|Year : 2019 | Volume
| Issue : 2 | Page : 118-121
Derotation gastropexy for a case of chronic mesentericoaxial gastric volvulus
Suhas Umakanth, Jayanth Bannur Nagaraja, Srinath Subbarayappa
Department of General Surgery, Apollo Hospital, Mysore, Karnataka, India
|Date of Submission||11-Oct-2018|
|Date of Acceptance||02-May-2019|
|Date of Web Publication||19-Jun-2019|
#2538, 5th Main, D Block, Kanakadasanagar, Dattagalli 3rd Stage, Mysore - 570 023, Karnataka
Source of Support: None, Conflict of Interest: None
Gastric volvulus is a rare disease with unknown incidence and having significant morbidity and mortality. Unstable vital signs and distressed appearance are not always present and diagnosis can be easily missed. It is the abnormal rotation of the whole or part of the stomach. Normally stomach is in position with the help of 4 ligaments (gastrohepatic, gastrosplenic, gastrocolic, phrenicocolic), laxity leading to volvulus. Organoaxial being common in adults and mesentericoaxial are the two types. They can present as acute, chronic, acute on chronic. Acute volvulus needs immediate resuscitation and urgent laparotomy and Chronic volvulus needs evaluation and elective surgery. Here we present a case of 49 year old gentleman with chronic gastric volvulus, who underwent derotation gastropexy at our institute.
Keywords: Anterior gastropexy, Brochardt's triad, chronic gastric volvulus, derotation gastropexy, mesentericoaxial volvulus
|How to cite this article:|
Umakanth S, Nagaraja JB, Subbarayappa S. Derotation gastropexy for a case of chronic mesentericoaxial gastric volvulus. Apollo Med 2019;16:118-21
| Introduction|| |
Gastric volvulus being one of the life-threatening conditions is characterized by the abnormal rotation of the stomach by >180°. Berti in 1861 first described it with an autopsy of a 61-year-old woman. Berg described successful operative treatment for gastric volvulus on two patients in 1895 and 1896. Incidence peaks in the fifth decade with children <1 year affected up to 10%–20%. The main presentation is with the foregut obstruction and with an acute, intermittent, or chronic symptoms. It is further complicated with the risk of strangulation resulting in necrosis, perforation, and shock. Mortality rates of acute volvulus range between 30% and 50% demanding the need for the early diagnosis and treatment.
| Case Report|| |
A 49 year old gentleman from the rural background was presented with the left upper quadrant pain and abdominal distension for 1 day. The pain was intermittent, increasing after meals and was associated with nausea. He had similar complaints in the past twice, admitted, evaluated, and diagnosed with gastric volvulus. He was advised surgery, but the patient demanded for conservative treatment. Examination revealed stable vitals and soft, distended upper abdomen [Figure 1], and tenderness with no guarding or rigidity. He was initially treated with intravenous fluids, nil by the mouth. Ryles tube insertion was a failure. Blood investigations were grossly normal.
Contrast-enhanced computed tomography (CT) of the abdomen showed grossly dilated stomach with volvulus perpendicular to the luminal axis [Figure 2] and [Figure 3]. Upper gastrointestinal (GI) scopy revealed esophageal and pyloric sphincter side by side [Figure 4].
|Figure 2: Computed tomography finding - grossly dilated stomach with volvulus perpendicular to luminal axis|
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|Figure 4: Upper gastrointestinal scopy - esophageal and pyloric sphincter side by side|
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With the final diagnosis of acute on chronic mesentericoaxial volvulus, he underwent exploratory laparotomy + Derotation gastropexy. Laparoscopy was not tried due to his acute presentation and distended abdomen. Postoperatively, he was gradually started orally, ambulating and was discharged on postoperative day 6. On his follow-up, he is doing well.
- Intraoperative findings as follows:
- Grossly dilated stomach with thinned out wall [Figure 5]
- Antrum at the gastroesophageal junction [Figure 6]
- No e/o ischemia
- Rest of the bowel – normal
- Anterior gastropexy being done [Figure 7].
| Discussion|| |
Gastric volvulus is characterized by abnormal rotation of the stomach for >180°. These are further classified depending on the etiology, axes, presentation, and cavity in which they present.
Based on etiology, primary volvulus occurs due to neoplasia, adhesions, or abnormality in the ligamentous attachment of the stomach. The stomach is maintained in its position with the help of four ligaments as follows: gastrohepatic, gastrosplenic, gastrophrenic, and gastrocolic ligaments. The ligamentous abnormalities, either agenesis or elongation or disruption acts as a leading factor for volvulus. Secondary volvulus occurs because of either abnormality in gastric anatomy or physiology or adjacent structures. Splenomegaly, resulting in elongation of the gastrosplenic ligament acts as a causative agent. Other associated conditions can be volvulus of transverse colon/hypoplasia of the left lobe of the liver.
Based on spaces, they are classified as intra-abdominal or intrathoracic. Abnormal spaces causing gastric volvulus occurs in three circumstances are as follows: paraesophageal hernia, hiatus hernia, and congenital or acquired eventration of the diaphragm. Intrathoracic volvulus being rare is associated with complications of ischemia, perforation, and cardiopulmonary compromise.
Another major classification is based on the axis of rotation as organoaxial, mesenteroaxial, or mixed variety [Table 1].,
Presentation depends on the type of volvulus, type of presentation, and level of obstruction. Accordingly, they can present as acute or chronic volvulus. Acute volvulus is characterized by the pain in the abdomen or pain in the lower chest with severe nonproductive retching. These when associated with the inability to pass nasogastric tube constitutes the Borchadt's triad (seen in 70% of cases). These are complicated further with ulceration, hematemesis, perforation, and pancreatic necrosis. In contrast, chronic presentation is characterized by nonspecific symptoms such as upper abdominal pain, dysphagia, and bloating which are usually mistaken as gastritis, peptic ulcer, and gallbladder disease.
Diagnosis is difficult as the condition being a rare one and is seldom considered first. Radiological investigations stay the mode of choice. The chest X-ray demonstrates retrocardiac air-filled mass. Abdominal X-ray shows increased soft-tissue density in the upper abdomen with the distended fluid-filled stomach. It is further confirmed by barium studies or CT scan. Although barium studies have high sensitivity and specificity, advantage with CT is better anatomy of adjacent structures.
Treatment aims at reduction of volvulus, prevention of recurrence, and repairing the predisposing factors. Immediate preoperative resuscitation and surgery need to be done for acute volvulus, whereas chronic volvulus can be treated electively. Although surgery is the treatment of choice for gastric volvulus, its conservative and minimally invasive methods have also been considered. Surgery involves the following steps – laparotomy + decompression (needle/trocar gastrostomy) + closure of gastrostomy, careful inspection of ischemia and derotation followed by gastropexy. Other steps are diaphragmatic hernia repair, simple gastropexy, and gastropexy with the division of the gastrocolic omentum (Tanner's operation), partial gastrectomy, fundo-antral gastrogastrostomy (Opolzer's operation), and repair of eventration of the diaphragm. The introduction of laparoscopic approaches has led to safer less invasive surgery. Endoscopic derotation together with percutaneous endoscopic gastrostomy has been described in patients with isolated gastric volvulus and significant comorbidity., Laparoscopic gastropexy is already well described for treating acute and chronic gastric volvulus.,
| Conclusion|| |
Acute, intermittent gastric volvulus in adults is regularly described in the literature. Conservative management of an intermittent gastric volvulus usually leads to the persistence of symptoms and repeated medical admissions, often with minor GI hemorrhage. When presenting as acute or recurrent volvulus, surgery will be the treatment, which could be done by an open or laparoscopic approach.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]