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

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Ananti" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Introduction Cascade stomach (CS) or “cup and spill,” is an anatomical and functional deformity where the gastric fundus folds dorsally toward the corpus, creating biloculation. Surgical treatments for CS include gastropexy, sleeve gastrectomy, and Nissen fundoplication, however, standardized guidelines are lacking. Case Presentation A 58-year-old male presented to our hospital with a 20 years history of rapid feeling of full and abdominal discomfort after eating. He had undergone Roux-en-Y gastrojejunostomy in 2000, with a recurrence of symptoms shortly thereafter. Imaging revealed biloculation of the stomach with ventral flexion of the fundus, and endoscopy revealed the absence of the stomach ridge. A diagnosis of ventral gastric cascade was made, and the patient was successfully treated with proximal sleeve gastrectomy. Methods A systematic search was conducted in PubMed, Scopus, ProQuest, Cochrane Library, EBSCOhost, and Google Scholar identified relevant studies. Articles were selected according to specific inclusion and exclusion criteria, resulting in the identification of five eligible studies. Results Sleeve gastrectomy demonstrated effective in alleviating symptoms by addressing biloculation and preventing axial rotation of the stomach. Comparative analyses revealed its advantages over gastropexy and gastrogastric anastomosis, offering long-term symptom resolution with minimal complications. Clinical Discussion Two studies highlighted the benefits of gastric sleeve resection in addressing non-functional gastric segments and preventing volvulus. Two other studies demonstrated that fundoplication could alleviate gastroesophageal reflux disease (GERD)-related symptoms. These cases emphasize the importance of tailoring surgical techniques to individual patient needs and balancing symptom relief and complication risks. Conclusion Sleeve gastrectomy is a promising option for CS, offering symptom resolution in recurrent cases. Further comparative studies are essential to establish the optimal surgical approaches and long-term outcomes. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-702/v1", "name": "Case Report: Comparative Analysis of Surgical Treatments with Sleeve..." } } ] } Home Browse Case Report: Comparative Analysis of Surgical Treatments with Sleeve... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Jeo WS, Mazni Y, Putranto AS et al. Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.12688/f1000research.160339.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] Wifanto Saditya Jeo https://orcid.org/0000-0003-2194-1304 1 , Yarman Mazni 1 , Agi Satria Putranto 1 , Febiansyah Ibrahim 1 , Anggini T. Ananti 1 Wifanto Saditya Jeo https://orcid.org/0000-0003-2194-1304 1 , Yarman Mazni 1 , [...] Agi Satria Putranto 1 , Febiansyah Ibrahim 1 , Anggini T. Ananti 1 PUBLISHED 17 Jul 2025 Author details Author details 1 Digestive Surgery Division, Department of Surgery, Cipto Mangunkusumo Hospital, Central Jakarta, Jakarta, Indonesia Wifanto Saditya Jeo Roles: Conceptualization, Investigation, Methodology, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Yarman Mazni Roles: Investigation, Methodology, Supervision Agi Satria Putranto Roles: Investigation, Methodology, Supervision Febiansyah Ibrahim Roles: Investigation, Methodology, Supervision Anggini T. Ananti Roles: Conceptualization, Resources, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction Cascade stomach (CS) or “cup and spill,” is an anatomical and functional deformity where the gastric fundus folds dorsally toward the corpus, creating biloculation. Surgical treatments for CS include gastropexy, sleeve gastrectomy, and Nissen fundoplication, however, standardized guidelines are lacking. Case Presentation A 58-year-old male presented to our hospital with a 20 years history of rapid feeling of full and abdominal discomfort after eating. He had undergone Roux-en-Y gastrojejunostomy in 2000, with a recurrence of symptoms shortly thereafter. Imaging revealed biloculation of the stomach with ventral flexion of the fundus, and endoscopy revealed the absence of the stomach ridge. A diagnosis of ventral gastric cascade was made, and the patient was successfully treated with proximal sleeve gastrectomy. Methods A systematic search was conducted in PubMed, Scopus, ProQuest, Cochrane Library, EBSCOhost, and Google Scholar identified relevant studies. Articles were selected according to specific inclusion and exclusion criteria, resulting in the identification of five eligible studies. Results Sleeve gastrectomy demonstrated effective in alleviating symptoms by addressing biloculation and preventing axial rotation of the stomach. Comparative analyses revealed its advantages over gastropexy and gastrogastric anastomosis, offering long-term symptom resolution with minimal complications. Clinical Discussion Two studies highlighted the benefits of gastric sleeve resection in addressing non-functional gastric segments and preventing volvulus. Two other studies demonstrated that fundoplication could alleviate gastroesophageal reflux disease (GERD)-related symptoms. These cases emphasize the importance of tailoring surgical techniques to individual patient needs and balancing symptom relief and complication risks. Conclusion Sleeve gastrectomy is a promising option for CS, offering symptom resolution in recurrent cases. Further comparative studies are essential to establish the optimal surgical approaches and long-term outcomes. READ ALL READ LESS Keywords cascade stomach, surgical treatment, sleeve gastrectomy, gastric sleeve resection, fundoplication, gastropexy Corresponding Author(s) Wifanto Saditya Jeo ( [email protected] ) Close Corresponding author: Wifanto Saditya Jeo Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Jeo WS et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Jeo WS, Mazni Y, Putranto AS et al. Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.12688/f1000research.160339.1 ) First published: 17 Jul 2025, 14 :702 ( https://doi.org/10.12688/f1000research.160339.1 ) Latest published: 17 Jul 2025, 14 :702 ( https://doi.org/10.12688/f1000research.160339.1 ) 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. Clinical question How effective is sleeve gastrectomy compared to other surgical options in improving gastrointestinal symptoms and outcomes in patients with cascade stomachs? 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. Selection criteria The inclusion criteria were as follows: (1) systematic reviews and meta-analyses, randomized clinical trials (RCTs), cohort studies, case reports, or case series, (2) availability of full-text articles, and (3) studies written in English. On the other hand, the exclusion criteria included: (1) guideline articles or scientific consensus documents; (2) molecular studies, correspondence, editorials, or commentaries; and (3) lack of discussion on surgical outcomes in patients with cascade stomach. Due to limited recent data, studies published within the last 15 years were considered. Older studies were included if they were deemed clinically relevant and supported by subsequent evidence. Critical appraisal Relevant literature addressing the clinical questions was critically analyzed using the Joanna Briggs Institute (JBI) checklist for case report studies provided by the Faculty of Health and Medical Sciences, University of Adelaide, South Australia. The level of evidence was evaluated in accordance with the 2011 Oxford CEBM guidelines. All the selected studies were validated and deemed appropriate for use as evidence in this case report. The outcomes of the critical analyses are summarized in Table 1 . Table 1. Critical appraisal of the articles. No Author, year 1 2 3 4 5 6 7 8 1 Schaffner et al. , 5 1941 Y Y Y Y Y Y Y Y 2 Battisti et al. , 7 1998 Y Y N Y Y Y Y Y 3 Schouten et al. , 6 2007 Y Y Y Y Y Y Y Y 4 Chhabra & Mongia, 1 2016 Y Y Y Y Y Y Y Y 5 Bondar et al. , 8 2023 Y Y Y Y Y Y Y Y 6 Jeo et al. , 21 2025 Y Y Y Y Y Y Y Y Y yes ; N not mentioned Questions: 1. Were patient’s demographic characteristics clearly described? 2. Was the patient’s history clearly described and presented as a timeline? 3. Was the current clinical condition of the patient on presentation clearly described? 4. Were diagnostic tests or assessment methods and the results clearly described? 5. Was the intervention(s) or treatment procedure(s) clearly described? 6. Was the post-intervention clinical condition clearly described? 7. Were adverse events (harms) or unanticipated events identified and described? 8. Does the case report provide takeaway lessons? 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 Table 2. Characteristics and summary of studies included. No Author, year Subjects Study design Intervention Outcome Level of evidence Beneficial Adverse 1. Schaffner et al., 5 1941 Male, 35 years old Case report Open gastric sleeve resection • The patient was discharged after 16 postoperative days, he experienced immediate relief, and the dietary was slowly increased. • After correnpondence follow-up he had no return in symptoms and has gained a considerable amount of weight. • Open surgery requires a longer post-operative time 5 2. Battisti et al., 7 1998 Male, 16 years old Case report Laparoscopic gastro-gastric anastomosis • Allowed the restoration of optimal gastric emptying. • At 3 months follow-up, the patient reported complete resolution of symptoms and 3 kg weight gain. Not mentioned 5 3. Schouten et al., 6 2007 Female, 54 years old Case report 1. Laparoscopic gastropexy (Nissen fundoplication) • The patient remained symptom-free for 6 months following the initial laparoscopic gastropexy. • Symptoms of dyspepsia and gastrointestinal pseudo-obstruction recurred thereafter 5 2. Laparoscopic gastric sleeve resection • The patient’s initial weight loss has reached a stable point. • Over a 24-month follow-up, the patient remained free from pain or gastrointestinal symptoms. • This procedure has not been previously reported in the literature as a treatment for CS 4. Chhabra & Mongia, 1 2016 Male, 57 years old Case report • Laparoscopic Nissen’s fundoplication • 5-year follow-up showed complete resolution of symptoms and a weight gain of 3.5 kg • Indicating a positive long-term outcome. Not mentioned 5 5. Bondar et al., 8 2023 Male, 55 years old Case report • Gastropexy, gastro-jejunostomy and jejuno-jejunal anastomoses. • The surgery was done with a very good outcome, according to structural issues of the stomach, preventing future complications like volvulus. • Surgical treatment addresses gastric deformation and improves delayed gastric emptying (DGE). • Patient showed complete resolution of symptoms during a 6-month follow-up period. Not mentioned 5 6. Jeo et al. , 21 2025 Male, 58 years old Case report 1. Roux-en-Y gastrojejunos-tomy bypass 2. Proximal sleeve gastrectomy 1. The complaints subsided after the surgery, but after a few months, it is reappeared. 2. Current procedure has shown good output, including: • Postoperative complaints were resolved. • No recurrence was observed during the two-year postoperative follow-up period. Not mentioned 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 Sleeve gastrectomy indication and caution This evidence suggests that sleeve gastrectomy significantly reduces symptoms of CS. However, outcomes such as nutritional deficiencies, weight reduction, and development of GERD following sleeve gastrectomy require further monitoring and comparison, as this procedure is often used in bariatric treatment. Schaffner et al.’s case showed significant symptom relief after surgery. The entire fundus was resected, leaving a strip on the lesser curvature. This pioneering approach demonstrated the potential for targeted surgery in cases unresponsive to conservative treatments, reducing the non-functional loculus, and preventing axial stomach rotation to alleviate symptoms such as DGE and reflux. According to the long-term outcome and follow-up of gastric resection in this case, a year after surgery, the patient had no return on symptoms and gained a considerable amount of weight. He was also able to carry on his work without burden. 5 The latest research by Schouten et al. expanded on this by performing laparoscopic sleeve gastrectomy in patients with recurrent CS following prior gastropexy procedures. The sleeve gastrectomy effectively addressed the biloculated structure of the stomach and prevented volvulus-like axial rotation, thereby providing long-term symptom resolution. These cases highlight the versatility of sleeve gastrectomy as a treatment for CS, particularly in patients with persistent or recurrent symptoms, offering a minimally invasive option with durable outcomes. Initially, the patient experienced weight loss after surgery. However, after 24 months of follow-up, the patient remained free of pain or gastrointestinal issues. She exhibited normal eating habits, favoring smaller meals, and her initial weight loss stabilized. 6 Nevertheless, apart from the advantages of sleeve gastrectomy in reducing the symptoms of CS, GERD is widely known to be a frequent complication associated with sleeve gastrectomy (SG) procedures. Normally, after food intake, the gastric fundus exerts pressure on the esophagus, triggering an anti-reflux mechanism through the contraction of the sling and clasp fibers. Sleeve gastrectomy (SG) disrupts these processes by excising the gastric fundus, modifying the angle of His, and increasing intragastric pressure, which may contribute to the development of GERD. However, the effect of SG on GERD continues to be a topic of debate. 16 Rebecchi et al. found an improvement in symptoms in patients with preoperative acid reflux, while a 5.4% incidence of newly developed (“de novo”) GERD was reported in individuals with normal preoperative pH monitoring. They emphasized two critical technical aspects, namely, a technically correct gastric resection without creating mid-stomach stenosis and a careful dissection of the angle of His, keeping a safe distance from the gastroesophageal junction. 17 Similarly, Daes et al. reported GERD resolution in most cases post-SG, identifying technical factors such as incisura angularis narrowing, fundus dilation, and persistent hiatal hernia Correcting these factors during surgery significantly reduces the incidence of GERD and the need for postoperative endoscopy. 16 Other complications associated in sleeve gastrectomy include uncommon but critical staple line malformations that can result in an irregularly shaped gastric tube, elevated intraluminal pressure, and an increased likelihood of gastric leaks caused by tissue ischemia. 17 – 19 These often arise from faulty staple line formation, poor tissue alignment, or technical errors during the stapling process. Additionally, pancreatic leaks, although rarely reported, can occur during SG, particularly in patients with a history of complex abdominal surgery that results in adhesions between the pancreas and stomach. 20 Further research comparing this approach to alternative surgical techniques such as gastropexy or fundoplication is essential to establish a standardized guide. Comparison of surgical technique Surgical techniques for treating CS vary in approach and outcome. Gastric Fundus Resection by Schaffner et al. (1941) was an early open surgical approach focused on removing the non-functional loculus to alleviate symptoms such as delayed gastric emptying (DGE) and reflux. The outcome was highly positive with long-term symptom resolution and significant patient satisfaction. However, the invasive nature of surgery poses risks inherent to open procedures. 5 Laparoscopic Gastro-Gastric Anastomosis by Battisti et al., 1998, shows a minimally invasive technique that joins the upper and lower chambers of the stomach, creating an alternative food passage. This resulted in complete symptom relief and weight gain at the 3-month follow-up. This approach is less invasive, but may not address axial rotation issues as effectively as other methods. 7 Laparoscopic Sleeve Gastrectomy (LSG) by Schouten et al. (2007) was used for recurrent CS after previous gastropexy failures. It addressed biloculation and axial rotation, leading to long-term relief with no reported complications for over 24 months. This procedure is minimally invasive and has durable outcomes, but may carry risks of post-sleeve GERD due to anatomical changes. 6 Laparoscopic Nissen Fundoplication by Chhabra & Mongia (2016) is an anti-reflux procedure that wraps the gastric fundus around the lower esophagus, addressing both CS and GERD. The patient experienced complete symptom resolution and weight gain over a 5-year follow-up. Although effective for reflux control, it may not fully resolve biloculation-related symptoms. 1 Hybrid Techniques by Bondar et al. (2023) were a combination of gastropexy, gastrojejunostomy, and jejunojejunal anastomoses that were performed to correct anatomical abnormalities and improve gastric motility. The patient reported complete symptom resolution at six months, highlighting the efficacy of the approach in complex cases unresponsive to simpler interventions. 8 All techniques were effective in resolving CS-related symptoms, with sleeve gastrectomy and hybrid techniques demonstrating durable outcomes in patients with recurrence. Laparoscopic techniques (gastro-gastric anastomosis, sleeve gastrectomy, Nissen fundoplication) provided reduced recovery times and lower complication rates compared to open fundus resection. 1 , 5 – 7 Nissen fundoplication specifically targeted GERD, whereas sleeve gastrectomy carried a risk of “de novo” GERD due to altered anatomy. 1 While in hybrid approaches by Bondar et al. offer flexibility in addressing combined anatomical and motility issues, particularly in resistant cases. 8 This comparison highlights that while each technique has strengths, the choice depends on individual patient factors, including symptom severity, anatomical complexity, and prior surgical history. Application of study results and case presentation The patient presented in this EBCR was diagnosed with a cascade stomach that is unique and rare because of the lack of detection in clinical practice with the presence of upper gastrointestinal symptoms. Based on the studies reviewed in this article, SG should be considered as a treatment option for this condition. In this patient, proximal sleeve gastrectomy was performed as the patient had already undergone Roux-en-Y gastrojejunostomy bypass surgery 20 years ago; however the symptoms reappeared, and after the current procedure demonstrated favorable outcomes, with no complications observed. Post-operative complaints were resolved without complications, and no recurrence was reported during the two-year follow-up period. However, the commentary regarding this procedure in treating cascade stomach is not well described in the literature. Hopefully, this case report will enhance the scientific basis for employing sleeve to treat complex or recurrent cases of CS. Strengths and limitations This study contributes significantly to the limited literature on cascade stomach (CS), offering valuable insights into the surgical management of this rare and often under-diagnosed condition. Based on the literature review, this study is the first to combine case-based evidence with a comprehensive analysis of existing research on the topic, offering a thorough perspective on the effectiveness of proximal sleeve gastrectomy in comparison to other methods. By including long-term follow-up data, this study underscores the durability of symptom resolution and functional improvements after surgery, which are critical for evaluating the clinical utility of the procedure. However, this study has certain limitations. The limited number of cases and lack of randomized controlled trials (RCTs) or meta-analyses in the literature review hinder the generalizability of the findings. Furthermore, potential confounding factors, such as variations in surgical techniques, patient anatomy, and pre-existing conditions, which may influence outcomes, have not been fully explored. This underscores the need for larger, multicenter studies to establish standardized management guidelines and comprehensively evaluate long-term risks. 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. Data availability The completed CARE Checklist is available on Figshare under the title “CARE Checklist for Case Report on Cascade Stomach Treated with Sleeve Gastrectomy”, DOI: https://doi.org/10.6084/m9.figshare.29444132 , 21 and is licensed under a CC0 1.0 license. Underlying data All data underlying the results are available as part of the article and no additional source data are required. Acknowledgements Not applicable. References 1. Chhabra MK, Mongia AK: Cascade stomach: a case report. Int. Surg. J. 2016; 3 (2): 1005–1008. https://www.ijsurgery.com/index.php/isj/article/view/235 2. Gulsen MT, Koruk I, Dogan M, et al. : Diagnostic accuracy of cascade stomach by upper gastrointestinal endoscopy in patients with obscure symptoms: a multi-center prospective trial. Clin. Res. Hepatol. Gastroenterol. 2011; 35 (7–8): 489–493. PubMed Abstract | Publisher Full Text 3. Kusano M, Hosaka H, Yasuoka H, et al. : New endoscopic classification of cascade stomach, a risk factor for reflux esophagitis. J. Gastroenterol. 2017; 52 (2): 211–217. PubMed Abstract | Publisher Full Text 4. Kusano M, Hosaka H, Moki H, et al. : Cascade stomach is associated with upper gastrointestinal symptoms: a population-based study. Neurogastroenterol. Motil. 2012; 24 (5): 451–455. PubMed Abstract | Publisher Full Text 5. Schaffner VD, Burton GV: Cascade stomach. Can. Med. Assoc. J. 1941; 45 (1): 52–56. PubMed Abstract 6. Schouten R, Freijzer P: Laparoscopic sleeve resection of a recurrent gastric cascade: a case report. J. Laparoendosc. Adv. Surg. Tech. A. 2007; 17 (3): 307–310. PubMed Abstract | Publisher Full Text 7. Battisti G, Natali G, Manno A, et al. : "Cascade stomach": laparoscopic treatment. Endoscopy. 1998; 30 (8 Suppl): S92–S93. PubMed Abstract | Publisher Full Text 8. Bondar OM, Kovalska OO, Paneque YH: Case of the successful use of gastro-jejunal with jejuno-jejunal anastomoses (and gastropexy) for treatment of the cascade stomach. Clin. Case Rep. Open Access. 2023; 6 (2): 248. https://www.ijsurgery.com/index.php/isj/article/download/9400/5664/41178 9. Wasti SF, Ali NS, Forrest A, et al. : Cascade (cup and spill) stomach. Abdom Radiol (NY). 2024; 49 (8): 2975–2977. PubMed Abstract | Publisher Full Text 10. Bernante P, Balsamo F, Rottoli M, et al. : Cascade stomach as a risk factor for incomplete resection of the gastric fundus in laparoscopic sleeve gastrectomy: a point of technique. Obes. Surg. 2020; 30 (12): 5139–5141. PubMed Abstract | Publisher Full Text 11. Kawada A, Kusano M, Hosaka H, et al. : Tu1148 cascade stomach correlates with metabolic syndrome, and closely relates to upper GI symptoms in Japanese people. Gastroenterology. 2012; 142 (5 Suppl 1): S-758. Publisher Full Text 12. Wang YJ, Hung KL, Yang JN, et al. : Gastric anatomic type is associated with obesity and gender. Obes. Facts. 2016; 9 (3): 221–229. PubMed Abstract | Publisher Full Text | Free Full Text 13. Kawada A, Kusano M, Hosaka H, et al. : Increase of transient lower esophageal sphincter relaxation associated with cascade stomach. J. Clin. Biochem. Nutr. 2017; 60 (3): 211–215. PubMed Abstract | Publisher Full Text | Free Full Text 14. Serra FE, Cohen RV: Gastroesophageal reflux disease after sleeve gastrectomy. Dig Med Res. 2024; 7 : 14. https://dmr.amegroups.org/article/view/9193/html 15. Rebecchi F, Allaix ME, Giaccone C, et al. : Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation. Ann. Surg. 2014; 260 (5): 909–915. Publisher Full Text 16. Daes J, Jimenez ME, Said N, et al. : Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes. Surg. 2012; 22 (12): 1874–1879. PubMed Abstract | Publisher Full Text | Free Full Text 17. Clapp B, Schrodt A, Ahmad M, et al. : Stapler malfunctions in bariatric surgery: an analysis of the MAUDE database. JSLS. 2022; 26 (1): e2021.00074. PubMed Abstract | Publisher Full Text | Free Full Text 18. Kwazneski D, Six C, Stahlfeld K: The unacknowledged incidence of laparoscopic stapler malfunction. Surg. Endosc. 2013; 27 (1): 86–89. PubMed Abstract | Publisher Full Text 19. Makanyengo SO, Thiruchelvam D: Literature review on the incidence of primary stapler malfunction. Surg. Innov. 2020; 27 (2): 229–234. PubMed Abstract | Publisher Full Text 20. Belluzzi A, Sample JW, Marrero K, et al. : Rare complications following laparoscopic sleeve gastrectomy. J. Clin. Med. 2024; 13 (15): 4456. PubMed Abstract | Publisher Full Text | Free Full Text 21. Jeo WS, Mazni Y, Putranto AS, et al. : CARE Checklist for Case Report on Cascade Stomach Treated with Sleeve Gastrectomy. Figshare. 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 17 Jul 2025 ADD YOUR COMMENT Comment Author details Author details 1 Digestive Surgery Division, Department of Surgery, Cipto Mangunkusumo Hospital, Central Jakarta, Jakarta, Indonesia Wifanto Saditya Jeo Roles: Conceptualization, Investigation, Methodology, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Yarman Mazni Roles: Investigation, Methodology, Supervision Agi Satria Putranto Roles: Investigation, Methodology, Supervision Febiansyah Ibrahim Roles: Investigation, Methodology, Supervision Anggini T. Ananti Roles: Conceptualization, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 17 Jul 2025, 14:702 https://doi.org/10.12688/f1000research.160339.1 Copyright © 2025 Jeo WS et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Jeo WS, Mazni Y, Putranto AS et al. Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.12688/f1000research.160339.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 17 Jul 2025 Views 0 Cite How to cite this report: al Asadi H. Reviewer Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r404855 ) The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-404855 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Sep 2025 Hala al Asadi , Weill Cornell Medicine, New York, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.176223.r404855 Thank you for allowing me to review this case report. The data regarding this rare disease is interesting. However, I think detailing some of the case you presented would add a lot to this paper. 1- What was the ... Continue reading READ ALL Thank you for allowing me to review this case report. The data regarding this rare disease is interesting. However, I think detailing some of the case you presented would add a lot to this paper. 1- What was the indication for the bypass in the 2000? was the diagnosis of Cascade stomach missed? Could you please clarify why this patient underwent bypass? and what was the official diagnosis at that time? 2- If the patient was not improving then why did it take 20 years to diagnose it? what the patient did after undergoing the bypass while his symptoms were worsening? 3- you are claiming that sleeve is an effective procedure. However, you mentioned that the patient has two-year follow-up only ? what if patient condition deteriorated over longer follow-up especially that in the papers you included in this case report- most of them they were over longer follow-up of more than 4 year? could you please address Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: I think this paper still needs to detailed more. please see comments attached I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT al Asadi H. Reviewer Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r404855 ) The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-404855 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Kehagias D. Reviewer Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r402169 ) The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-402169 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Aug 2025 Dimitrios Kehagias , Hull University Teaching Hospitals NHS Trust, Hull, England, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.176223.r402169 Thank you for the opportunity to review this interesting case study with review of the literature. The authors present a case of cascade stomach and elaborate on the surgical techniques described in the current literature, since the exact treatment is ... Continue reading READ ALL Thank you for the opportunity to review this interesting case study with review of the literature. The authors present a case of cascade stomach and elaborate on the surgical techniques described in the current literature, since the exact treatment is not established. Below are my comments and suggestions to the authors: 1. As this is not a systematic review, critical appraisal of the articles is not required. When presenting a case report is better to accompany it with a narrative review rather a systematic, which involves analysis of data. The flowchart should be kept and it would be better to present this study as "Case report and literature review". You should not mention systematic search or systematic review, since these are different methods. I would suggest you provide only the search syntaxis, the flowchart and remove selection criteria and critical appraisal. Change the approach to "case report and literature review" (which does not include methods and results. 2. In the flow chart you show that 4 studies were included, in results you mention five articles were selected, but in critical appraisal table 1 you present 6 studies. You need to resolve these discrepancies. 3. Mention in the discussion that resection increases the risk of leak from the staple line, while fundoplication or gastropexy do not have this risk. Therefore, what needs to be found out is whether sleeve gastrectomy leads to better functional results compared to gastropexy or fundoplication. If yes then sleeve gastrectomy could be a more rational approach. Add this reference regarding staple line leaks after sleeve gastrectomy "Verras, Georgios-Ioannis et al. “Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients.” Journal of personalized medicine vol. 13,9 1422. 21 Sep. 2023, doi:10.3390/jpm13091422" 4. Careful use the abbreviations and mention them only in the beginning (for example SG) 5. Table 2 is well presented and quite informative, while limitations are correctly acknowledged. 6. If there is no evidence of GERD, why to perform a Nissen and not another type of anterior fundoplication? Have the authors considered the chance for endoscopic sleeve gastroplasty, which is increasingly used as a bariatric operation. Potentially in this case, it could be even more beneficial. Add also these insights in the discussion. 7. Regarding the case description I have the following points that need to be addressed: - Since he underwent Roux-en-Y gastrojejunostomy, this means that he had a gastric resection. Roux-en-Y involves the creation of two anastomosis. Unless it was just a gastrojejunostomy without resection of stomach. In that case you should mention it as "gastrojejunostomy". Although, I cannot understand the exact indication of the previous RenY - Annotate where exactly is the fundus in figure 1. Fundus is supposed to be in the left side of the patient. It seems like the images are inverted and I do not know the reason. - Figure 2 does not show anything useful. Someone cannot understand where exactly is the fundus. It is just two pictures of the lumen, without any annotation or any useful information. - In sleeve gastrectomy we do not take the omentum out. Why did you dissect it with the stomach? Did you consider of performing the operation minimally invasive? Also, from the image 3 it does not look that the patient had roux-en-y gastrojejunostomy. You should revise this. Thank you again. I believe with these revisions the manuscript will be even more strengthened. I am looking forward to the revised version. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gastrointestinal Surgery, Metabolic Bariatric Surgery, Minimally Invasive Surgery, Colorectal Surgery, Upper Gastrointestinal Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kehagias D. Reviewer Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r402169 ) The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-402169 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 17 Jul 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 17 Jul 25 read read Dimitrios Kehagias , Hull University Teaching Hospitals NHS Trust, Hull, UK Hala al Asadi , Weill Cornell Medicine, New York, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 al Asadi H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Sep 2025 | for Version 1 Hala al Asadi , Weill Cornell Medicine, New York, USA 0 Views copyright © 2025 al Asadi H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for allowing me to review this case report. The data regarding this rare disease is interesting. However, I think detailing some of the case you presented would add a lot to this paper. 1- What was the indication for the bypass in the 2000? was the diagnosis of Cascade stomach missed? Could you please clarify why this patient underwent bypass? and what was the official diagnosis at that time? 2- If the patient was not improving then why did it take 20 years to diagnose it? what the patient did after undergoing the bypass while his symptoms were worsening? 3- you are claiming that sleeve is an effective procedure. However, you mentioned that the patient has two-year follow-up only ? what if patient condition deteriorated over longer follow-up especially that in the papers you included in this case report- most of them they were over longer follow-up of more than 4 year? could you please address Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise I think this paper still needs to detailed more. please see comments attached I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) al Asadi H. Peer Review Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r404855) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-404855 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Kehagias D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Aug 2025 | for Version 1 Dimitrios Kehagias , Hull University Teaching Hospitals NHS Trust, Hull, England, UK 0 Views copyright © 2025 Kehagias D. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review this interesting case study with review of the literature. The authors present a case of cascade stomach and elaborate on the surgical techniques described in the current literature, since the exact treatment is not established. Below are my comments and suggestions to the authors: 1. As this is not a systematic review, critical appraisal of the articles is not required. When presenting a case report is better to accompany it with a narrative review rather a systematic, which involves analysis of data. The flowchart should be kept and it would be better to present this study as "Case report and literature review". You should not mention systematic search or systematic review, since these are different methods. I would suggest you provide only the search syntaxis, the flowchart and remove selection criteria and critical appraisal. Change the approach to "case report and literature review" (which does not include methods and results. 2. In the flow chart you show that 4 studies were included, in results you mention five articles were selected, but in critical appraisal table 1 you present 6 studies. You need to resolve these discrepancies. 3. Mention in the discussion that resection increases the risk of leak from the staple line, while fundoplication or gastropexy do not have this risk. Therefore, what needs to be found out is whether sleeve gastrectomy leads to better functional results compared to gastropexy or fundoplication. If yes then sleeve gastrectomy could be a more rational approach. Add this reference regarding staple line leaks after sleeve gastrectomy "Verras, Georgios-Ioannis et al. “Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients.” Journal of personalized medicine vol. 13,9 1422. 21 Sep. 2023, doi:10.3390/jpm13091422" 4. Careful use the abbreviations and mention them only in the beginning (for example SG) 5. Table 2 is well presented and quite informative, while limitations are correctly acknowledged. 6. If there is no evidence of GERD, why to perform a Nissen and not another type of anterior fundoplication? Have the authors considered the chance for endoscopic sleeve gastroplasty, which is increasingly used as a bariatric operation. Potentially in this case, it could be even more beneficial. Add also these insights in the discussion. 7. Regarding the case description I have the following points that need to be addressed: - Since he underwent Roux-en-Y gastrojejunostomy, this means that he had a gastric resection. Roux-en-Y involves the creation of two anastomosis. Unless it was just a gastrojejunostomy without resection of stomach. In that case you should mention it as "gastrojejunostomy". Although, I cannot understand the exact indication of the previous RenY - Annotate where exactly is the fundus in figure 1. Fundus is supposed to be in the left side of the patient. It seems like the images are inverted and I do not know the reason. - Figure 2 does not show anything useful. Someone cannot understand where exactly is the fundus. It is just two pictures of the lumen, without any annotation or any useful information. - In sleeve gastrectomy we do not take the omentum out. Why did you dissect it with the stomach? Did you consider of performing the operation minimally invasive? Also, from the image 3 it does not look that the patient had roux-en-y gastrojejunostomy. You should revise this. Thank you again. I believe with these revisions the manuscript will be even more strengthened. I am looking forward to the revised version. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Gastrointestinal Surgery, Metabolic Bariatric Surgery, Minimally Invasive Surgery, Colorectal Surgery, Upper Gastrointestinal Surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Kehagias D. Peer Review Report For: Case Report: Comparative Analysis of Surgical Treatments with Sleeve Gastrectomy in Recurrent Cascade Stomach [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :702 ( https://doi.org/10.5256/f1000research.176223.r402169) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-702/v1#referee-response-402169 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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