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International Journal of Surgery 8 (2010) 18–24

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International Journal of Surgery

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Review A review article on gastric : A challenge to diagnosis and management

F. Rashid a,b,*, T. Thangarajah b, D. Mulvey b, M. Larvin a,b, S.Y. Iftikhar a,b

a Division of GI Surgery, University of Nottingham, Graduate Entry Medical School, Royal Derby Hospital, Derby, DE22 3DT, UK b Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK

article info abstract

Article history: Acute gastric volvulus is a life-threatening condition, but its intermittent nature and vague symptoms Received 14 August 2009 may make diagnosis difficult. Imaging is usually only diagnostic if carried out when patients are Received in revised form symptomatic. The population affected ranges from paediatric age group to elderly with multiple 26 October 2009 co-morbidities. Laparoscopic repair is advisable once a diagnosis is reached. This review on gastric Accepted 3 November 2009 volvulus focuses on the diagnostic and management challenges encountered, together with strategies for Available online 10 November 2009 dealing with them. Lessons have emerged which may assist in dealing with such a rare presentation in future. Keywords: Gastric volvulus Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. Management of gastric volvulus

1. Introduction variant, which although uncommon, is considered a surgical emergency due to the risk of ischaemic necrosis, perforation and Gastric volvulus is recognised to be a life-threatening condition, serious cardiorespiratory compromise.9 It is therefore imperative thus prompt diagnosis and treatment is imperative.1 It is charac- that diagnosis and treatment are not delayed. In addition to its site, terised by abnormal rotation of the of more than 180. gastric volvulus may also be classified according to its cause, axis of It was first described in 1866 by Berti based on the autopsy of rotation and whether it presents acutely or chronically. a 61-year old woman.25 The peak age group of incidence is in the Based on aetiology, both primary and secondary forms of gastric fifth decade with children less than one year old making up 10–20% volvulus have been recognised. The primary (idiopathic) subtype of cases. No association with either sex or race has been reported.2,3 occurs as a result of neoplasia, adhesions or an abnormality in the In 30% of cases the volvulus occurs as a primary event, but it is more attachment of the stomach. Regarding the latter, the stomach is commonly secondary to another cause.2,4 The main consequence of normally fixed to the abdominal wall by four ligaments: the the disorder is foregut obstruction that may be acute, recurrent, gastrocolic, gastrohepatic, gastrophrenic, and gastrosplenic. intermittent or chronic.3,5,6 Furthermore, there is a risk of stran- Together with the and the gastroesophageal junction, these gulation which may result in necrosis, perforation and hypo- ligaments provide anchorage and therefore prevent malrotation. volaemic shock. As such, the mortality rates for acute volvulus Failure of these supportive mechanisms as a result of agenesis, range from 30 to 50% highlighting the importance of early diagnosis elongation, or disruption of the gastric ligaments may predispose to and treatment.2,4,6–8 primary gastric volvulus. Alternatively, a secondary gastric volvulus may arise because of disorders of gastric anatomy or gastric 2. Classification function or abnormalities of adjacent organs such as the diaphragm or spleen. In adults, the most common association is with a para- Gastric volvulus is conventionally thought of as an intra- esophageal however traumatic defects, diaphragmatic abdominal condition. There are reports though of an intra-thoracic eventration and phrenic nerve paralysis have also been repor- ted.3,5,6,10–12 The three remaining categories of gastric volvulus that exist are * Corresponding author. Division of GI Surgery, University of Nottingham, Grad- defined according to their axes of rotation. Organo-axial volvulus is uate Entry Medical School, Royal Derby Hospital, Derby, DE22 3DT, UK. Tel.: þ44 the most common. Occurring in 60% of cases, this subtype is 7817168102; fax: þ44 1332787878. associated with para-esophageal and diaphragmatic E-mail addresses: [email protected], [email protected] eventration. It is characterised by rotation around an axis adjoining (F. Rashid), [email protected] (T. Thangarajah), david.mulvey@derbyhospitals. nhs.uk (D. Mulvey), [email protected] (M. Larvin), [email protected] the gastroesophageal junction and the pylorus and therefore causes (S.Y. Iftikhar). the greater curvature of the stomach to rest superior to the lesser

1743-9191/$ – see front matter Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2009.11.002 F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24 19

Fig. 1. Chest radiograph. This demonstrates kyphoscoliosis and an anterior containing a partial gastric volvulus. curvature, resulting in an ‘inverted’ stomach. The distinguishing a mucosal tear due to .3,5,14 In contrast, patients who have feature of this particular variant is that it lies in the horizontal plane a chronic gastric volvulus may present with nonspecific symptoms when viewed on plain , a fact that may aid with diag- which may go unnoticed. These include mild upper abdominal nosis.3,5,10–12 pain, dysphagia, bloating, and pyrosis. Such features may be chronic The second type of gastric volvulus is mesenteroaxial. This less and are often misattributed to other upper gastrointestinal disor- commonly encountered variant is not usually associated with ders such as .3,10 diaphragmatic anomalies and is characterised by rotation of the Reported complications of a gastric volvulus include ulceration, stomach along an axis perpendicular to its longitudinal axis. In this perforation, hemorrhage, pancreatic necrosis, and omental avul- position the stomach lies in the vertical plane with the antrum and sion.12–14 On rare occasions, rotation of the stomach may even pylorus rotated anterior and superior to the gastroesophageal cause disruption of the splenic vessels resulting in hemorrhage and junction. The third and rarest form of gastric volvulus is when the splenic rupture.15 stomach rotates about both the organo-axial and mesenteroaxial axes resulting in a combined volvulus.3,5 4. Investigations

3. Clinical presentation Gastric volvulus is a rare condition that is seldom considered in the first instance when a patient presents with abdominal or chest The clinical presentation of patients with gastric volvulus pain associated with and . Diagnosis is therefore depends upon the speed of onset, the type of volvulus and the difficult and is conventionally achieved radiologically in patients degree of obstruction. Those with the acute form present with pain with appropriate clinical findings. Chest radiographs demonstrate in the upper abdomen or lower chest associated with severe a retrocardiac, air-filled mass whereas abdominal films show an retching.3,6,11 These, in conjunction with the inability to pass increased soft-tissue density in the upper abdomen consistent with a nasogastric tube formulate Borchadt’s triad, noted to occur in as a distended fluid-filled stomach. However, these features may be many as 70% of cases.2,26 may also be seen and is absent in cases of intermittent obstruction ad therefore further 11 thought to occur due to mucosal sloughing as a result of or imaging is often necessary to confirm diagnosis. This is typically achieved using either upper gastrointestinal barium studies or computer tomography.2,3,5,11–13,15 According to Teague et al.,4 it is barium studies that are most reliable being diagnostic in 14 of 25 observed cases.

5. Management

Treatment of gastric volvulus has changed over recent decades. Upon diagnosis of the condition the patient should be kept prone and a nasogastric tube inserted to facilitate decompression.3,11 Immediate surgical consultation should then be obtained, partic- ularly in the case of an acute volvulus where the risk of vascular compromise and death are high.10,15 For the majority of cases operative intervention will be planned however successful results have been reported with a conservative approach too.4,5 If an emergency laparotomy is undertaken several operative strategies can be employed. As described by Tanner these include diaphragmatic hernia repair, simple gastropexy, gastropexy with division of the gastrocolic omentum (Tanner’s operation), partial gastrectomy, fundo-antral gastrogastrostomy (Opolzer’s operation) and repair of eventration of the diaphragm.3,4 Despite several operations being available, it is open surgical reduction with or Fig. 2. Abdominal x-ray showing gross scoliosis. without gastropexy that is most frequently performed. However, 20 F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24

Fig. 3. Intraoperative images of the abdominal cavity showing an anterior diaphragmatic hernia.

Fig. 4. Upper gastrointestinal contrast series employing barium contrast. (Complete herniation of the stomach into the thoracic cavity). due to the risks associated with such major open surgery a more principal aims of surgery include reduction of the volvulus, the conservative approach to management has also been alluded to. prevention of recurrence and repairing any predisposing factors This tends to be confined to either the elderly population or those such as diaphragmatic defects.6,8,15,16 with chronic gastric volvulus. Less invasive techniques currently Due to the paucity of literature comparing laparoscopic and employed include laparoscopic surgery or endoscopic reduction open surgery it is difficult to compare their respective outcomes. It with insertion of a percutaneous gastrostomy tube.2–4,7,8 The has been shown though that laparoscopic surgery does entail fewer

Fig. 6. Dissection around the right crus of the diaphragm. Liver was retracted using Fig. 5. Partially twisted stomach being retrieved into the abdominal cavity. Nathanson’s liver retractor. F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24 21

Fig. 7. Big hiatal hole visible. Fig. 9. Grasper is being passed through the posterior oesophageal window. complications and a shorter length in hospital stay. It may therefore nature of the symptoms. Together, these aspects made diagnosis be suitable for those who present a significant risk to open surgery extremely challenging and therefore delayed management. or those with chronic gastric volvulus.4 The patient was haemodynamically stable and therefore the initial management was primarily medical. An upper gastrointes- 6. Gastric volvulus in the presence of kyphoscoliosis tinal was performed which revealed an extensive rolling , and a surgical review was requested. At that stage it We recently had a case of gastric volvulus within an extensive was judged that immediate surgery was not indicated, partly due to diaphragmatic hiatal hernia. This occurred in a patient also the high risks associated with the medical co-morbidities. Subse- suffering from severe learning difficulties and marked kyphosco- quently, further hospital admissions with recurrent post-prandial liosis (Fig. 2). The poor mental and physical health of the patient vomiting and weight loss prompted referral to a specialist upper created major challenges to diagnosis and treatment. Lessons gastrointestinal surgical unit for an opinion on elective surgery. emerged which may assist in dealing with such a rare presentation During workup, a further upper gastrointestinal endoscopy and an in future. upper gastrointestinal barium contrast series was performed. Plain A 65 year old lady with severe learning difficulties and long- radiographs were consistent with gastric incarceration with the standing marked kyphoscoliosis presented to the Emergency known hiatal hernia [Figs. 1 and 2]. Endoscopy confirmed a hiatal Department with hematemesis. She was in receipt of long-term hernia but no abnormality of the stomach was visible. The upper complete personal care in a residential home due to here poor gastrointestinal barium contrast series confirmed a large hiatal physical and mental health. Medical co-morbidities included hernia, which included the entire stomach as well as part of the obesity, diabetes mellitus controlled by diet, hypertension and transverse colon [Fig. 4], these findings prompted suspicion of an grand mal epilepsy. Initial medical assessment was challenging due organo-axial gastric volvulus. to poor communication and immobility. The diagnosis was A laparoscopic hiatal repair was planned. A detailed history hampered by the marked kyphoscoliotic deformity that made from her carers suggested that the patient had also been suffering radiograph interpretation difficult. This was compounded by the from intermittent attacks of , and ultrasonography inability of the patient to provide a history and the intermittent demonstrated a contracted gallbladder containing .

Fig. 8. Peritoneal sac being divided anterior to the oesophagus. Fig. 10. Dissection of the left crus and the peritoneal sac. 22 F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24

Fig. 11. Lower oesophagus is now fully mobilized. Fig. 13. Gortex suture has been applied from left to right crus of the diaphragm behind the oesophagus.

Surgery was performed wholly laparoscopically by an experienced consultant upper gastrointestinal surgeon. Pre-operative assess- Lower oesophagus was slinged using nylon tape (Fig. 12). Crural Ò ment was carried out by a senior consultant anaesthetist who repair was undertaken with interrupted Gortex sutures placed classified the patient as American Society of Anaesthesiologists posterior to the oesophagus (Figs. 9, 11 & 13) and anterior (Fig. 14) (ASA) Grade 3, in view of her body habitus and co-morbidities. The to the oesophagus to reduce the size of the large defect (Fig. 3). patient’s family and carers understood the risks of both operative Repair of the extensive defect remaining required two porcine and non-operative management, and elected for surgery. They also meshes of size 7 10 cm (Surgisis Biodesign, Cook Ireland, Ltd., agreed to assist nursing and medical staff with ward care Limerick, Ireland). These were placed on lay onto gortex inter- throughout the hospitalisation. rupted sutures which were used to bring the crurae together and She was intubated in the ‘beach chair’ position because of the secured with a Protac stapler (Fig. 15). A 50 French gauge (16 mm) risk of reflux and aspiration, and the difficulties created by her Maloney bougie was employed to ensure against tightness on the kyphoscoliosis. The operating table was positioned and carefully oesophagus to prevent postoperative dysphagia. An anterior cushioned to compensate for the kyphosis. gastropexy and cholecystectomy were then carried using the A four port approach was used, employing two 10 mm ports pre-positioned laparoscopic ports. (primary port in the supraumiblical position, the other in the left Immediate postoperative care was provided in the surgical high hypochondrium in the mid clavicular line). Nathenson’s liver dependency unit. After 24 h the patient was transferred to the retractor was used via a 5 mm incision in the midline just below the surgical ward, but developed acute respiratory symptoms. Chest xiphoid process. One right upper quadrant 5 mm port in the right radiographs were unhelpful as the patient could not be instructed mid clavicular line and a further 5 mm ports on the left side of the to inspire deeply, and in view of the deterioration and potential for upper abdomen were employed (Fig. 5). operative complications, thoracic computed tomography was The key operative findings included a large diaphragmatic hiatal performed. This demonstrated bilateral lung consolidation, pleural hernia (Fig. 3), with the sac containing omentum, part of the effusions and a 13 cm diameter mediastinal collection extending transverse colon and the stomach in an organo-axial volvulus into the left hemithorax. Intensive physiotherapy and antibiotics configuration (Fig. 5). A small densely fibrosed gallbladder was led to steady improvement, and the patient was able to be adherent to the stomach. There were multiple adhesions between discharged from hospital on the tenth postoperative day. Patient stomach and the diaphragmatic crura (Figs. 6–8 and 10). Crural has been followed up at 10 months interval and remains dissection and creation of posterior oesophageal window was done. asymptomatic.

Fig. 12. Lower oesophagus is being slinged with the nylon tape. F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24 23

Fig. 14. Loose placement of interrupted Gortex suture to approximate crura anterior to the oesophagus and to create a secure base for placement of porcine mesh.

Fig. 15. Repair reinforced with porcine mesh using protac stapler.

7. Summary The surgical management of gastric volvulus is usually straightforward, requiring de-rotation, reduction of the hernial Gastric volvulus occurs when the stomach rotates abnormally. It contents into the abdominal cavity and repair of the hernial defect. may be organo-axial, twisting around an axis from pylorus to In children, percutaneous gastropexy by a combined laparoscopic oesophagogastric junction, or mesenteroaxial, along a transverse and gastroscopic approach has been described.18 Other techniques gastric axis. Severe postural deformity is known to precipitate include gastrojejunostomy, fundo-antral gastrostomy (Opelzer‘s displacement of abdominal viscera due to abnormal tensions procedure), partial gastrectomy, division of any congenital bands, induced in the ligamentous attachments of the stomach. This simple gastropexy, gastropexy with division of the gastrocolic permits gastric hypermobility and therefore introduces a potential omentum (Tanner‘s procedure), all with or without repair of for volvulus.1 diaphragmatic hernia, have also been described.4 A gastric volvulus can present acutely without prior symptoms The introduction of laparoscopic approaches has led to safer less as complete obstruction, or may be chronic and intermittent with invasive surgery. Endosopic de-rotation together with percuta- partial obstruction. Prompt recognition is vital to prevent life- neous endoscopic gastrostomy has been described in patients with threatening complications such as infarction and perforation. isolated gastric volvulus and significant co-morbidity.19,20 Laparo- When a patient presents with sustained retching, localized scopic gastropexy is already well described for treating acute and epigastric distension and it proves impossible to pass an nasogas- chronic gastric volvulus.21–24 tric tube (Borchardt’s Triad),17 it suggests a completely obstructed gastric volvulus.17 However, frequently not all signs are evident and 8. Conclusion the presentation is protean. With mental impairment, diagnosis clearly becomes more difficult, whilst severe co-morbidities Although intermittent gastric volvulus in adults is regularly compound the challenge to diagnosis and management. described in the literature, laparoscopic intervention remains novel In a typical presentation of gastric volvulus, an erect abdominal and unproven. A laparoscopic approach to intermittent gastric radiograph may demonstrate double air-fluid levels in the antrum volvulus complicated by kyphoscoliosis, mental impairment and and fundus, or a single air bubble with no additional luminal gas. biliary colic has not previously been described. Conservative However in our patient, the association of anatomical deformity management of an undiscovered, intermittent gastric volvulus due to kyphoscoliosis, an inability to provide an adequate history usually leads to persistence of symptoms and repeated medical compounded by the co-existence of biliary colic, and the inter- admissions, often with minor gastrointestinal hemorrhage with mittent nature of gastric volvulus led to an atypical presentation. a negative endoscopy. The review highlights the value of an upper Consequently diagnosis was delayed and management decisions gastrointestinal contrast series, bearing in mind the intermittent were hindered. nature of the problem. When the diagnosis is suspected or 24 F. Rashid et al. / International Journal of Surgery 8 (2010) 18–24 achieved, an early referral for a laparoscopic procedure should be 8. Channer LT, Squires GT, Price PD. Laparoscopic repair of gastric volvulus. JSLS made to an experienced specialist laparoscopic surgeon. 2000;4:225–30. 9. al-Salem AH. Intrathoracic gastric volvulus in infancy. Pediatr Radiol 2000;30:842–5. Conflict of interest 10. Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in children. J Pediatr None declared. Surg 2005;40:855–8. 11. Karande TP, Oak SN, Karmarkar SJ, Kulkarni BK, Deshmukh SS. Gastric volvulus in childhood. J Postgrad Med 1997;43:46–7. Acknowledgement 12. Shivanand G, Seema S, Srivastava DN, Pande GK, Sahni P, Prasad R, et al. Gastric volvulus: acute and chronic presentation. Clin Imaging 2003;27:265–8. 13. Oh SK, Han BK, Levin TL, Murphy R, Blitman NM, Ramos C, et al. Gastric volvulus F Rashid and T Thangarajah reviewed the literature and wrote in children: the twists and turns of an unusual entity. Pediatr Radiol the initial draft of the manuscript. Pre-operative assessment and 2008;38:297–304. general anaesthesia were provided by D Mulvey. SY Iftikhar 14. Estevao-Costa J, Soares-Oliveira M, Correia-Pinto J, Mariz C, Carvalho JL, da Costa JE, et al. Acute gastric volvulus secondary to a morgagni hernia. Pediatr performed the operation assisted by F Rashid. All authors Surg Int 2000;16:107–8. contributed to the manuscript, and all read and approved the 15. Kotobi H, Auber F, Otta E, Meyer N, Audry G, He´lardot PG. Acute mesenteroaxial final version. gastric volvulus and congenital diaphragmatic hernia. Pediatr Surg Int 2005;21:674–6. 16. Mangray H, Latchmanan NP, Govindasamy V, Ghimenton F. Grey’s ghimenton Consent gastropexy: an anatomic make-up for management of gastric volvulus. JAm Coll Surg 2008;206:195–8. Written informed consent was obtained from the patient‘s next 17. Cole BC, Dickinson SJ. Acute volvulus of the stomach in infants and children. Surgery 1971;70:707–17. of kin, for publication of this case report and any accompanying 18. Cameron BH, Blair GK. Laparoscopic-guided gastropexy for intermittent gastric images. 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