The Management and Outcomes of Acute Gastric Volvulus

Duncan Light, FRCS, David Links, Michael Griffin, FRCS, MD. Royal Victoria Infirmary, Newcastle upon Tyne

Introduction: Acute gastric volvulus is a rare condition with a high mortality for acute ischaemia. It can present with vague symptoms and requires prompt diagnosis. This is controversial in the literature with some authors advocating contrast swallow or gastroscopy. The management is also controversial with limited published series and long term results. This study was undertaken to investigate the acute management, diagnosis and long term outcomes of patinets presenting with acute gastric volvulus.

Methods: Cases were reviewed retrospectively from 2004 to 2014. Patients presenting as an emergency admission with acute gastric volvulus were included.

Results: 37 patients were included. The mean age was 71 years old. All patients presented with vomiting and chest/epigastric pain. A paraoesophageal hernia was the cause in 34 patients, 5 of whom had previous surgery. CT was diagnostic in 26/26 patients. Barium swallow was diagnostic in 2/4 patients. OGD was diagnostic in 9/20 patients. All patients had an NG tube placed and 8 patients were treated conservatively and made a full recovery. 29 patients proceeded to surgery. 9 had a laparoscopic repair with 2 open conversions. 4 patients had gastric necrosis, all had open surgery with resection. 3 patients had a mediastinal perforation, 1 patient required an additional thoracotomy. All patients with viable stomach had a hiatal repair (where appropriate), 11 had a gastropexy and 11 had a fundoplication. Early complications occurred in 8/29 patients. Mortality for gastric necrosis/perforation was 30%. Mean post op stay was 4 days for laparoscopic repair and 8 days for uncomplicated open surgery. 9/29 had transient dysphagia post operatively. 4 of these patients had a recurrence, 1 patient had a redo procedure and the rest were managed conservatively. 3/8 patients treated conservatively had an elective procedure subsequently. All patients were discharged uneventfully after follow up of up to 2 years.

Conclusions: Acute gastric volvulus requires early resuscitation and diagnosis. CT should be favoured in assessment and an NG tube placed promptly. A conservative management may be considered safely in stable patients. Surgical management should be prompt for unstable patients. Gastric ischaemia or perforation has a mortality of 30%. Laparoscopic repair has a shorter post op stay but has a higher recurrence rate. Long term results were equal for gastropexy or fundoplication. Surgery for patients without gastric ischaemia has good long term outcomes with minimal morbidity.