AIM: Gastric twist is a rare, however, troublesome complication of laparoscopic sleeve gastrectomy. This report describes a case complicated by perforation and leak in addition to twist. The patient was managed conservatively and successfully. CASE PRESENTATION: A 29-year-old female patient with a body mass index (BMI) of 41.3 kg/m2 (111 kg/1.64 m), who underwent gastric band insertion six years ago, recently experienced postprandial vomiting. Endoscopic examination revealed grade A esophagitis, minor antral gastropathy, and mild bulbar duodenitis. Her BMI was calculated at 33.1 kg/m2 (89 kg/1.64 m). One week later, she had a laparoscopic band removal and sleeve gastrectomy using an endo GIA Tri-stapler. Both the surgical and postoperative periods proceeded without complications, and she was discharged home the next day after surgery. The patient was readmitted after two weeks due to an organo-axial gastric volvulus, which was managed with stent placement. Six weeks following, a stomach leak and peri splenic fluid collection were diagnosed. A 12 mm Ovesco clip was employed to seal a perforation situated 35 cm from the incisors. Subsequently, a MEGA bariatric stent was placed. RESULTS: Two months after the removal of the MEGA stent, the patient had recovered completely and was in good health. CONCLUSIONS: Gastric twist after sleeve gastrectomy is a rare condition; a high index of suspicion is required for diagnosis. Prioritize conservative treatment to prevent the risk of revisional surgery.