A Case of 100-Year-Old Woman Successfully Treated for Upside Down Stomach with Laparoscopic Surgery

Mikito Mori, MD PhD, Yasunori Akutsu, MD PhD, Hideki Hayashi, MD PhD, Hiroshi Kawahira, MD PhD, Naoyuki Hanari, MD PhD, Hisahiro Matsubara, MD PhD. Department of Frontier Surgery, Graduate School of Medicine, Chiba

Hiatal hernias (HH) are generally classified into four distinct types. While type I HH, also known as a sliding hernia, is the most common type, type II, III and IV HH are classified as paraesophageal hernias and much less common. Type I is characterized by an esophagogastric junction (EGJ) and a cardia that migrates cephalad through an enlarged esophageal hiatus. Type II HH is characterized by herniation of gastric fundus into the mediastinum, whereas the EGJ remains in an intra-abdominal position. Type III HH involves herniation of the stomach with the EGJ into the mediastinum and type IV HH is characterized by an intrathoracic stomach along with associated viscera, such as spleen, colon, small bowel or pancreas. The extreme form of type III HH results in a completely inverted intrathoracic stomach, which is so-called upside down stomach. We report a case of a 100-year-old woman successfully treated for upside down stomach with laparoscopic surgery. She was admitted to our hospital because of hematemesis accompanied with acute respiratory and renal failure. Chest X-ray showed the effusion in the whole left pleural cavity and atelectasis in the left lung lobe. Abdominal computed tomography revealed the entire gastric incarceration into the left pleural cavity with esophageal hiatal hernia and with gastric volvulus. She was diagnosed as upside down stomach caused by combined esophageal hiatal hernia with organoaxial gastric volvulus, and underwent laparoscopic surgery because her general condition was so stable that she could stand the operation. After the incarcerated stomach and the greater omentum were easily reduced into her abdominal cavity, the hiatus could be directly closed, and then Toupet fundoplication was performed to prevent reflux esophagitis. Postoperative course was uneventful, and she was discharged on the 13th day after the operation. Upside down stomach is an uncommon presentation of hiatal hernia, and presents some catastrophic complications that include massive bleeding, strangulation, and perforation. Upside down stomach should be repaired as soon as possible after recognition to avoid the complications of gastric incarceration. Traditionally, repair of upside down stomach has been performed through an open laparotomy or thoracotomy. With the advent of laparoscopy, upside down stomach is now being approached with minimally invasive techniques. Recently, some studies have reported that laparoscopic repair of upside down stomach is technically feasible, effective, and safe compared with traditional open surgical approach. With the aging of the population in our country, the number of patients suffering from this disease will increase and laparoscopic surgery for upside down stomach may become the standard approach for elderly patients with multiple medical problems.