Maria K Bejar, MD, Adolfo Leyva, MD, Eduardo Gonzalez, MD, Mario Rodarte, MD. Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud — SSNL. Monterrey, N.L.
Introduction: Gastric volvulus is an abnormal rotation of the stomach along its longitudinal or transverse axis. 80-90% occur in adults after the 5th decade of life and have a 30-50% mortality.
Objective: case report of a patient with acute gastric volvulus treated with succesful laparoscopic surgery.
Summary: a 64 year old male with pathologic history of type II hiatal hernia (HH) and Gastroesophageal Reflux Disease, treated with laparoscopic fundoplication and cruroplasty. He attends the hospital due to intense thoracoabdominal pain for the past 12 hours, nausea and dyspnea. He refers having ocassional morning cough, pyrosis and dyspnea on exertion for the last two months. He has a BMI of 26kg/m2 and presents tachypnea, tachycardia, left lung base hypoventilation, epigastric abdominal pain, no peritoneal signs and diminished peristalsis. Laboratory tests were normal. The Chest X-ray (Fig 1a) showed an air-fluid level in the left hemithorax. In the abdomen Computed Tomography (CT) (Fig 1b) a type III HH was observed with total protrusion of the stomach through the diaphragm and rotation of the same in its longitudinal axis. Upper endoscopy was made, but the scope couldn't advance. A laparoscopic approach was performed, herniated stomach (Fig 2) was reduced and the previous fundoplication dismantled. During hernia reduction, a left tension pneumothorax was produced so a pneumo-kit was placed, resolving the problem. The greater curvature of the stomach was ischemic and it was incidentally perforated (Fig 3), having gastric material contaminating the abdominal cavity. A subtotal gastrectomy and an omega gastro-jejunal anastomosis were made (Fig 4). The hermeticity of the anastomosis was verified through an air test, with no leaks observed. The postoperative course was uneventful.
Discussion: Gastric volvulus is an uncommon condition; 70% are due to secondary causes. 60% are organo-axial volvulus. Borchadt’s triad occurs in 70% of the acute cases. CT has a 100% sensitivity. Upper endoscopy should be done in the operating room to try to detorse and reduce the volvulus. The current surgical technique includes dissection and excision of the herniary sac, reposition of the gastroesophageal junction 2-3 cm below the diaphragm to diminish recurrence and cruroplasty. Mesh placement is recommended except when there is contamination.
Conclusions: the laparoscopic approach is the first choice of treatment for gastric volvulus, due to better results in terms of intrahospitalary stay, patient satisfaction and symptomatic resolution. A gastric resection is justified when there is ischemia, necrosis or perforation secondary to strangulation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94555
Program Number: P459
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster