Laparoscopic suture gastropexy for gastric volvulus: a report of 14 cases

Acute primary gastric volvulus with open suture gastropexy: a case report

Introduction and importance

Gastric volvulus is rare and may result in a closed-loop obstruction. Even with appropriate management, mortality may occur in up to 50% of patients. The conventional treatment for acute gastric volvulus has been immediate operation with reduction and detorsion of the volvulus.

Case presentation

Here, the authors present a case of acute gastric volvulus following fasting. The patient underwent definitive surgical treatment with detorsion and gastropexy, and was discharged with no postoperative complications.

Clinical discussion

Acute gastric volvulus is a rare yet serious medical condition that requires immediate diagnosis and intervention to prevent complications. The case presented highlights the importance of recognizing both common and subtle signs of gastric volvulus, though nonspecific symptoms may delay diagnosis. In this patient, the acute onset of symptoms following a large meal and failure to pass a nasogastric tube were early indicators that prompted imaging and led to the diagnosis of mesenteroaxial gastric volvulus. CT imaging played a crucial role in confirming the diagnosis, demonstrating its value in acute abdominal presentations where symptoms overlap with other causes of gastrointestinal obstruction. This case also emphasizes the importance of early intervention to avoid ischemic complications and improve survival rates.

Conclusion

Acute gastric volvulus is a rare, potentially life-threatening condition that can easily be missed due to nonspecific symptoms. Early recognition, prompt imaging, and immediate surgical intervention are critical to preventing serious complications such as strangulation and necrosis.

High risk and low incidence diseases: Pediatric digestive volvulus

INTRODUCTION

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments.

CONCLUSION

An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Acute Gastric Volvulus: A Rare Complication of Hiatal Hernia

Gastric volvulus, characterized by stomach rotation, is a rare condition arising from congenital or acquired factors. Predominantly affecting pediatric and elderly populations, it necessitates a high index of suspicion for timely diagnosis. Delayed recognition may precipitate severe complications such as ischemia, strangulation, and septic shock, often culminating in fatal outcomes. We present a case of a 71-year-old male initially admitted for suspected gastroenteritis, subsequently developing acute gastric volvulus during hospitalization, necessitating immediate surgical intervention. This case contributes to the scant literature on gastric volvulus in the elderly demographic.

Functional results after hiatal repair and gastropexy without fundoplication in patients with paraoesophageal hernia

PURPOSE

Paraoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Surgical gastropexy without fundoplication is an accepted alternative procedure; however, outcomes and functional results are rarely described. Our study aims to evaluate short-term outcomes and the long-term quality of life after gastropexy as treatment for PEH.

METHODS

Single center cohort analysis of all consecutive patients who underwent gastropexy for PEH without fundoplication. Postoperative outcomes and functional results were retrospectively collected. Reflux symptoms developed postoperatively were reported using the validated quality of life questionnaire: GERD-Health Related Quality of Life Qestionnaire (GERD-HRQL).

RESULTS

Thirty patients (median age: 72 years (65-80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 patients (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17-50) months. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL scale of 4 (1-6). 72% (n = 21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2-19) versus 3 (0-6), p = 0.100.

CONCLUSION

Gastropexy without fundoplication was performed by laparoscopy in most cases with acceptable complications rates. Two-thirds of patients reported symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good. Although the rate of PEH recurrence requiring a new re-intervention remained increased (23%), it does not seem to affect long-term functional results.

Gastric Volvulus: A Rare Cause of Intestinal Occlusion

Gastric volvulus (GV) is a rare condition characterized by the rotation of all or part of the stomach around its transversal or longitudinal axis. We report the case of a 76-year-old woman with the acute form of GV, likely exacerbated by hiatal hernia and age-related ligamentous relaxation, evolving for a week before her admission. She underwent a midline laparotomy with fundoplication at 270° and anterior gastropexy. GV poses life-threatening risks in its acute presentation. Surgical management entails restoring the hemodynamic stability, surgical detorsion of the volvulus, and addressing the etiology (hiatal hernia).

Chronic gastric volvulus with diaphragmatic eventration: Case presentation

INTRODUCTION AND IMPORTANCE

Gastric volvulus is a rare clinical entity which occurs due to the rotation of the stomach and can have life-threatening complications. This condition can have an acute or chronic presentation and its symptoms will vary according to the degree of obstruction and rapidity of onset.

CASE PRESENTATION

We report a case of a 84-year-old male with history of frequent periods of constipation and lack of appetite who presented to the emergency room with left-sided abdominal pain and distension and persistent nausea, without the ability to vomit. Abdominal radiograph, computed tomography scan of the abdomen, contrast-enhanced examination and upper endoscopy were consistent with a gastric volvulus secondary to diaphragmatic eventration. The patient's symptoms resolved after nasogastric tube placement and fluid resuscitation. However, he was proposed to a laparoscopic anterior gastropexy to prevent symptom recurrence. He remains asymptomatic after 3 years of follow-up.

CLINICAL DISCUSSION

The diagnosis of gastric volvulus is based mainly on clinical presentation and abdominal imaging. The main principles of surgical intervention include stomach decompression with volvulus reduction, followed by gastropexy and correction of any predisposing intra-abdominal factors.

CONCLUSION

Definitive treatment of both acute and chronic gastric volvulus includes a surgical approach. Laparoscopic anterior gastropexy has been found to be a viable alternative in these patients.

Congenital Diaphragmatic Hernia With Intra Thoracic Gastric Volvulus: A Rare, Life-Threatening Combination

Congenital diaphragmatic hernia (CDH) is a known cause of secondary gastric volvulus (GV). Both entities are life-threatening, either alone or in exceedingly rare instances when they occur in combination. Here, we describe one such rare combination of CDH and secondary GV in a nine-year-old boy, who presented to us with recurrent episodes of abdominal pain. Urgent laparotomy was done after radiological evaluation (X-ray of chest and abdomen and contrast-enhanced CT chest and abdomen), which revealed mesenterico-axial volvulus of the stomach, secondary to an underlying diaphragmatic defect in the left hemidiaphragm, thus establishing the cause (diaphragmatic defect) and effect (GV), and resulting in a favourable outcome.

A case report on secondary mesentero-axial gastric volvulus

Mesentero-axial gastric volvulus is a rare presentation to a surgical casualty unit with sinister complications and significant mortality and morbidity. Clinical assessment should be done with high suspicion in the case of an associated anatomical defect. Accurate diagnosis and timely intervention would drastically reduce morbidity and mortality. The present patient is a 63-year-old male with an acute and chronic presentation of a secondary mesentero-axial gastric volvulus with a large hiatal hernia who underwent open surgical repair with unremarkable postop recovery.

Development and validation of a composed canine simulator for advanced veterinary laparoscopic training

The development of innovative simulation models for veterinary laparoscopic surgery training is a priority today. This study aimed to describe a didactic simulation tool for the training of total laparoscopic gastropexy (TLG) with intracorporeal sutures in dogs. CALMA Veterinary Lap-trainer composite simulator (CLVTS) was developed from a plaster cast of 2 Great Dane canines mimicking the space and the correct position to carry out a TLG. After video instruction, 16 veterinarians with different degrees of experience in minimally invasive surgery (Experts, n = 6 and intermediates, n = 10) evaluated four sequential simulating TLG with intracorporeal suturing in the CLVTS. Subsequently, they completed an anonymous questionnaire analyzing the realism, usefulness, and educational quality of the simulator. The CLVTS showed a good preliminary acceptance (4.7/5) in terms of the usefulness and adequacy of the exercises that, in the participants' opinion, are appropriate and are related to the difficulty of the TLG. In addition, both experienced and intermediate surgeons gave high marks (4.5/5) to the feeling of realism, design, and practicality. There were no significant differences between the responses of the two groups. The results suggest that the CVLTS has both face and content validity. Where it can be practiced in a structured environment for the development of a total laparoscopic gastropexy with intracorporeal suture and without compromising patient safety, but still has some limitations of the scope of the study. Further studies are needed to establish the ability to assess or measure technical skills, including the degree of transferability to the actual surgical environment.

‘Back-and-Forth Stomach’ CT Imaging Findings of a Pathophysiologic Entity Causing Acute Gastric Volvulus

Background: Gastric volvulus (GV) is a life-threatening emergency condition that prompts emergent surgical management. With the advent of high-resolution computed tomography (CT), the role of radiologists in its diagnosis has become essential. Although many cases of GV have been described in the literature, its pathophysiology is still poorly understood. In addition, there is substantial terminological confusion with associated entities such as paraesophageal hernia, upside-down stomach, organo-axial or chronic GV. Methods: We conducted a retrospective review of clinical, radiological findings and other relevant data for seven patients with previous radiological diagnoses of a large hiatus hernia who presented with acute GV to the emergency department of our institution. We report data on age, sex, medical history, clinical presentation, imaging, treatment and outcomes for each case. Results: The CT findings at acute presentation showed the antrum lying above the diaphragm and dilated fundus below the diaphragm. By comparing the position of the stomach at acute presentation with previous imaging examinations, we confirmed a hypothesis put forward by a few authors decades ago that re-herniation of the gastric fundus into the abdomen is a common pathophysiologic trigger leading to acute GV. This hypothesis has not been supported by modern imaging examinations. Conclusions: We have provided imaging evidence supporting that the pathophysiology of many GVs is based on caudal re-descent of hiatal hernia into the abdominal cavity. Given the terminological disparity used in the literature in this context, we believe it appropriate to introduce and extend the term ‘back-and-forth stomach’ to refer to this type of GV.

Chronic gastric volvulus secondary to eventration of the left hemidiaphragm due to radiation-induced phrenic nerve palsy: a rare presentation

Partial mesentericoaxial gastric volvulus associated with acquired eventration of the left dome of the diaphragm is very rare. We present the case of a 65-year-old man who presented with features of gastric outlet obstruction. He had a prior history of laryngeal cancer for which total laryngectomy was done, and adjuvant radiotherapy was administered. He was subsequently diagnosed with eventration of the left dome of the diaphragm and partial gastric volvulus. The patient recovered completely with conservative management and was discharged.

Let's (Not) Twist Again: Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy in Paediatric Gastric Volvulus

INTRODUCTION

In the setting of intermittent abdominal pain accompanied by gastro-intestinal obstruction, gastric volvulus should be suspected.

AREAS COVERED

A 10-year-old girl was admitted to our hospital for intermitted abdominal pain associated with recurrent non-bilious vomiting and acute weight loss. The radiological images performed at the district general hospital were reported as negative. After careful review of the imaging, a gastric volvulus was suspected. Exploratory laparoscopy confirmed the diagnosis; laparoscopic-assisted percutaneous endoscopic gastrostomy was performed. The postoperative upper gastro-intestinal study showed stomach in its normal shape and position.

EXPERT COMMENTARY

Gastric volvulus is a potential life-threatening condition with a good outcome when promptly recognized. Laparoscopic-assisted percutaneous endoscopic gastrostomy is a safe and curative procedure in the case of suspected gastric volvulus, avoiding the need for a secondary procedure. In pediatric patients, it facilitates direct inspection of the stomach and abdominal cavity, reducing the need for a second procedure. This procedure may emerge as a 'gold standard' for gastric volvulus treatment.

Outcomes after Laparoscopic Gastropexy as an Alternative for Paraesophageal Hernia Repair

Background:

Outcomes after laparoscopic gastropexy (LG), performed as an alternative to formal paraesophageal hernia (PEH) repair in patients with giant PEH, have been rarely studied. This manuscript evaluates complications and long-term quality-of-life after LG.

Methods:

An IRB-approved protocol was used to identify patients who underwent LG to alleviate symptoms of acute or chronic gastric obstruction secondary to a paraesophageal hernia. Postoperative outcomes and quality-of-life data were retrospectively collected via chart review and prospectively via phone interview.

Results:

Twenty-six patients underwent LG, with a median age of 76 (52 – 91). Median follow-up was 28 (3 to 55) months. Gastropexy was the chosen intervention due to comorbid conditions (23, 88%), gastric inflammation (2, 8%), or intraoperative instability (1, 4%). Nine (35%) suffered postoperative complications, and 2 (8%) required reoperation. At the time of follow-up, 7 (27%) had died, 3 (11%) could not be reached. Sixteen (62%) completed the follow-up survey. Fourteen (88%) reported symptom resolution. Ten (62%) still required antireflux medication. Median Gastroesophageal Reflux Disease-Health Related Quality of Life score was 4.5 (0 to 19). Fourteen (88%) denied current dietary restrictions. All reported satisfaction with the operation.

Conclusion:

Laparoscopic PEH repair remains the standard of care for the management of giant PEH. However, a subcategory of patients with high operative risk could be candidates for a shorter operative intervention. As our data infers, LG is a reasonable alternative in this patient population. While the continued use of antisecretory medications is sometimes required, LG restores the ability to tolerate full meals without restrictions and results in excellent patient satisfaction.

Gastric remnant mesentero-axial volvulus following Roux-en-Y esophagojejunostomy: A rare complication

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Acute gastric volvulus is characterized by abnormal rotation of the stomach by more than 180°, creating a closed loop obstruction with the risk of strangulation, necrosis and perforation.

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Diagnosis of gastric volvulus is challenging due to non-specific presentation and rarity of this clinical condition.

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The diagnosis is even more challenging in patients with altered anatomy and requires high index of suspicion.

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Extensive gastric mobilization is a key step in several foregut and bariatric surgeries.

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This mobilization will leave the stomach with no attachments posteriorly and along the greater curvature, increasing the likelihood of volvulus.

Introduction

Acute gastric volvulus is a surgical emergency with a mortality as high as 15–20%. The rarity of gastric volvulus requires high index of clinical suspicion especially in the patients with altered anatomy, to allow immediate surgical intervention and reduce the morbidity and mortality.

Presentation of case

We present an unusual case of gastric remnant volvulus several months following Roux-en-Y esophagojejunostomy performed in an obese patient for severe, recurrent gastroesophageal reflux disease (GERD) and failed prior fundoplication. The patient was treated with gastropexy and Stamm gastrostomy tube.

Discussion

Gastric volvulus is a rare phenomenon, in which the stomach rotates around the short (mesentero-axial) or longitudinal (organo-axial) axes. Diagnosis of gastric volvulus is challenging due to non-specific presentation and rarity of this clinical condition. The diagnosis of volvulus in patients with altered anatomy is even more challenging, requiring a high index of suspicion, and heavily relies on cross sectional imaging.

Conclusion

Extensive gastric mobilization is a key step in several foregut and bariatric surgeries, this will leave the stomach with no attachments posteriorly and along the greater curvature and increases the likelihood of volvulus.

Case Report: Late-Presenting Congenital Diaphragmatic Hernia With Tension Gastrothorax

A congenital diaphragmatic hernia (CDH) occurs when the abdominal contents protrude into the thoracic cavity through an opening in the diaphragm. The main pathology lies in the maldevelopment or defective fusion of the pleuroperitoneal membranes. Delayed diagnosis in later childhood as in the index case reported here can lead to life-threatening complications such as tension gastrothorax and gastric volvulus. Such life-threatening conditions should be managed emergently avoiding misdiagnoses and untoward harm to the patient. We report a pediatric case of an 8-year-old boy who presented with respiratory distress, chest pain, and non-bilious vomiting. He was initially diagnosed with tension pneumothorax, and the chest x-ray was interpreted as hydropneumothorax. A chest tube placement was planned but was withheld due to excessive vomiting. A nasogastric (NG) tube was placed, and a barium-filled radiograph showed an intrathoracic presence of the stomach. A diagnosis of a congenital diaphragmatic hernia with tension gastrothorax was made. The posterolateral (Bochdalek) diaphragmatic hernia was repaired successfully. This case report highlights the importance of including a late-presenting CDH in the differential diagnoses of pediatric patients who present with respiratory distress, chest pain, non-bilious vomiting, and radiological findings suggestive of tension pneumothorax.

The Surgical Management of Acute Gastric Volvulus: Clinical Outcomes and Quality of Life Assessment

Background: Surgery is the mainstay of treatment for gastric volvulus. Despite its rarity, early experience from recent publications suggests that laparoscopy is a safe and effective approach for the treatment of acute gastric volvulus. Yet, more data focusing on patients' postoperative quality of life (QoL) is needed. The aim of this study is to report our institutional experience with the management of acute gastric volvulus, assessing surgical outcomes and postoperative QoL. Materials and Methods: We performed a retrospective review of a prospectively maintained database, looking for patients with gastric volvulus, requiring emergency laparotomic or laparoscopic surgery, between 2016 and 2018. Follow-up included clinical evaluation, barium swallow X-ray, and two QoL questionnaires-Gastroesophageal Reflux Disease-Health-Related Quality of Life and Gastrointestinal Symptom Rating Scale. Results: Over a 3-year period, 9 patients underwent emergency surgery for acute gastric volvulus, 5 (55%) of which were performed laparoscopically. In this group, the only postoperative complication was found in 1 (20%) patient who presented mild delayed gastric empty. In the laparotomic group, 3 patients (75%) had immediate (30-day) postoperative complications-1 pneumonia, 1 bowel obstruction, and 1 sepsis with multiorgan failure. At a median follow-up of 25 (15-48) months, hiatal hernia recurred in 1 (20%) patient after laparoscopic repair. No recurrence occurred in the open group. With a 100% response rate, QoL questionnaires revealed that 80% of the subjects treated laparoscopically were fully satisfied of the surgical approach, reporting slightly better QoL scores than the open surgery group. Conclusions: Improved postoperative clinical outcomes and QoL after laparoscopic repair of acute gastric volvulus provide encouraging evidence in support of this minimally invasive approach as an alternative to laparotomy.

Successful outcome in acute gastric volvulus in a low resource hospital setting in Bangladesh: A case report

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Life-threatening surgical emergency in a 17-year-old boy with common symptoms, abdominal pain and vomiting.

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Likely to be misdiagnosed due to the rarity of the disease.

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High index of clinical suspicion is crucial. Borchardt’s triad can be very helpful in acute cases.

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Quickly identified and Successfully treated.

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Timely treatment can prevent grave complications.

Introduction

Gastric volvulus is a rare medical emergency that can be fatal if not recognized early. Its rarity makes it quite challenging to diagnose but delaying in diagnosis and treatment can lead to fatal complications. Meticulous assessment and broadened differential diagnosis are thus crucial. Organoaxial volvulus, in which the stomach rotates 180 degrees around its long axis, is the most common subtype of gastric volvulus, occurring predominantly in infants and older adults.

Presentation of the case

Here, we present a case of acute organoaxial gastric volvulus in a 17-year-old male presenting to a low-resource hospital in Bangladesh with severe upper abdominal pain and postprandial vomiting. Initial assessment revealed severe epigastric tenderness and mild dehydration. Plain abdominal x-ray showed a hugely distended bowel with single air fluid level and thoracic herniation of the stomach. The patient was resuscitated then sent to the operating theatre for urgent laparotomy and sleeve gastrectomy with anterior gastropexy. Treatment was successful, and the patient survived.

Discussion

Acute gastric volvulus, a life-threatening surgical emergency can be treated successfully if identified timely. Though the CT scan is diagnostic, Borchardt’s triad can be helpful as well.

Conclusion

This is the second consecutive case managed by the same surgeon in the same hospital, highlighting that high index of clinical suspicion is an important tool to diagnose this condition early. Timely diagnosis and treatment are essential to avoid fatal complications, denoting the importance of documenting such cases.

Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair

Background and Objectives:

A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients.

Methods:

A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups.

Results:

Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence.

Conclusion:

Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Primary gastric volvulus: a report of two cases

Gastric volvulus is an uncommon cause of gastric obstruction. It can be classified as primary when no underlying condition is identified as the cause for the rotation. An acute presentation includes typical symptoms and is frequently detected by imaging studies. Chronic cases present with intermittent vague symptoms and imaging studies may be normal during the symptomatic interval. The lack of specific symptoms and signs delays the diagnosis of chronic volvulus. However, appropriate treatment demands prompt diagnosis. We report two cases of primary gastric volvulus, with chronic or subacute symptoms and normal imaging studies during the asymptomatic periods. Both were treated surgically and had an uneventful follow-up.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Second-look laparostomy for perforated gangrenous gastric volvulus to prevent total gastrectomy

A 42-year-old Caucasian woman presented to the emergency department with severe upper abdominal pain and vomiting. Clinically, she was septic, and abdominal examination suggested peritonitis. Following immediate resuscitation, the patient was stabilised and underwent urgent contrast-enhanced CT of the abdomen and pelvis. This revealed a mesenteroaxial gastric volvulus with traction on the mesentery and a small volume of free fluid. She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension. This mandated a damage-control approach for the patient's safety entailing a limited-sleeve gastrectomy and laparostomy formation. Stabilisation in the intensive care unit allowed for a safer return to the operating room. On second look 24 hours later, previously ischaemic non-viable-looking portions of the stomach had recovered their blood supply. The patient was discharged 31 days postoperatively after recovering from the operations, postoperative wound infections and pleural effusions.

Acute Paraesophageal Hernia: Laparoscopic Repair With Adjunct T-Fastener Gastropexy for the High Operative Risk Patient

BACKGROUND

In the emergent setting, most paraesophageal hernia (PEH) repairs are done by laparotomy with adjunct gastropexy or gastrostomy tube (GT) placement. This adjunct to the repair can be performed expeditiously by a laparoscopic approach by utilizing T-fasteners. We present our case series of patients with PEHs and acute gastric volvulus that were managed with laparoscopy and how patient characteristics can influence the repair technique.

METHODS

Patients with high operative risk who underwent laparoscopic hiatal hernia repair with adjunct T-fastener gastropexy in the emergent setting between July 2014 and July 2016 were included in this study.

RESULTS

Thirteen patients underwent successful PEH repair and all were classified as urgent/emergent upon admission. In total, 30.7% were performed laparoscopically. The median patient age was 84 years. A laparoscopic GT or gastropexy was performed for fixation of the stomach. Crural closure by an anterior cruroplasty was performed in all patients. There were no mortalities. One patient required conversion of gastropexy into a GT given symptoms of dysphagia. Prolonged length of stay was related to postdischarge institutionalization. All patients remained free of obstructive symptoms.

CONCLUSIONS

Laparoscopic PEH repair with adjunct gastropexy or GT placement should be considered in emergent cases for elderly patients with predominately obstructive symptoms. Laparoscopy for PEH repair is challenging and requires technical skills. T-fastener gastropexy or GT placement is safe, simple, and obviates the need for intracorporeal suturing. It also may be used to improve physician comfort with laparoscopy and to expedite the repair in this high-risk population.

Gastric Volvulus: A Rare Entity Case Report and Literature Review

Gastric volvulus is a rare entity defined as an abnormal rotation of the stomach around itself. It is a diagnosis of exclusion; the clinical index of suspicion is always low and is mostly diagnosed on imaging or on the surgery table. When it occurs, it is an emergency due to the risk of strangulation and consequent gangrene of the stomach. Mesentero-axial (MA) gastric volvuli constitute one-third of all cases. Here, we are present an interesting case of acute MA gastric volvulus diagnosed with imaging and treated subsequently.

Subacute Gastric Volvulus: A Report of Two Cases with Review of Literature

Gastric volvulus is a rare medical entity that requires high index of suspicion for diagnosis and treatment as it has different implications in terms of clinical presentation, diagnosis, imaging support, pathological behavior, and evaluation. When it presents acutely, it may be easily detected. However, in patients with subacute presentation, symptoms are vague due to episodic twisting and untwisting. Definite preoperative diagnosis can be established if imaging is performed during symptomatic interval. The main aim of this report was to stress on the need for keeping high index of suspicion for this medical condition and for imaging the patient during symptomatic interval.

A case report on gastric volvulus of a 17 years old boy from Bangladesh

INTRODUCTION

Gastric volvulus is a rare and true surgical emergency which is life threatening if not recognized and treated quickly. There have been approximately 300 reported cases globally till now. This condition most often occurs during 5th decade of life but there are over 100 reported pediatric cases also. This following rare incidence was such a case of a young patient in Bangladesh. It was the first case of gastric volvulus managed by the surgery department of the concerned hospital.

PRESENTATION OF CASE

A 17year old boy with frequent post meal vomiting presented with abdominal fullness and mild upper abdominal pain for 2 months. He was absolutely constipated for 2 weeks. On examination, there was distension of abdomen with mild tenderness. He had no significant respiratory distress. Plain X-ray revealed elevation of left hemi-diaphragm. The contrast meal study showed organoaxial volvulus of stomach. Elevation of left hemidiaphragm and an ectopic subdiaphragmatic kidney was found in CT scan of chest.

DISCUSSION

After adequate preparation, the patient was subjected to laparotomy and anterior gastropexy with plication of left hemi diaphragm was done. Gastric volvulus can manifest as an acute abdominal emergency or as a chronic intermittent problem. It requires a high index of suspicion and proper investigation.

CONCLUSION

It should be suspected in congenital abnormalities of diaphragm and associate with many other congenital abnormalities like ectopic kidney. Early surgical repair remains the treatment of choice.

A rare case of post-splenectomy gastric volvulus managed by laparoscopic anterior gastropexy

We report an extremely rare case of recurrent gastric volvulus after open splenectomy for hereditary spherocytosis. The initial episode was managed by endoscopic derotation. Later, for recurrent symptoms, she was successfully managed by laparoscopic anterior gastropexy.

The management of gastric volvulus in elderly patients

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Endoscopy is necessary for management of gastric volvulus.

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Endoscopic reduction is effective as first aid for gastric volvulus.

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Endoscopic gastropexy is available for gastric volvulus in elderly patients.

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Laparoscopic gastropexy can be an alternative to hernia repair in poor condition.

Introduction

Gastric volvulus is torsion of the stomach and requires immediate treatment. The optimal treatment strategy for patients with gastric volvulus is not established, because of significant variations in the cause and clinical course of this condition.

Presentation of cases

We describe our experience with six elderly patients with gastric volvulus caused by different conditions using various approaches. This includes two patients managed with endoscopic reduction, followed by endoscopic or laparoscopic gastropexy.

Discussion

Endoscopy is a necessary first step to determine the optimal treatment strategy, and endoscopic reduction is often effective. The indications for surgical repair of gastric volvulus depend on the patient’s overall condition, and several options are available. In some elderly patients with severe comorbidities, major surgery may have an unacceptably high risk. We propose a novel treatment strategy for gastric volvulus in the elderly and a review of the literature.

Conclusion

Early endoscopy is necessary in patients with gastric volvulus. Endoscopic or laparoscopic gastropexy may be adequate therapy in selected elderly patients.

Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report

A 43-year-old female was referred to our hospital for sudden onset of abdominal pain, fullness, and vomiting. Physical examination revealed abdominal distension with mild epigastric tenderness. Abdominal radiography showed massive gastric distension and plain computed tomography (CT) a markedly enlarged stomach filled with gas and fluid. A large volume of gastric contents was suctioned out via a nasogastric (NG) tube. Contrast-enhanced CT showed a grossly distended stomach with displacement of the antrum above the gastroesophageal junction, and the spleen was dislocated inferiorly. Upper gastrointestinal (GI) series showed the greater curvature to be elevated and the gastric fundus to be lower than normal. Acute mesenteroaxial gastric volvulus was diagnosed. GI endoscopy showed a distortion of the gastric anatomy with difficulty intubating the pylorus. Various endoscopic maneuvers were required to reposition the stomach, and the symptoms showed immediate and complete solution. GI fluoroscopy was performed 3 days later. Initially, most of the contrast medium accumulated in the fundus, which was drawn prominently downward, and then began flowing into the duodenum with anteflexion. Elective laparoscopic surgery was performed 1 month later. The stomach was in its normal position, but the fundus was folded posteroinferiorly. The spleen attached to the fundus was normal in size but extremely mobile. We diagnosed a wandering spleen based on the operative findings. Gastropexy was performed for the treatment of gastric volvulus and wandering spleen. The patient remained asymptomatic, and there was no evidence of recurrence during a follow-up period of 24 months. This report describes a rare adult case of acute gastric volvulus associated with wandering spleen. Because delay in treatment can result in lethal complications, it is critical to provide a prompt and correct diagnosis and surgical intervention. We advocate laparoscopic surgery after endoscopic reduction because it is a safe and effective procedure with lower invasiveness.

[Laparoscopic gastric sleeve in gastric volvulus secondary to diaphragmatic eventration in an adult patient]

BACKGROUND

Acute gastric volvulus is a rare, but potentially life-threatening, cause of upper gastrointestinal obstruction.

CLINICAL CASE

Male of 60 years old with severe epigastric pain and abdominal distension with haematemesis on two occasions. The patient was haemodynamically stable, with abdominal distension and palpable epigastric fullness. Hematic cytology showed: haemoglobin 8.2g/dl and haematocrit 27%. Abdominal X-ray showed an elevation of left diaphragm with a hugely dilated stomach. A nasogastric tube was inserted. Endoscopy was performed. There was no active bleeding, but it was impossible to reach the duodenum due to the stomach distortion. The upper gastrointestinal X-ray study showed the appearance of an inverted stomach in the chest and an organoaxial gastric torsion. The CT scans of thorax and abdomen showed a gastric ascent into the thoracic cavity. Laparoscopic surgery was performed, finding the left hemi-diaphragm elevated, and the stomach, splenic angle of the colon, the spleen and tail of the pancreas were also raised. A linear gastrectomy (gastric sleeve) was performed. The postoperative progress was satisfactory. Oral feeding was started 72 hours after surgery, and the patient was discharged, and has remained asymptomatic during the following by 8 years.

CONCLUSIONS

Emergency physicians must maintain a high level of suspicion in patients that present with signs and symptoms suggesting upper digestive tract occlusion. The gastric sleeve is an excellent alternative to avoid recurrence of gastric volvulus.

Chronic Gastric Volvulus with Laparoscopic Gastropexy after Endoscopic Reduction: A Case Report

Gastric volvulus is an uncommon clinical entity. There are three types of gastric volvulus; organoaxial, mesenteroaxial and combined type. This condition can lead to a closed-loop obstruction or strangulation. Traditional surgical therapy for gastric volvulus is based on an open approach. Here we report a successful case of a patient with chronic gastric volvulus with a laparoscopic treatment. A 79-year-old woman came to the emergency department with epigastric pain accompanied by nausea for 2 weeks. Abdominal computed tomography revealed markedly distended stomach with transposition of gastroesophageal Junction and gastric antrum. Barium meal study revealed presence of the antrum was folded over 180 degrees that was located above gastroesophageal junction. We attempted an endoscopic reduction, but it was unsuccessful. The patient got laparoscopic anterior gastropexy. Based on our result, laparoscopic gastropexy can be considered as a good choice of the treatment for gastric volvulus.

Delayed diaphragmatic rupture presenting with acute gastric volvulus

Gastric volvulus is a rare complication of diaphragmatic rupture. We report the case of an 82-year-old man who presented following an out-of-hospital cardiac arrest. Chest radiography and thoracic computed tomography revealed an acute gastric volvulus and a chronic diaphragmatic hernia containing transverse colon and abdominal viscera. He had complained of retching and associated epigastric pain prior to collapse, and had sustained a motorcycle accident approximately 60 years earlier. Insertion of a nasogastric tube was unsuccessful (completing Borchardt's diagnostic triad) and his condition prevented both operative and endoscopic reduction of his volvulus. He died soon afterwards.

Acute gastric volvulus treated with laparoscopic reduction and percutaneous endoscopic gastrostomy

Acute gastric volvulus requires emergency surgery, and a laparoscopic approach for both acute and chronic gastric volvulus was reported recently to give good results. The case of a 50-year-old patient with acute primary gastric volvulus who was treated by laparoscopic reduction and percutaneous endoscopic gastrostomy is described here. This approach seems to be feasible and safe for not only chronic gastric volvulus, but also acute gastric volvulus.

Laparoscopic repair of a late-presenting Bochdalek diaphragmatic hernia with acute gastric volvulus

An otherwise healthy 17-year-old boy presented to the paediatric emergency department with acute severe epigastric pain. An admission abdominal radiograph demonstrated gastric dilation, associated with an elevated left hemidiaphragm. Subsequent barium contrast imaging confirmed the diagnosis of organoaxial acute gastric volvulus (AGV). Emergent exploratory laparoscopy revealed AGV with migration of the stomach, spleen, pancreatic tail, splenic flexure, left kidney and adrenal through a left-sided Bochdalek diaphragmatic hernia. Following careful mobilisation of the displaced structures, a mesh closure of the diaphragmatic defect was performed. The patient's postoperative chest radiograph was unremarkable, and he was discharged on the sixth postoperative day after an uneventful recovery. At 2 months the patient was well and asymptomatic, with normal barium contrast imaging results.

Gastric volvulus and wandering spleen: a rare surgical emergency

Gastric volvulus is a rare but potentially life-threatening clinical entity due to possible gastric necrosis. A wandering spleen may also be associated with gastric volvulus. Patients presenting with the triad epigastralgia, vomiting followed by retching, and difficulty or inability to pass a nasogastric tube into the stomach are likely to have gastric volvulus. The operating surgeon should include this rare entity in the differential diagnosis when dealing with a patient with such a clinical profile. Herein, we present a case of gastric volvulus associated with a wandering spleen in a 28-year-old Caucasian woman and we provide a brief review of the literature on this issue.

[Laparoscopic treatment of acute gastric volvulus]

INTRODUCTION

Gastric volvulus is an uncommon clinical condition and is associated with type ii-iii hiatal hernias. Its acute presentation constitutes a surgical emergency. Despite its low frequency, results of laparoscopic treatment have already been published.

MATERIAL AND METHODS

A retrospective study was performed on all cases diagnosed with gastric volvulus undergoing laparoscopic surgery between 1998 and 2010. The surgical technique, the post-operative outcome, and the clinical follow-up are described.

RESULTS

A total of 10 cases were identified, one was a primary gastric volvulus, and the remainder were secondary. A laparoscopic anterior gastropexy as the sole procedure was performed on 7 patients. A Nissen fundoplication with mesh reinforcement of the crural closure was performed on the 3 remaining cases. Postoperative outcome was uneventful in 9 patients, with an early start of the diet, and hospital discharge between 48-72 h. After a mean follow-up period of 18 months, radiological hernia recurrence occurred in one case but recurrence of the volvulus was not observed.

CONCLUSION

Laparoscopic anterior gastropexy is, in our experience, an effective and safe procedure with a low morbidity, for the treatment of acute gastric volvulus in patients with high surgical risk.

Miscellaneous disorders and their management in gastric surgery: volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction

This article focuses on less common diseases that surgeons are called on for management options. Five topics-volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction from peptic ulcer disease-are frequently used to evaluate surgical knowledge. Knowledge of these topics is useful for residents preparing for an in-training examination or board certification. Patients with these diseases require multidisciplinary management with oncologists and/or gastroenterologists, and mastery of these topics allows surgeons to effectively participate in the multidisciplinary care of these patients and advocate for surgical management when appropriate.

Conservative management of chronic gastric volvulus: 44 cases over 5 years

AIM: To investigate clinical outcomes of patients with chronic gastric volvulus (GV) who were managed conservatively over a 5-year period.

METHODS: A total of 44 consecutive patients with chronic GV, as diagnosed by barium study between October 2002 and July 2008 were investigated. All of these patients received conservative management initially without anatomical correction. Their clinical manifestations, diagnostic work-ups, and clinical outcomes were analyzed. We sought to identify independent risk factors for poor outcome by using the Cox proportional hazards model.

RESULTS: The enrolled patients were predominantly male (n = 37, 84%) and of advanced age (median: 71 years old, interquartile range: 57.5-78 years). Abdominal pain and fullness were the most common presentations. During the follow-up period (median: 16 mo, up to 69 mo), there was no severe complication, but symptomatic recurrence was noted in 28 patients (64%). Only one patient turned to elective surgery for frequent symptoms. Peritoneal adhesion was the only independent risk factor associated with recurrence (hazard ratio: 2.58, 95% CI: 1.08-6.13, P = 0.033).

CONCLUSION: Symptomatic recurrence of chronic GV is very common although serious complications infrequently occur with conservative management. Peritoneal adhesion is independently associated with recurrence.

Acute giant gastric volvulus causing cardiac tamponade

INTRODUCTION

Acute gastric volvulus is an uncommon condition which is rarely associated with cardiac impairment.

DISCUSSION

We report a patient with an acute giant gastric volvulus causing cardiac tamponade. Prompt decompression was unsuccessful and the patient died prior to definitive treatment.

Outcomes of surgical treatment of intrathoracic stomach

The purpose of this study is to assess the long-term outcomes after surgical repair of intrathoracic stomach. Prospectively collected data was retrospectively reviewed. Patients underwent a phone questionnaire 1 year postoperatively to assess gastroesophageal reflux disease-related symptoms and surgical satisfaction. In addition, objective evaluation for integrity of hiatal hernia repair was undertaken either by esophagram or endoscopy. Any recurrence was considered a failure. Forty-one patients underwent surgical repair of a large paraesophageal hernia with intrathoracic stomach during the study period. Thirty-four patients underwent a laparoscopic repair, and seven patients underwent a transthoracic repair. An antireflux procedure was performed on 28 patients, and 13 patients had only hernia reduction and hiatal closure. In the laparoscopic group, two patients required conversion to open laparotomy, as one was unable to tolerate the pneumoperitoneum, and the other had mediastinal bleeding. Thirty-eight (93%) were available for 1-year follow-up. There were three (7.8%) recurrences, one requiring emergency transabdominal repair, and the other two being asymptomatic 1-cm recurrences. All patients report a high degree of satisfaction with surgery. There is a high incidence of short esophagus in patients with intrathoracic stomach. The surgical repair is safe and durable, with high patient satisfaction at 1-year follow-up.

Delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by computed tomography: a case report

Introduction

Gastric volvulus is a rare condition. Presenting acutely, mesenteroaxial gastric volvulus has characteristic symptoms and may be easily detected with upper gastrointestinal contrast studies. In contrast, subacute, intermittent cases present with intermittent vague symptoms from episodic twisting and untwisting. Imaging in these cases is only useful if performed in the symptomatic interval.

Case presentation

We describe a patient with a long history of intermittent chest and epigastric pain. An earlier barium meal was not diagnostic. Diagnosis was finally secured during the current admission by a combination of (1) serum investigations, (2) endoscopy, and finally (3) computed tomography.

Conclusion

Non-specific and misleading symptoms and signs may delay the diagnosis of intermittent, subacute volvulus. Imaging studies performed in the well interval may be non-diagnostic. Elevated creatine kinase and aldolase of a non-cardiac cause and endoscopic findings of ischaemic ulceration and difficulty in negotiating the pylorus may raise the suspicion of gastric volvulus. In this case, abdominal computed tomography with spatial reconstruction was crucial in securing the final diagnosis.