acquired, with etiological factors including aerophagia, congenital deformities, peptic ulcers, upper gastric malignancies, perigastric adhesions, external compressions (e.g., from splenic flexure syndrome), or structural anomalies such as shortened diaphragmatic ligaments and altered gastric suspensory anatomy. The incidence of CS varies widely depending on the diagnostic modality and population studied, reported at 2.4% via radiological examination in Turkey, 2.5% and 58% via endoscopy in Turkey and Japan, respectively, and 13.6%–19.5% in barium studies in Bulgaria and Japan, respectively. Notably, a higher prevalence was observed among males.³ Despite being relatively uncommon, CS can cause significant symptoms, such as early satiety, postprandial discomfort, and reflux, particularly when it leads to impaired gastric emptying or abnormal motility.⁴

Medical management with proton pump inhibitors, prokinetics, or antispasmodics typically yields limited results, although some symptomatic relief has been reported with post-ure-related breathing exercises.^4,5 Surgical intervention is often considered for refractory or recurrent cases, with several approaches described in the literature. These include laparoscopic gastropexy (to fix the flaccid fundus to the diaphragm after adhesiolysis), gastro-gastric anastomosis (creating a direct passage between the two chambers), sleeve gastrectomy (removing the non-functional upper loculus to prevent torsion), gastrojejunostomy, and Nissen fundoplication (esophagogastric fundoplasty) described in the literature.¹

However, no standardized guidelines currently exist, and high-level evidence remains limited. Although the literature is sparse, isolated case reports and small series have documented successful surgical outcomes in patients with CS, suggesting the potential role of surgery in symptom resolution. We present the case of a 58-year-old male with a 20-year history of postprandial fullness who was previously treated with Roux-en-Y gastrojejunostomy. The symptoms recurred over time, including post-meal dyspnea and functional impairment. Physical examination results were unremarkable. Imaging and endoscopy confirmed a ventrally folded fundus consistent with the ventral gastric cascade. The patient underwent proximal sleeve gastrectomy, which resulted in complete symptom resolution and no recurrence at two-year follow-up.

This case highlights the role of surgery in symptomatic CS, and supports the need for clearer evidence-based guidance. This evidence-based case report aims to review and synthesize the highest quality data available on the surgical management of CS, to inform future clinical decision-making, and potentially contribute to the development of standardized treatment protocols.

Case report

We report the case of a 58-year-old Asian male worked as an official worker and presented to our hospital in July 2020 with a long-standing complaint of postprandial fullness. He reported early satiety and abdominal discomfort after consuming only a small amount of food, with symptoms that had persisted intermittently over the past 20 years. He denied associated nausea or vomiting, but noted increasing difficulty in breathing and performing daily activities after meals. He found temporary relief by lying down or straightening his body. There was no relevant family history of gastrointestinal diseases. The patient underwent Roux-en-Y gastrojejunostomy in 2000 because of similar complaints. Although this procedure initially alleviated the patient’s symptoms, it gradually recurred a few months postoperatively and progressively worsened over time.

No abnormalities were detected during physical examination. The Laboratory findings were within normal limits. A contrast study of the esophagus, stomach, and duodenum (Esophagus-Maag-Duodenum/OMG series) shown in Figure 1 revealed biloculation of the stomach between the fundus and corpus, with the fundus deviating ventrally. A barium contrast study demonstrated a fluid level in the fundus, and fluoroscopy confirmed ventral flexion of the gastric fundus. Upper gastrointestinal endoscopy revealed a pronounced fundal pouch upon entry into the stomach ( Figure 2a) and a marked ridge separating the fundus and the corpus ( Figure 2b). These findings support the diagnosis of the ventral gastric cascade.

Figure 1. Oesophagus Maag Duodenum (OMG) radiology examination shown biloculation of the stomach.

Figure 2. Endoscopic examination of the patient’s oesophagus and gaster.

In August 2020, the patient underwent a laparoscopic proximal sleeve gastrectomy. The folded fundus was resected using a linear stapling device, as shown in Figure 3a–c. The Postoperative recovery was uneventful, and the patient reported complete resolution of symptoms. The patient remained symptom-free during the two-year follow-up period with no evidence of recurrence. The patient remained symptom-free during the two-year follow-up period with no evidence of recurrence.

Figure 3. Intraoperative proximal sleeve gastrectomy.

A 58-year-old male who came to our hospital in July 2020 and complained that his stomach felt rapidly full after eating only a few meals over the past 20 years. He had undergone Roux-en-Y gastrojejunostomy bypass surgery in 2000 because of this complaint. After this operation, the complaints subsided, but after a few months, they reappeared. Currently, patients complain that it is difficult to breathe and perform daily activities after meals. The patient had to straighten his body or lie down so that the symptoms receded slowly. Nausea vomiting was not observed.

The physical examination results were normal. In contrast, as shown in Figure 1, a study of the Esophagus Maag Duodenum (OMG) radiology examination of the stomach found biloculation of the stomach between the fundus and corpus. The fundus deviated ventrally, recognized by the barium contrast-forming fluid level in the fundus of the stomach. Fluoroscopy contrast examination confirmed that the gaster fundus was flexed toward the ventral side. Endoscopic examination revealed fundal pouch formation upon entering the stomach ( Figure 2a) and a pronounced ridge separating the fundus and the body of thestomach ( Figure 2b).

A diagnosis of ventral gastric cascade was established, and proximal sleeve gastrectomy was performed by resecting the folded fundus with stapling tools, as shown in Figure 3a-c. Postoperative complaints resolved uneventfully, and another contrast study was scheduled for evaluation. No recurrence was observed during the two-year postoperative follow-up period.

Methods

Literature searching strategy

This study was structured as an evidence-based case report adhering to SCARE criteria. A literature search was conducted on November 22 and 23, 2024, across seven journal databases: PubMed, Scopus, ProQuest, The Cochrane Library, EBSCOhost, and Google Scholar using keywords (“cascade stomach”) OR (“biloculation of the gastric cavity”) AND (“gastric sleeve resection”) OR (“sleeve gastrectomy”) AND (“Nissen fundoplication”) OR (“gastropexy”). The flowchart in Figure 4 illustrates the search strategy employed for each database.

Figure 4. Flowchart diagram depicting the literature search process.

Results

Five articles were selected and reviewed for this case report. The characteristics of each study are summarized in Table 2. Resection of the gastric sleeve was the first reported surgical procedure for treating a cascade stomach in a 35 years old described by Schaffner et al.⁵ in 1941. This procedure helps reduce the size of the loculus and prevents axial rotation of the stomach. Surgical correction, including fundus resection, provides significant symptom relief, demonstrating the condition’s complex etiology and the potential benefits of targeted surgical interventions.⁵

Subsequently, Schouten et al.⁶ performed laparoscopic gastric sleeve resection for recurrent cascade stomach (CS) with satisfactory results. He described the case of a 54-year-old woman with CS who was successfully treated using a laparoscopic gastropexy approach in 1999; however, symptoms recurred after 4 years, necessitating gastropexy. Otherwise, a more aggressive surgical approach was adopted for the patient who later underwent laparoscopic sleeve gastrectomy due to persistent symptoms. However, this technique has not been previously documented in literature as a treatment for this condition. Considerations for this new approach are based on the suggestions in the literature that the symptoms of the gastric cascade are caused by either the change in the stomach shape or the “volvulus-like” axial rotation of the fundus. It addresses the cascade stomach by interrupting the typical biloculation and preventing axial rotation through resection of the fundus. He suggested sleeve gastrectomy as a valuable option for recurrent CS that is unresponsive to other interventions.⁶

Another procedure reported to treat the cascade stomach with a minimally invasive technique was first performed by Battisi et al.⁷ namely laparoscopic gastro-gastric anastomosis. The upper gastric part was connected with the lower part -giving rise to the term ‘anastomosis’- hence, alternative channels for food passage were formed. He demonstrated significant success in alleviating symptoms and restoring normal gastric function using this technique.⁷

In a case report by Chhabra et al.,¹ a 57-year-old male with a diagnosis of cascade stomach underwent Nissen fundoplication after nonoperative treatment proved ineffective. Nissen fundoplication is another recommended surgical management for CS. In Nissen’s fundoplication, the upper part of the gastric loculus was used to create a sheath around the lower part of the esophagus. This technique served as both gastropexy and obliterated dead space in the upper loculus. The patient experienced no complications, and at a 5-year follow-up, his condition had completely resolved with a 3.5 kg weight gain.¹

Recently, Bondar et al.⁸ detailed the case of a 55-year-old male presenting with upper gastrointestinal symptoms and was ultimately diagnosed with a cascade stomach characterized by a biloculated gastric cavity and pyloroduodenal thickening leading to luminal narrowing. After conservative treatment was ineffective, the patient underwent exploratory laparotomy, including gastropexy, gastrojejunostomy, and jejunojejunal anastomoses, with the stomach anchored to the diaphragm to prevent postoperative volvulus. The surgery was successful, resulting in complete symptom resolution at the months follow-up, demonstrating the efficacy of this approach in managing cascade stomach cases resistant to conservative treatment.⁸

Discussion

Cascade stomach (CS) is a rare anatomical abnormality in which the stomach is divided into two chambers: an upper, inert sac (typically the fundus), and a lower active compartment responsible for motility. The condition often involves the backward folding of the fundus, creating a “cascade” effect visible in radiographic studies.^1,9 Interestingly, CS has also been linked to obesity and metabolic syndrome. The elevated intra-abdominal pressure, responsible for this association, drives the stomach upward toward the diaphragm, causing the fundus to bend backward and ultimately bulge into the lesser sac above the splenic artery and pancreas.^10–12

Symptoms occur when the upper sac fills and spills contents into the lower chamber, disrupting mixing and propulsion, resulting in delayed gastric emptying (DGE).^4,14 DGE is associated with an increased frequency of transient lower esophageal sphincter relaxation (TLESR), which heightens the risk of gastroesophageal reflux disease (GERD) as TLESR events occur more often.^10,13,15 Associated upper gastrointestinal symptoms associated with CS include reflux symptoms including heartburn, regurgitation, and burping that arise from elevated intra-gastric pressure; dyspepsia symptoms such as feelings of post-meal fullness, bloating, early satiety, nausea, vomiting, and loss of appetite are linked to DGE; and epigastralgia symptoms encompass epigastric pain and heat caused by mucosal stretching and irritation.^2,4

Population studies by Kusano et al. involving more than 1000 subjects showed that CS patients are twice as likely to develop symptoms compared to the general population, with women showing even higher odds.⁴ Additionally Bernante et al. reported that CS has been observed in 8.8% of 253 bariatric surgery patients, highlighting its potential underdiagnosis. These findings emphasize the need for improved detection and management strategies for this rare disorder.¹⁰

Conclusion

Proximal sleeve gastrectomy is an effective intervention for CS, offering significant symptom resolution and long-term improvement. It also has a positive effect on the resection of the stomach, which prevents biloculation. The evidence from the case report and reviewed literature underscores the capacity of the procedure to address biloculated gastric structures and prevent axial rotation as key contributors to the pathophysiology of CS. Further research is needed to optimize surgical interventions for CS, ensuring both efficacy and minimization of potential complications, such as weight loss, GERD, and gastric leakage.

Consent

Written informed consent for publication of clinical details and/or clinical images was obtained from the patient for publication of this case report. A copy of the written consent form is available for review by the Editor-in-Chief of this journal upon request.