International Journal of Surgery

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1 International Journal of Surgery 8 (2010) Contents lists available at ScienceDirect International Journal of Surgery journal homepage: Review A review article on gastric volvulus: 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: Received 14 August 2009 Received in revised form 26 October 2009 Accepted 3 November 2009 Available online 10 November 2009 Keywords: Gastric volvulus Management of gastric volvulus Acute gastric volvulus is a life-threatening condition, but its intermittent nature and vague symptoms may make diagnosis difficult. Imaging is usually only diagnostic if carried out when patients are symptomatic. The population affected ranges from paediatric age group to elderly with multiple co-morbidities. Laparoscopic repair is advisable once a diagnosis is reached. This review on gastric volvulus focuses on the diagnostic and management challenges encountered, together with strategies for dealing with them. Lessons have emerged which may assist in dealing with such a rare presentation in future. Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. 1. Introduction Gastric volvulus is recognised to be a life-threatening condition, thus prompt diagnosis and treatment is imperative. 1 It is characterised by abnormal rotation of the stomach of more than 180. It was first described in 1866 by Berti based on the autopsy of a 61-year old woman. 25 The peak age group of incidence is in the fifth decade with children less than one year old making up 10 20% of cases. No association with either sex or race has been reported. 2,3 In 30% of cases the volvulus occurs as a primary event, but it is more commonly secondary to another cause. 2,4 The main consequence of the disorder is foregut obstruction that may be acute, recurrent, intermittent or chronic. 3,5,6 Furthermore, there is a risk of strangulation which may result in necrosis, perforation and hypovolaemic shock. As such, the mortality rates for acute volvulus range from 30 to 50% highlighting the importance of early diagnosis and treatment. 2,4, Classification Gastric volvulus is conventionally thought of as an intraabdominal condition. There are reports though of an intra-thoracic * Corresponding author. Division of GI Surgery, University of Nottingham, Graduate Entry Medical School, Royal Derby Hospital, Derby, DE22 3DT, UK. Tel.: þ ; fax: þ addresses: farhan.rashid@nottingham.ac.uk, farhan_rashid@hotmail.com (F. Rashid), tanujan1@hotmail.com (T. Thangarajah), david.mulvey@derbyhospitals. nhs.uk (D. Mulvey), mike.larvin@nottingham.ac.uk (M. Larvin), ifti@netcomuk.co.uk (S.Y. Iftikhar). variant, which although uncommon, is considered a surgical emergency due to the risk of ischaemic necrosis, perforation and serious cardiorespiratory compromise. 9 It is therefore imperative that diagnosis and treatment are not delayed. In addition to its site, gastric volvulus may also be classified according to its cause, axis of rotation and whether it presents acutely or chronically. Based on aetiology, both primary and secondary forms of gastric volvulus have been recognised. The primary (idiopathic) subtype occurs as a result of neoplasia, adhesions or an abnormality in the attachment of the stomach. Regarding the latter, the stomach is normally fixed to the abdominal wall by four ligaments: the gastrocolic, gastrohepatic, gastrophrenic, and gastrosplenic. Together with the pylorus and the gastroesophageal junction, these ligaments provide anchorage and therefore prevent malrotation. Failure of these supportive mechanisms as a result of agenesis, elongation, or disruption of the gastric ligaments may predispose to primary gastric volvulus. Alternatively, a secondary gastric volvulus may arise because of disorders of gastric anatomy or gastric function or abnormalities of adjacent organs such as the diaphragm or spleen. In adults, the most common association is with a paraesophageal hernia however traumatic defects, diaphragmatic eventration and phrenic nerve paralysis have also been reported. 3,5,6,10 12 The three remaining categories of gastric volvulus that exist are defined according to their axes of rotation. Organo-axial volvulus is the most common. Occurring in 60% of cases, this subtype is associated with para-esophageal hernias and diaphragmatic eventration. It is characterised by rotation around an axis adjoining the gastroesophageal junction and the pylorus and therefore causes the greater curvature of the stomach to rest superior to the lesser /$ see front matter Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi: /j.ijsu

2 F. Rashid et al. / International Journal of Surgery 8 (2010) Fig. 1. Chest radiograph. This demonstrates kyphoscoliosis and an anterior diaphragmatic hernia containing a partial gastric volvulus. curvature, resulting in an inverted stomach. The distinguishing feature of this particular variant is that it lies in the horizontal plane when viewed on plain radiography, a fact that may aid with diagnosis. 3,5,10 12 The second type of gastric volvulus is mesenteroaxial. This less commonly encountered variant is not usually associated with diaphragmatic anomalies and is characterised by rotation of the stomach along an axis perpendicular to its longitudinal axis. In this position the stomach lies in the vertical plane with the antrum and pylorus rotated anterior and superior to the gastroesophageal junction. The third and rarest form of gastric volvulus is when the stomach rotates about both the organo-axial and mesenteroaxial axes resulting in a combined volvulus. 3,5 3. Clinical presentation The clinical presentation of patients with gastric volvulus depends upon the speed of onset, the type of volvulus and the degree of obstruction. Those with the acute form present with pain in the upper abdomen or lower chest associated with severe retching. 3,6,11 These, in conjunction with the inability to pass a nasogastric tube formulate Borchadt s triad, noted to occur in as many as 70% of cases. 2,26 Hematemesis may also be seen and is thought to occur due to mucosal sloughing as a result of ischemia or a mucosal tear due to retching. 3,5,14 In contrast, patients who have a chronic gastric volvulus may present with nonspecific symptoms which may go unnoticed. These include mild upper abdominal pain, dysphagia, bloating, and pyrosis. Such features may be chronic and are often misattributed to other upper gastrointestinal disorders such as peptic ulcer disease. 3,10 Reported complications of a gastric volvulus include ulceration, perforation, hemorrhage, pancreatic necrosis, and omental avulsion On rare occasions, rotation of the stomach may even cause disruption of the splenic vessels resulting in hemorrhage and splenic rupture Investigations Gastric volvulus is a rare condition that is seldom considered in the first instance when a patient presents with abdominal or chest pain associated with nausea and vomiting. Diagnosis is therefore difficult and is conventionally achieved radiologically in patients with appropriate clinical findings. Chest radiographs demonstrate a retrocardiac, air-filled mass whereas abdominal films show an increased soft-tissue density in the upper abdomen consistent with a distended fluid-filled stomach. However, these features may be absent in cases of intermittent obstruction ad therefore further imaging is often necessary to confirm diagnosis. 11 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 Fig. 2. Abdominal x-ray showing gross scoliosis. 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, particularly 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 without gastropexy that is most frequently performed. However,

3 20 F. Rashid et al. / International Journal of Surgery 8 (2010) 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 conservative approach to management has also been alluded to. This tends to be confined to either the elderly population or those with chronic gastric volvulus. Less invasive techniques currently employed include laparoscopic surgery or endoscopic reduction with insertion of a percutaneous gastrostomy tube. 2 4,7,8 The principal aims of surgery include reduction of the volvulus, the prevention of recurrence and repairing any predisposing factors such as diaphragmatic defects. 6,8,15,16 Due to the paucity of literature comparing laparoscopic and open surgery it is difficult to compare their respective outcomes. It has been shown though that laparoscopic surgery does entail fewer Fig. 5. Partially twisted stomach being retrieved into the abdominal cavity. Fig. 6. Dissection around the right crus of the diaphragm. Liver was retracted using Nathanson s liver retractor.

4 F. Rashid et al. / International Journal of Surgery 8 (2010) 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 be suitable for those who present a significant risk to open surgery or those with chronic gastric volvulus Gastric volvulus in the presence of kyphoscoliosis We recently had a case of gastric volvulus within an extensive diaphragmatic hiatal hernia. This occurred in a patient also suffering from severe learning difficulties and marked kyphoscoliosis (Fig. 2). The poor mental and physical health of the patient created major challenges to diagnosis and treatment. Lessons emerged which may assist in dealing with such a rare presentation in future. A 65 year old lady with severe learning difficulties and longstanding marked kyphoscoliosis presented to the Emergency Department with hematemesis. She was in receipt of long-term complete personal care in a residential home due to here poor physical and mental health. Medical co-morbidities included obesity, diabetes mellitus controlled by diet, hypertension and grand mal epilepsy. Initial medical assessment was challenging due to poor communication and immobility. The diagnosis was hampered by the marked kyphoscoliotic deformity that made radiograph interpretation difficult. This was compounded by the inability of the patient to provide a history and the intermittent nature of the symptoms. Together, these aspects made diagnosis extremely challenging and therefore delayed management. The patient was haemodynamically stable and therefore the initial management was primarily medical. An upper gastrointestinal endoscopy was performed which revealed an extensive rolling hiatal hernia, and a surgical review was requested. At that stage it was judged that immediate surgery was not indicated, partly due to the high risks associated with the medical co-morbidities. Subsequently, further hospital admissions with recurrent post-prandial vomiting and weight loss prompted referral to a specialist upper gastrointestinal surgical unit for an opinion on elective surgery. During workup, a further upper gastrointestinal endoscopy and an upper gastrointestinal barium contrast series was performed. Plain radiographs were consistent with gastric incarceration with the known hiatal hernia [Figs. 1 and 2]. Endoscopy confirmed a hiatal hernia but no abnormality of the stomach was visible. The upper gastrointestinal barium contrast series confirmed a large hiatal hernia, which included the entire stomach as well as part of the transverse colon [Fig. 4], these findings prompted suspicion of an organo-axial gastric volvulus. A laparoscopic hiatal repair was planned. A detailed history from her carers suggested that the patient had also been suffering from intermittent attacks of biliary colic, and ultrasonography demonstrated a contracted gallbladder containing gallstones. Fig. 8. Peritoneal sac being divided anterior to the oesophagus. Fig. 10. Dissection of the left crus and the peritoneal sac.

5 22 F. Rashid et al. / International Journal of Surgery 8 (2010) Fig. 11. Lower oesophagus is now fully mobilized. Surgery was performed wholly laparoscopically by an experienced consultant upper gastrointestinal surgeon. Pre-operative assessment was carried out by a senior consultant anaesthetist who classified the patient as American Society of Anaesthesiologists (ASA) Grade 3, in view of her body habitus and co-morbidities. The patient s family and carers understood the risks of both operative and non-operative management, and elected for surgery. They also agreed to assist nursing and medical staff with ward care throughout the hospitalisation. She was intubated in the beach chair position because of the risk of reflux and aspiration, and the difficulties created by her kyphoscoliosis. The operating table was positioned and carefully cushioned to compensate for the kyphosis. A four port approach was used, employing two 10 mm ports (primary port in the supraumiblical position, the other in the left hypochondrium in the mid clavicular line). Nathenson s liver retractor was used via a 5 mm incision in the midline just below the xiphoid process. One right upper quadrant 5 mm port in the right mid clavicular line and a further 5 mm ports on the left side of the upper abdomen were employed (Fig. 5). The key operative findings included a large diaphragmatic hiatal hernia (Fig. 3), with the sac containing omentum, part of the transverse colon and the stomach in an organo-axial volvulus configuration (Fig. 5). A small densely fibrosed gallbladder was adherent to the stomach. There were multiple adhesions between stomach and the diaphragmatic crura (Figs. 6 8 and 10). Crural dissection and creation of posterior oesophageal window was done. Fig. 13. Gortex suture has been applied from left to right crus of the diaphragm behind the oesophagus. Lower oesophagus was slinged using nylon tape (Fig. 12). Crural repair was undertaken with interrupted Gortex Ò sutures placed posterior to the oesophagus (Figs. 9, 11 & 13) and anterior (Fig. 14) to the oesophagus to reduce the size of the large defect (Fig. 3). Repair of the extensive defect remaining required two porcine meshes of size 7 10 cm (Surgisis Biodesign, Cook Ireland, Ltd., Limerick, Ireland). These were placed on lay onto gortex interrupted sutures which were used to bring the crurae together and secured with a Protac stapler (Fig. 15). A 50 French gauge (16 mm) Maloney bougie was employed to ensure against tightness on the oesophagus to prevent postoperative dysphagia. An anterior gastropexy and cholecystectomy were then carried using the pre-positioned laparoscopic ports. Immediate postoperative care was provided in the surgical high dependency unit. After 24 h the patient was transferred to the surgical ward, but developed acute respiratory symptoms. Chest radiographs were unhelpful as the patient could not be instructed to inspire deeply, and in view of the deterioration and potential for operative complications, thoracic computed tomography was performed. This demonstrated bilateral lung consolidation, pleural effusions and a 13 cm diameter mediastinal collection extending into the left hemithorax. Intensive physiotherapy and antibiotics led to steady improvement, and the patient was able to be discharged from hospital on the tenth postoperative day. Patient has been followed up at 10 months interval and remains asymptomatic. Fig. 12. Lower oesophagus is being slinged with the nylon tape.

6 F. Rashid et al. / International Journal of Surgery 8 (2010) 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 Gastric volvulus occurs when the stomach rotates abnormally. It may be organo-axial, twisting around an axis from pylorus to oesophagogastric junction, or mesenteroaxial, along a transverse gastric axis. Severe postural deformity is known to precipitate displacement of abdominal viscera due to abnormal tensions induced in the ligamentous attachments of the stomach. This permits gastric hypermobility and therefore introduces a potential for volvulus. 1 A gastric volvulus can present acutely without prior symptoms as complete obstruction, or may be chronic and intermittent with partial obstruction. Prompt recognition is vital to prevent lifethreatening complications such as infarction and perforation. When a patient presents with sustained retching, localized epigastric distension and it proves impossible to pass an nasogastric tube (Borchardt s Triad), 17 it suggests a completely obstructed gastric volvulus. 17 However, frequently not all signs are evident and the presentation is protean. With mental impairment, diagnosis clearly becomes more difficult, whilst severe co-morbidities compound the challenge to diagnosis and management. In a typical presentation of gastric volvulus, an erect abdominal radiograph may demonstrate double air-fluid levels in the antrum and fundus, or a single air bubble with no additional luminal gas. However in our patient, the association of anatomical deformity due to kyphoscoliosis, an inability to provide an adequate history compounded by the co-existence of biliary colic, and the intermittent nature of gastric volvulus led to an atypical presentation. Consequently diagnosis was delayed and management decisions were hindered. The surgical management of gastric volvulus is usually straightforward, requiring de-rotation, reduction of the hernial contents into the abdominal cavity and repair of the hernial defect. In children, percutaneous gastropexy by a combined laparoscopic and gastroscopic approach has been described. 18 Other techniques include gastrojejunostomy, fundo-antral gastrostomy (Opelzer s procedure), partial gastrectomy, division of any congenital bands, simple gastropexy, gastropexy with division of the gastrocolic omentum (Tanner s procedure), all with or without repair of diaphragmatic hernia, have also been described. 4 The introduction of laparoscopic approaches has led to safer less invasive surgery. Endosopic de-rotation together with percutaneous endoscopic gastrostomy has been described in patients with isolated gastric volvulus and significant co-morbidity. 19,20 Laparoscopic gastropexy is already well described for treating acute and chronic gastric volvulus Conclusion Although intermittent gastric volvulus in adults is regularly described in the literature, laparoscopic intervention remains novel and unproven. A laparoscopic approach to intermittent gastric volvulus complicated by kyphoscoliosis, mental impairment and biliary colic has not previously been described. Conservative management of an undiscovered, intermittent gastric volvulus usually leads to persistence of symptoms and repeated medical admissions, often with minor gastrointestinal hemorrhage with a negative endoscopy. The review highlights the value of an upper gastrointestinal contrast series, bearing in mind the intermittent nature of the problem. When the diagnosis is suspected or

7 24 F. Rashid et al. / International Journal of Surgery 8 (2010) achieved, an early referral for a laparoscopic procedure should be made to an experienced specialist laparoscopic surgeon. Conflict of interest None declared. Acknowledgement F Rashid and T Thangarajah reviewed the literature and wrote the initial draft of the manuscript. Pre-operative assessment and general anaesthesia were provided by D Mulvey. SY Iftikhar performed the operation assisted by F Rashid. All authors contributed to the manuscript, and all read and approved the final version. Consent Written informed consent was obtained from the patient s next of kin, for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. References 1. Flanagan NM, McAloon J. Gastric volvulus complicating cerebral palsy with kyphoscoliosis. Ulster Med J 2003;72: Chau B, Dufel S. Gastric volvulus. Emerg Med J 2007;24: McElreath DP, Olden KW, Aduli F. Hiccups: a subtle sign in the clinical diagnosis of gastric volvulus and a review of the literature. Dig Dis Sci 2008; 53: Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. Br J Surg 2000;87: Cribbs RK, Gow KW, Wulkan ML. Gastric volvulus in infants and children. Pediatrics 2008;122:e Godshall D, Mossallam U, Rosenbaum R. Gastric volvulus: case report and review of the literature. J Emerg Med 1999;17: Al-Salem AH. Acute and chronic gastric volvulus in infants and children: who should be treated surgically? Pediatr Surg Int 2007;23: Channer LT, Squires GT, Price PD. Laparoscopic repair of gastric volvulus. JSLS 2000;4: al-salem AH. Intrathoracic gastric volvulus in infancy. Pediatr Radiol 2000;30: Darani A, Mendoza-Sagaon M, Reinberg O. Gastric volvulus in children. J Pediatr Surg 2005;40: Karande TP, Oak SN, Karmarkar SJ, Kulkarni BK, Deshmukh SS. Gastric volvulus in childhood. J Postgrad Med 1997;43: Shivanand G, Seema S, Srivastava DN, Pande GK, Sahni P, Prasad R, et al. Gastric volvulus: acute and chronic presentation. Clin Imaging 2003;27: Oh SK, Han BK, Levin TL, Murphy R, Blitman NM, Ramos C, et al. Gastric volvulus in children: the twists and turns of an unusual entity. Pediatr Radiol 2008;38: 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 Surg Int 2000;16: Kotobi H, Auber F, Otta E, Meyer N, Audry G, Hélardot PG. Acute mesenteroaxial gastric volvulus and congenital diaphragmatic hernia. Pediatr Surg Int 2005;21: Mangray H, Latchmanan NP, Govindasamy V, Ghimenton F. Grey s ghimenton gastropexy: an anatomic make-up for management of gastric volvulus. JAm Coll Surg 2008;206: Cole BC, Dickinson SJ. Acute volvulus of the stomach in infants and children. Surgery 1971;70: Cameron BH, Blair GK. Laparoscopic-guided gastropexy for intermittent gastric volvulus. J Pediatr Surg 1993;28: Baudet JS, Armengol-Miro JR, Medina C, Accarino AM, Vilaseca J, Malagelada JR. Percutaneous endoscopic gastrostomy as a treatment for chronic gastric volvulus. Endoscopy 1997;29: Eckhauser ML, Ferron JP. The use of dual percutaneous endoscopic gastrostomy (DPEG) in the management of chronic intermittent gastric volvulus. Gastrointest Endosc 1985;31: Siu WT, Leong HT, Li MK. Laparoscopic gastropexy for chronic gastric volvulus. Surg Endosc 1998;12: Morelli U, Bravetti M, Ronca P, Cirocchi R, De Sol A, Spizzirri A, et al. Laparoscopic anterior gastropexy for chronic recurrent gastric volvulus: a case report. J Med Case Reports 2008;2: Koger KE, Stone JM. Laparoscopic reduction of acute gastric volvulus. Am Surg 1993;59: Bhandarkar DS, Shah R, Dhawan P. Laparoscopic gastropexy for chronic intermittent gastric volvulus. Indian J Gastroenterol 2001;20: Berti A. Singolare attortigliamento dell esofago col duodeno sequito da rapida morte. Gazz Med Ital 1866;9: Borchardt M. Kur Pathologie and Therapie des magen volvulus. Arch Kin Chir 1904;74: