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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 118-121

Derotation gastropexy for a case of chronic mesentericoaxial gastric volvulus


Department of General Surgery, Apollo Hospital, Mysore, Karnataka, India

Date of Submission11-Oct-2018
Date of Acceptance02-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Suhas Umakanth
#2538, 5th Main, D Block, Kanakadasanagar, Dattagalli 3rd Stage, Mysore - 570 023, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_77_18

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  Abstract 


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

How to cite this URL:
Umakanth S, Nagaraja JB, Subbarayappa S. Derotation gastropexy for a case of chronic mesentericoaxial gastric volvulus. Apollo Med [serial online] 2019 [cited 2019 Dec 12];16:118-21. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/118/260690




  Introduction Top


Gastric volvulus being one of the life-threatening conditions is characterized by the abnormal rotation of the stomach by >180°.[1] Berti in 1861 first described it with an autopsy of a 61-year-old woman.[2] Berg described successful operative treatment for gastric volvulus on two patients in 1895 and 1896.[3] 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.[1] 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.[1]


  Case Report Top


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.
Figure 1: Distended abdomen - left upper quadrant

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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 3: Computed tomography finding - Grossly dilated stomach

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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].
Figure 5: Grossly dilated stomach with thinned out wall

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Figure 6: Antrum at the gastroesophageal junction

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Figure 7: Anterior gastropexy

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  Discussion Top


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.[4] The stomach is maintained in its position with the help of four ligaments as follows: gastrohepatic, gastrosplenic, gastrophrenic, and gastrocolic ligaments.[1] 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.[1] 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.[5]

Another major classification is based on the axis of rotation as organoaxial, mesenteroaxial, or mixed variety [Table 1].[6],[7]
Table 1: Classification on the basis of axis of rotation

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Presentation depends on the type of volvulus, type of presentation, and level of obstruction. Accordingly, they can present as acute or chronic volvulus.[8] 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).[8] 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.[9]

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.[6]

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.[10] 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.[11],[12] Laparoscopic gastropexy is already well described for treating acute and chronic gastric volvulus.[13],[14]


  Conclusion Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rashid F, Thangarajah T, Mulvey D, Larvin M, Iftikhar SY. A review article on gastric volvulus: A challenge to diagnosis and management. Int J Surg 2010;8:18-24.  Back to cited text no. 1
    
2.
Berti A. Singular attachment of the esophagus with the duodenum followed by rapid death. Gazz Med Ital 1866;9:139.  Back to cited text no. 2
    
3.
Berg J. Zwei falle von axendrehung des magens: Operation; heilung. Nord Med Arkiv 1897;30:1-8.  Back to cited text no. 3
    
4.
Wasselle JA, Norman J. Acute gastric volvulus: Pathogenesis, diagnosis, and treatment. Am J Gastroenterol 1993;88:1780-4.  Back to cited text no. 4
    
5.
al-Salem AH. Intrathoracic gastric volvulus in infancy. Pediatr Radiol 2000;30:842-5.  Back to cited text no. 5
    
6.
Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: Appearances at multimodality imaging. Radiographics 2009;29:1281-93.  Back to cited text no. 6
    
7.
Etienne D, Ona MA, Reddy M. Atypical presentation of gastric volvulus. Gastroenterology Res 2017;10:147-8.  Back to cited text no. 7
    
8.
Shivanand G, Seema S, Srivastava DN, Pande GK, Sahni P, Prasad R, et al. Gastric volvulus: Acute and chronic presentation. Clin Imaging 2003;27:265-8.  Back to cited text no. 8
    
9.
McElreath DP, Olden KW, Aduli F. Hiccups: A subtle sign in the clinical diagnosis of gastric volvulus and a review of the literature. Dig Dis Sci 2008;53:3033-6.  Back to cited text no. 9
    
10.
Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. Br J Surg 2000;87:358-61.  Back to cited text no. 10
    
11.
Baudet JS, Armengol-Miró JR, Medina C, Accarino AM, Vilaseca J, Malagelada JR, et al. Percutaneous endoscopic gastrostomy as a treatment for chronic gastric volvulus. Endoscopy 1997;29:147-8.  Back to cited text no. 11
    
12.
Eckhauser ML, Ferron JP. The use of dual percutaneous endoscopic gastrostomy (DPEG) in the management of chronic intermittent gastric volvulus. Gastrointest Endosc 1985;31:340-2.  Back to cited text no. 12
    
13.
Morelli U, Bravetti M, Ronca P, Cirocchi R, De Sol A, Spizzirri A, et al. Laparoscopic anterior gastropexy for chronic recurrent gastric volvulus: A case report. J Med Case Rep 2008;2:244.  Back to cited text no. 13
    
14.
Palanivelu C, Rangarajan M, Shetty AR, Senthilkumar R. Laparoscopic suture gastropexy for gastric volvulus: A report of 14 cases. Surg Endosc 2007;21:863-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

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