Hariruk Yodying, MD1, Thammanij Rookkachart, MD1, Thanatorn Sricharoen, MD2. 1Department of surgery ,Sirindhorn medical center Hospital , Srinakharinwirot University, 2Department of radiology ,Sirindhorn medical center Hospital , Srinakharinwirot University
Background: Intrathoracic gastric volvulus is a life-threatening condition of paraesophageal hernia. The therapeutic is a challenge because in acute volvulus it may lead to gastric strangulation and necrosis. Most patients are elderly and with a significant associated medical illness which has higher morbidity and mortality of major surgery. We present a laparoscopic surgery is safe in paraesophageal hernia with acute intrathoracic gastric volvulus in a high-risk patient.
Case presentation: An 80-year-old woman with underlying of diabetes mellitus and hypertension was transferred from an outlying hospital with anemia, dysphagia, urinary tract infection and aspiration pneumonia. She had severe recurrent emesis after admission. CT scan of the chest and abdomen revealed a large esophageal hiatal hernia, and most of the stomach was in the inferior mediastinum with organoaxial gastric volvulus. Endoscopy revealed flat pigmented spot gastric ulcer which compatible with Cameron lesion and twisting of gastric folds without evidence of ischemia. The endoscopic reduction was unsuccessful. A laparoscopic surgery was performed and the herniated stomach was successfully reduced. The hernial sac was excised. The crura were approximated and reinforced with composite mesh. Nissen fundoplication was performed along with gastropexy of the greater curve of the stomach to the abdominal wall. There was no perioperative complication. She tolerated enteral diet on a postoperative day 3. She had an uneventful recovery and discharged in 2 weeks after treatment of her associated medical illnesses. She had no relapse of previous symptoms at her six-month follow-up assessment.
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Discussion: Endoscopic reduction of acute gastric volvulus may be the first option in a patient with severe comorbidities. However, if there is evidence of ischemia or failure of endoscopic reduction, surgical treatment should be considered. Laparoscopic reduction and gastropexy may be a less-invasive and viable alternative to the more aggressive surgical procedure but definitive surgery with repair hiatal hernia can be done in a selected patient.
Conclusion: Minimally invasive treatments of acute gastric volvulus with paraesophageal hernia, either endoscopic or laparoscopic offer the option for reducing morbidity and mortality in elderly with significant comorbidities. The definitive laparoscopic surgery can be accomplished successfully and safely when it is performed with meticulous attention to the surgical technique and perioperative care.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86463
Program Number: P440
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster