Axial gastric volvulus - Forum

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Jorjo

Axial gastric volvulus - Ärzteforum

Post#1 »

A pt, 28 yo, male, sent from the province because of heartburn, epigastric pain, alleviated with the ingestion of food and antacids.

Presents vomiting with some fresh blood grooves and a scope is performed :

Erosive haemorrhagic gastritis and active peptic duodenal ulcer.

Arrived last Sunday night, we decide to repeat endoscopy which shows impossibility to overcome the esophagogastric junction and so, a UGD x- ray with barium is performed :

Scarce passage of contrast medium showing 2 pouches partially filled with fluids and air. No piloric passage.

Concludes : Mesenterico axial gastric volvulus .

We'll operate the pt tomorrow and our plan is approach through an upper medium laparotomy, devolvulation regarding carefully for any sign of ischemia, explore for hiatal hernia, gastric pexia to parietal peritoneum and, if a duodenal ulcer is present, supraselective vagotomy. If necessary, a partial distal gastric resection with a B2 reconstruction.

Any suggestions prior to surgery?


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Surgeon

Re: Axial gastric volvulus - Ärzteforum

Post#2 »

This is an emergency! You yourself mention the possibility of ischemia and yet you "well operate tomorrow"?? By tomorrow there is obviously more chance for ischemia.

I understand the HSV for DU and the gastropexy for paraesophageal hernia. Why do you mention B2 gastrectomy? Why not mention Whipple's?

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Treatment guru

Re: Axial gastric volvulus - Ärzteforum

Post#3 »

I agree that this should be considered a surgical emergency unless the patient's symptoms of epigastric pain have resolved indicating spontaneous reduction of the volvulus. In one series, 7 of 25 cases presented with gangrene of the stomach, the distinctive feature of those cases being GI bleeding, acute cardiorespiratory distress and shock.

One approach which I have taken in this setting, is to first explore the patient laparoscopically. Often the stomach is easy to reduce. If there no significant hiatal hernia or paraesophageal hernia, gastropexy is relatively easy with either suturing technique or even easier T-bar fasteners. T-bar fasteners may be found in your interventional radiology suite if your X-ray department does radiologically placed percutaenous gastrostomy tubes. One approach described in the literature is to combine the laparoscopy with EGD and after reducing the stomach, performing a standard PEG type of gastrostomy to fixate the stomach.

In your patient I might consider planning a combined laparoscopic/endoscopic procedure. If on reduction of the stomach, EGD does not show narrowing of the pyloric channel and there is no other pathology to deal with (like a hiatal hernia), then a simple gastropexy and medical management of his ulcer might be considered.

My very first laparoscopic paraesophageal hernia presented with an acute volvulus. This was before we had started doing laparoscopic Nissan's. I was too foolish to realize how difficult these cases can be. Fortunately we got through it with good results. I can definitely say it should not be the way you start out doing laparoscopic surgery of the stomach.

Jorjo

Re: Axial gastric volvulus - Ärzteforum

Post#4 »

This morning, early, we had the chance of regarding accurately a chest XRay of the pt. and it was possible to see that, in lateral view, there was a backward occupation of the right supradiaphragmatic space with something that resembled colon.

That was important as it changed the whole context of the primary pathology.

The pt seemed in an excellent shape and had no signs of any sort of complication.

Once in OR, we practiced a medium upper laparotomy and, to our surprise, at exploration there was a big right Bochdalek diaphragmatic hernia, some 12 cms in diameter and inside it there was, rotated in 180 degrees, the stomach and a good part of the transverse colon.

Once liberated both viscerae from adhesions, it was quite easy to restore them to the abdominal cavity.

No hiatal hernia was found and an active, non sthenotic, peptic duodenal ulcer was confirmed.

Closure of the Bochdalek hernia was performed with a patch of Marlex and a supraselective vagotomy was done uneventfully.

Gastropexia or gastrostomy as a medium of fixing the stomach appeared not to be necesary as the stomach returned to it's normal anatomic position and the diaphragmatic hole was closed.

So, we were in front of a Bochdalek diaphragmatic hernia, a wide one, with a volvulated stomach inside of it, without isquemic or necrotic compromise, that also included partial transverse colon.Besides, a duodenal ulcer that was treated surgically with the SSV.

Must tell you that the operation was uneventfull.

If any comments or observations do deserve this case, please let me know.

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