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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

GASTRIC VOLVULUS


N Desmartines, MD, S Stieger, MD, FH Harder, MD, Basel, Switzerland

1. Summary


Gastric volvulus is an abnormal rotation of all or part of the stomach. It presents as an obstruction of the gastroesophageal junction and requires an emergency procedure. The treatment of choice is laparoscopic gastropexy with fixation of the fundus to the diaphragm and then the greater curvature to the abdominal wall using 4 or 5 non-absorbable sutures.

2. Keywords


Stomach, volvulus

3. Patient


25-year-old female

4. History of surgery


None

5. History of present illness


Patient complains of diffuse, aspecific hypogastric pain occurring with no relation to food intake.
The clinical examination is not specific. Ultrasound examination of the abdomen does not show any pathology. Gastroscopy shows no abnormality.

6. Esogastroduodenal contrast examination


Diagnosis is confirmed by esogastroduodenal contrast examination.

7. Definition


Gastric volvulus is an abnormal rotation of all or part of the stomach.

8. Evolution


1866: First description: (Berti et al. )
1895: Successful procedure with 2 patients: Berg et al.
1930: Anatomical study: Buchanan et al. , 1930
1968: Description of etiological factors: Tanner et al. , 1968

9. Anatomy and etiology


The stomach is fixed by four ligaments: the gastrohepatic, gastrosplenic, gastrocolic and phrenoesophageal ligaments. A ligament anomaly is responsible for stomach rotation. Three additional conditions may be associated with gastric volvulus:
1. Gastric pathology such as chronic distention, pyloric stenosis or a congenital anomaly;
2. Pathology affecting neighboring organs such as splenomegaly, hypoplasy of the left lobe of the liver or volvulus of the transverse colon;
3. Association with a paraesophageal hernia, hiatal hernia or hernia of the abdominal wall (65% of children / adolescents with gastric volvulus present with such hernias as it is the case in 81% of children younger than 12).

10. Types of volvulus


Two groups of volvulus should be distinguished:
- organo-axial volvulus with the pylorus and the cardia as fixed anatomical structures;
- mesenterico-axial volvulus with the cardia as a fixed anatomical structure.
In pediatrics, gastric volvulus is associated with a hernia of the diaphragm (65-81%) or a malrotation. In the adult, it is associated with a paraesophageal hernia in 7% to 15% of cases, a Bochdalek hernia, hypoplasy of the left lobe of the liver or with a splenomegaly. It may also be idiopathic.

11. Diagnosis


Chronic volvulus usually presents with clinical signs mimicking cholelithiasis or peptic (ulcer) disease. Dysphagia is an uncommon symptom, yet it may be associated with it. Radiological diagnosis is established by esogastroduodenal contrast examination.
Acute volvulus occurs as an obstruction of the gastroesophageal junction with the following triad of symptoms: vomiting, epigastric pain and inability to introduce a gastric tube. Conventional radiography shows a highly dilated stomach.

12. Discussion


Acute volvulus requires an emergency procedure either by laparotomy or by laparoscopy. Treatment modalities depend on the actual complications. Several types of treatments have been proposed and are outlined below. The objective is to reduce the volvulus, to decompress the stomach if necessary and then to prevent recurrences. Treatment modalities may include:
  • gastropexy (conventional or laparoscopic);
  • gastrostomy catheter;
  • gastroenterostomy;
  • colopexy (to the diaphragm);
  • partial gastric resection;
  • cruropexy associated with fundoplication.
Gastric resection should only be proposed in cases of gastric perforation and colonic resections only in cases of ischemia. An associated hernia should be repaired simultaneously and combined with gastropexy.
The treatment of choice for chronic gastric volvulus is currently laparoscopic gastropexy with fixation of the fundus to the diaphragm and then the greater curvature to the abdominal wall using 4 or 5 non-absorbable stitches.
Figure
Figure 12.a
Figure
Figure 12.b

13. References


  1. Farag S, Fiallo V, Nash S, Navab F: Gastric perforation in a case of gastric volvulus. Am J Gastroenterol 1996;91(9):1863-4.
  2. Ghosh S, Palmer KR: Double percutaneous endoscopic gastrostomy fixation: An effective treatment for recurrent gastric volvulus. Am J Gastroenterol 1993; 88(8): 1271-2.
  3. Koger KE, Stone JM: Laparoscopic reduction of acute gastric volvulus. Am Surg 1993;59(5):325-8.
  4. Umehara Y, Kimura T, Okubo T, et al. : Laparoscopic gastropexy in a patient with chronic gastric volvulus. Surg Laparosc Endosc 1992;2(3):261-4.