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Treatment of Acute and Chronic Gastric Volvulus

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Treatment of Acute and Chronic Gastric Volvulus Annals of the Royal College of Surgeons of England (I978) vol 6o ASPECTS OF TREATMENT* Treatment of acute and chronic gastric volvulus A R Askew FRCS Consultant Surgeon, Groote Schuur Hospital, Cape Townt Introduction hepatic omentum and along the greater curve A gastric volvulus is defined as an abnormal by the gastrosplenic and gastrocolic ligaments; rotation of the stomach. The condition was abnormal lengthening of these ligaments, first described by Berti in i866 in a female together with the presence of a duodenal patient at autopsy and the finst successful mesentery, is necessary before a primary operation was performed by Berg in I897 after torsion can occur. percutaneous decompression of the stomach A secondary volvulus is associated with other with a trocar and cannula. A chronic gastric upper abdominal abnormalities. Diaphragmatic volvulus was first demonstrated radiologically defects, with attraction of the stomach into by Rosselet in 1920'. an abnormal space, are the most coummon. These are paraoesophageal hiatus hernia, Classification traumatic diaphragmatic hernia, and eventra- Three types of volvulus have been described tion of the diaphragm. Secondary volvulus according to the axis of rotation. These are: has also been described in association with a i) Organoaxial The axis of rotation passes choledochoduodenal band2 and peptic ulcera- through the pylorus and the oesophagogastric tion3' 4. junction - that is, the long axis of the stoimach. This is the commonest type, being seen in 657o of cases. Acute volvulus 2) Mesenterioaxial Torsion occurs around An acute gastric volvulus presents as an acute the short axis of the stomach, which is at abdominal emergency with abdominal pain, right angles to the long axis, passing through inability to vomit, and abdominal distension. the greater and lesser curves. It occurs in 307o Borchardt in I904' described a diagnostic of cases. triad of retching and inability to vomit, severe 3) Combined This is a mixture of the pre- epigastric pain and distension, and failure vious two types. to pass a nasogastric tube. However, with Gastric volvulus may be total or partial, gentle persistence it is usually possible to pass the former being most frequent. In the organo- a nasogastric tube and thus decompress the axial type the transverse colon comes to lie stomach. The diagnosis can be confirmed on anterior to the stomach (anterior volvulus) in a plain abdonal X-ray, which will show a ratio of i i cases to i' and in the mesenterio- a large air-filled viscus in the upper abdomen. axial type the pylorus moves across to the left Figure i is an X-ray of a go-year-old woman (anterior) in a ratio of 5 cases to i. Acute with an acute volvulus in whom a nasogastric volvulus is seen more frequently than chronic tube was passed with ease. She underwent (ratio 3: 2). successful laparotomy, reduction of the volvulus, and fixation by anterior gastropexy. Aetiology Early operation in a case of an acute Primary gastric volvulus, in which there is no volvulus is mandatory; delay may lead to associated intra-abdominal abnormality, ac- strangulation and gangrene of the twisted counts for 3070 of cases. The stomach is stomach. When it is impossible to pass a suspended along its lesser curve by the gastro- nasogastric tube, in the poor-risk case direct Present address: Radcliffe Infirmary, Oxford aspiration of the stomach will effect a degree *Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor Treatment of acute and chronic gastric volvulus 327 especally if the stomnach is grossly distended. The volvulus should first be corrected and decompression of the stomach completed via the nasogastric tube. Thereafter any under- lying diaphragmatic abnormality can be cor- rected and any congenital bands should be divided. Corection of eventration of the dia- phragm by plication, prosthetic replacement, or excision and sutute can be considered in the acute case if the patient is fit, and should be performed in all chronic cases. The simplest method of fixation of the stomach to preven-t rerotation is an anterior gastropexy, suturing the stomach along the length of the gastrocolic omentum to the anterior abdominal wall'. A more extensive gastropexy with division of the gastrodic FIG. I Barium study of an acute gastric omentum and displacement of the colon and volvulus. omentum to fill the left subphrenic area, as advocated by Tanner4, is not indicated in the of decompression while the patient is prepared acute case. Partal gastrectomny should be per- for surgery. formed only if there is associated hour-glas At laparotomy it may be difficult to distin- stomach or peptic ulceration or if part of the guish the axis -of rotation in the acute case, stomach wall is found to be gangrenous. FIGS 2-5 Consecutive bar- ium films showing develop,- ment of a gastric valvulus during a barium-mel ex- amination. 4 328 A R Askew Chronic volvulus has been reduced. In the recent literature Chronic gastric volvulus may present with there has been no case of a recurrence vague abdominal symptoms or postprandial following repair of the diaphragmatic ab- pain, abdonal distension, belching, vomiting, normality and simple reduction of the volvulus or gastrointestinal bleeding. The diagnosis can without additional fixation" 4' 6' 7. With child- be made radioloically by barium-meal ex- ren simple reduction of the volvulus with or amination. Great care must be taken to exclude without fixation of the stomach by means of other upper abdominal abnormalities. Asso- a gastrostomy gives excellent results irrespect- dated diaphragmatic lesions will be seen in ive of associated diaphragmatic abnormalities, many cases. A volvulus may also be produced and there has been only one recorded case during a barium-meal examination. Figures of recurrence after use of this method3. Tanner 2-5 show the development of a gastric volvulus has stated that simple anterior gastropexy m a man who presented with vague upper usually leads to recurrence and hence advocates abdominal discomfort and in whom no other the more extensive procedure of colonic abdominal abnonnality was demonstrated displacement4, but a review of the recent radiologically. An anterior gastropexy produced literature" 6-8 does not support this view. Thus relief of symptoms. The radiological appear- anterior gastropexy is the operation of choice. ances must be distinguished from those of a Although persistent or severe abdominal cascade (cup-and-spill) stomach, in which symptoms are indications for surgery, as there is loculation and dilatation of the fundus, in the acute case, there are patients with the contrast medium first filling the fundus radiologically demonstrable chronic volvulus and then spilling over into the body and and no other detectable intra-abdominal antrum (Fig. 6). A gastric volvulus has two abnormality who have been successfully fluid levels, whereas a cascade stomach has managed conservatively with a bland diet and only one level5. antacids. Thus a chronic gastric volvulus per If there is an associated diaphragmatic se should not be regarded as an indication abnormality this should be corrected as out- for surgery. to lined earlier, and it may be unnecessary I wish to thank Professor John Terblanche for his add an anterior gastropexy once the volvulus help and encouragement in the preparation of this paper and for his permission to publish data on patients admitted to his unit. I am indebted to V;V Dr W S Meyers for Figure 6. References I Berti, A (i866), Berg, J (i897), Rosselet, A (I922), and Borchardt, A (i9o4), cited in: Wastell, C, and Ellis, H (I97I) British Journal of Surgery, 58, 557. 2 Du Plessis, D J (1972) South African Journal of Surgery, sO, 701. 3 Cole, B C, and Dickinson, S J (I97I) Surgery, 70, FIG.6Typicl cupand-sill.somach 707. 4 Tanner, N C (i968) American Journal of Surgery, I1-15, 505. 5 Beranbaum, S L, Gottlieb, C, and Lefferts, D (I954) American Journal of Roentgenology, 72, 625. 6 Dietel, M (I973) Canadian Journal of Surgery, i6, 195. 7 Carlisle, B B, and Hayes, C W (1967) American Journal of Surgery, 113, 579. FIG. 6.Typical..... cpa siltmh 8 Gosin, S, and Ballinger, W F (I965) American Journal of Surgery, Iog, 642..
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