日外科系連会誌 38(6):1180 1185,2013 Case Report A Surgical Case of a Large Esophageal Hiatus Hernia with an Upside Down Stomach in a Patient of Advanced Age Takeshi Shimakawa, Shinichi Asaka, Atsuko Usuda, Kentaro Yamaguchi, Shunichi Shiozawa, Kazuhiko Yoshimatsu, Takao Katsube and Yoshihiko Naritaka Department of Surgery, Tokyo Womenʼs Medical University Medical Center East Abstract Cases of so-called upside down stomach, or volvulus of the stomach prolapsing into the mediastinum, are rare. We encountered a patient of advanced age who developed a large esophageal hiatus hernia with an upside down stomach, which was surgically treated. An 89-year-old female patient had repeated vomiting and hematemesis requiring emergency hospital admission. Upper gastrointestinal contrast study revealed severe esophageal hiatus hernia and gastric volvulus resulting in the stomach turning upside down. Computed tomography showed prolapse of the large portion of the stomach into the mediastinum. Because the patient had undergone epigastric laparotomy, surgery was initiated with opening the upper abdomen followed by returning the stomach into the peritoneal cavity. The hiatus hernia was sutured, and floppy Nissen fundoplication was performed as well as stomach fixation under the diaphragm. The patientʼs food intake was favorable postoperatively, and she was discharged. Key words: gastric volvulus, upside down stomach, advanced age Introduction Mild sliding esophageal hiatus hernia is frequently encountered while so-called upside down stomach, or volvulus of the stomach prolapsing into the mediastinum, is rare 1-8). We encountered a patient of ad- Received: June 19, 2013/Accepted: July 10, 2013 Correspondence to: Takeshi Shimakawa Department of Surgery, Tokyo Womenʼs Medical University Medical Center East, 2-1-10 Nishiogu Arakawa-ku, Tokyo 116-8567, Japan Table 1 Results of the laboratory tests on admission WBC RBC Hb Ht Plt TP Alb GOT GPT T.Bil 5,100 352 10 4 10.9 32.9 18.7 10 4 /μl /μl g/dl % /μl 5.9 g/dl 2.9 g/dl 20 IU/l 15 IU/l 0.6 mg/dl ALP γ-gtp BUN Cre Na K Cl CRP PT cystatin C 387 IU/l 13 IU/l 18.2 mg/dl 0.4 mg/dl 144 meq/l 3.5 meq/l 105 meq/l 0.1 mg/dl 12.4 sec 1.3 mg/l vanced age who developed a large esophageal hiatus hernia with an upside down stomach, which was surgically treated. Here we report the case with some discussion of the relevant literature. Case Report An 89-year-old female patient had repeated episodes of vomiting and hematemesis resulting in emergency admission to our hospital. These events were noted during rehabilitation after surgery for a femoral neck fracture performed at another hospital in May 2010. The patient had also previously undergone laparotomic cholecystectomy for cholelithiasis. On admission, the patient presented mild anemia and severe kyphosis. A surgical scar was also noted on the upper abdominal midline. Laboratory results indicated mild anemia, hypoproteinemia, hypoalbuminemia, and decreased renal function (Table 1 ). A chest x-ray revealed the enlarged mediastinal shadow and disappearance of gastric bubbles on the left side of the upper abdomen (Fig. 1a ). Thoracoabdominal computed tomography revealed prolapse of the entire stomach into the posterior mediastinum, displacing the heart anteriorly (Fig. 1b ). Upper gastrointestinal endoscopy showed a mixed- 1180
A surgical case of a large esophageal hiatus hernia with an upside down stomach in a patient of advanced age Fig. 1 A chest x-ray revealed the enlarged mediastinal shadow and disappearance of gastric bubbles on the left side of the upper abdomen (a). Thoracoabdominal CT revealed prolapse of the entire stomach into the posterior mediastinum (b). Fig. 2 Upper gastrointestinal endoscopy showed a large esophageal hiatus hernia and grade-a gastroesophageal reflux disease with bleeding. The stomach was severely deformed (a). Upper gastrointestinal contrast study showed no esophageal stenosis but the entire stomach had prolapsed into the mediastinum, presenting a so-called upside down stomach (b). type large esophageal hiatus hernia and grade-a gastroesophageal reflux disease (GERD) with bleeding. The stomach was severely deformed with massive coffee-like fluid retention and food residue. The endoscopy was not able to reduce the deformation of the stomach (Fig. 2a ). Upper gastrointestinal contrast study showed no esophageal stenosis but the entire stomach had prolapsed into the mediastinum, presenting a so-called upside down stomach, or mesenteroaxial volvulus of the stomach in which the pyloric end was placed over the cardiac end (Fig. 2b ). These findings led to the conclusion that the repeated vomiting and hematemesis were attributable to the mixed-type esophageal hiatus hernia with an upside down stomach due to gastric volvulus. It was also determined that the condition cannot be cured by conservative therapy because the gastric volvulus was not reduced by the endoscopy with the remaining heart displacement. Therefore, a quasiemergency surgery was performed despite the patientʼs advanced age (89 years). The surgery was started with laparotomy, not laparoscopy, because the patient had previously undergone laparotomic cholecystectomy by opening the upper abdominal midline. A midline incision was made on the upper abdomen to detach the adhesion due to the previous surgery. The stomach that 1181
日本外科系連合学会誌第 38 巻 6 号 Fig. 3 Operative finding showed a large esophageal hiatus hernia. Fig. 4 Postoperatively, chest x-ray revealed improvement of the enlarged mediastinal shadow (a). CT showed no prolapse of the stomach into the posterior mediastinum (b). had prolapsed into the posterior mediastinum was then returned to the peritoneal cavity. The hernia sac was removed, and the hernia orifice was then directly sutured and closed. Furthermore, floppy Nissen fundoplication was performed for prevention of reflux. This is a surgical procedure that utilizes an esophageal bougie which is inserted to calibrate the cardiac region. Finally, the gastric fundus was sutured and fixed to the crura of the diaphragm to complete the surgery. The total operation time was 128 minutes with minimal bleeding volume (Fig. 3 ). The patientʼs respiratory and circulatory functions were stable during and after surgery, and the postoperative clinical course was uneventful. The patient started oral food intake from the 4th postoperative day. Postoperatively, chest x-ray revealed improvement of the enlarged mediastinal shadow (Fig. 4a ), and thoracoabdominal computed tomography showed no prolapse of the stomach into the posterior mediastinum (Fig. 4b ). Upper gastrointestinal contrast study demonstrated improved esophageal hiatus hernia, normal positioning of the stomach in the peritoneal cavity, and favorable contrast flow with no reflux (Fig. 5a ). Upper gastrointestinal endoscopy showed improvement of the esophageal hiatus hernia, GERD and deformation of the stomach (Fig. 5b ). The patient had no problem with food intake thereafter, and three weeks after operation she returned to the physician who referred her to us in order to participate in a rehabilitation program for the surgically treated femoral neck fracture. 1182
A surgical case of a large esophageal hiatus hernia with an upside down stomach in a patient of advanced age Fig. 5 Upper gastrointestinal contrast study demonstrated improved esophageal hiatus hernia, normal positioning of the stomach in the peritoneal cavity (a). Upper gastrointestinal endoscopy showed improvement of the esophageal hiatus hernia (b). Discussion Mild sliding esophageal hiatus hernia is frequently encountered while so-called upside down stomach, or volvulus of the stomach prolapsing into the mediastinum, is rare 9). There have also been a small number of such cases in Western countries 9-11), and the incidence of upside down stomach is reported to be 6.2% of all esophageal hiatus hernia cases 2). A total of only 58 cases, including the present one, of upside down stomach has also been reported in Japan 3, 12, 13). Of these cases, elderly patients are more frequent with a mean age of 72.8 years ; however, the number of those aged 85 years and over was very small, only 7, including our patient. Of these 58 patients, there are 8 males and 50 females, the latter representing the overwhelming majority. A total of 53 patients (91.4%) had undergone surgical treatment including laparoscopic procedures. Volvulus of the stomach, on the other hand, is a condition where the stomach is rotated beyond its physiological limits and is also a relatively rare disease. The first case of this disease was reported by Berti 14) in 1866, among the autopsied cases, followed by the first surgical case reported by Berg 15) in 1897. Since then, there has been an increasing number of cases across the world. The pathogenesis of the disease is idiopathic, in neonates and infants, due to underdevelopment of the ligaments holding the stomach and other causes. On the other hand, gastric volvulus developing in adults is often secondary to the existing conditions such as esophageal hiatus hernia and other diaphragmatic hernia, eventration of the diaphragm, and gastric tumor. The present case is also volvulus of the stomach secondary to the prolapse of the entire stomach into the mediastinum induced by the esophageal hiatus hernia. The possible causes of the condition include fragile muscular tissue due to the patientʼs advanced age, increased abdominal pressure, and kyphosis noted commonly among elderly people, all of which may be attributed to the increased pressure difference between the thoracic and abdominal cavities, the enlargement of the hiatus hernia, and the prolapse of the stomach into the mediastinum leading to the gastric volvulus. The most commonly used classification of gastric volvulus is Singletonʼs classification 16). The types of gastric volvulus are as follows: 1) organoaxial (long-axial) or mesenteroaxial (short-axial) according to the direction of volvulus, 2)complete or incomplete according to the degree of volvulus, 3)idiopathic or secondary according to the pathogenesis, and 4)acute or chronic according to the time of the disease onset. The organoaxial type may occur acutely 16). The present case of gastric volvulus was classified into mesenteroaxial (short-axial), complete, and chronic type. Common 1183
日本外科系連合学会誌第 38 巻 6 号 clinical symptons include vomiting, upper abdominal pain, and abdominal distention, which may vary depending on the direction or degree of the volvulus 1). Borchardtʼs triad 17) consists of three symptoms characteristic of gastric volvulus: retching without vomit, marked upper abdominal pain and distention, and the inability to pass a nasogastric tube. However, the chronic type is often not associated with these symptoms 1, 2). Computed tomography is a simple and useful tool to diagnose gastric volvulus. The clinical progress of gastric volvulus may often be chronic, and conservative treatments including gastric tube decompression and endoscopic reduction may be effective 18). Surgical treatments such as elective stomach fixation are selected for cases refractory to conservative treatments or those of repeated recurrence. However, because the present case was volvulus with an inverted upside down stomach due to esophageal hiatus hernia, reefing of hiatal hernia and fundoplication for preventing reflux were required in addition to reduction of the volvulus. Cases of gastric volvulus treated with laparoscopic procedures have recently been increasing since Dallemagne et al. 19) reported a case of laparoscopic surgery performed for esophageal hiatus hernia in 1991. In the present case, however, surgery was initiated by opening the upper abdomen because of possible severe adhesion associated with the patientʼs history of epigastric laparotomy. Acute gastric volvulus has been indicated for emergency surgery because of the possibility of gastric necrosis or perforation 20). Gastric tube decompression and endoscopic reduction may also be useful, and they should be first attempted 21), in particular, for cases of the mesenteroaxial type, in which these procedures may be more effective. However, volvulus with gastric perforation, necrosis or hemorrhage as well as that refractory to conservative treatments should be surgically treated. The stomach, which has abundant blood flow with developed collateral blood routes, is unlikely to suffer necrosis, although Allen et al. 22) reported that gastric necrosis was found in 3 of 5 patients who received emergency surgery among a total of 147 patients with prolapse of the stomach into the thoracic cavity. Of them, 119 patients received elective surgery. Therefore, prompt diagnosis and appropriate selection of treatment modalities are necessary. In the present case, there was no problem with gastric blood flow based on the chronic type of the disease. In conclusion, we report a case of a surgically treated large esophageal hiatus hernia with an upside down stomach in a patient of advanced age. Similar cases are expected to increase further with the increasing number of elderly people. Safe and accurate treatment, including laparoscopy, should be considered after prompt diagnosis, taking into account the patientʼs age and general condition. References 1) Obuchi T, Sasaki A, Nakajima J, et al : Surgical management of hiatus hernia with chronic gastric volvulus : report of two cases. Esophagus 7 : 59-63, 2010 2) Perdikis G, Hinder RA, Filipi CJ, et al : Laparoscopic paraesophageal hernia repair. Arch Surg 132 : 586 589, 1997 3) Mori M, Akutsu Y, Hayashi H, et al : A Case of 100-year-old Woman Successfully Treated for Upside Down Stomach with Laparoscopic Surgery. Jpn J Gastroenterol Surg 44 : 1389-1396, 2011 4)Kercher KW, Matthews BD, Ponsky JL, et al : Minimally invasive management of paraesophageal herniation in the high-risk surgical patient. Am J Surg 182 : 510-514, 2001 5) Wasselle JA, Norman J : Acute gastric volvulus : pathogenesis, diagnosis, and treatment. Am J Gastroenterol 88 : 1780-1784, 1993 6) Branday JM : Acute gastric volvulus. Report of 2 cases and review of the literature. West Indian Med J 32 : 106-108, 1983 7) Kanai T : About gastric volvulus. Stomach Intestine 4 : 731 742, 1969 8) Hladikl P, Cap R, Holecek T : Acute stomach volvulus- case report. Acta Med (Hradec Kralove) 47 : 281 283, 2004 9) Lee TC, Liu KL, Lin MT, et al : Unusual cause of emesis in an octogenarian : organoaxial gastric volvulus associated with paraesophageal diaphragmatic hernia. J Am Geriatr Soc 54 : 555 557, 2006 10) Blum MG, Sundaresan RS : Giant hiatal hernia with gastric volvulus complicating pneumonectomy. Ann Thorac Surg 81 : 1491 1492, 2006 11) Kram M, Gorenstein L, Eisen D, et al : Acute esophageal necrosis associated with gastric volvulus. Gastrointest Endosc 51 : 610 612, 2000 12) Ishino Y, Ohi M, Hiro J, et al : Esophageal hiatal hernia complicated with parahiatal hernia diagnosed and treated by laparoscopic surgery. J Jpn Soc Endosc Surg 17 : 367-372, 2012 13) Asada T, Uchiyama S, Shimayama T, et al : Three patients with esophageal hiatal hernia showing upside down stomach. J Jpn Surg Assoc 73 : 821-826, 2012 14) Berti A : Singolare attortihliamento deleʼesophago col duodeno sequita da rapida motre. Gass Med Ital 9 : 139, 1866 1184
A surgical case of a large esophageal hiatus hernia with an upside down stomach in a patient of advanced age 15) Berg J : Zwei Falle von axendrehung des magens operation ; heilung. Nord Med Arkiv 30 : 1, 1897 16) Singleton AC : Chronic gastric volvulus. Radiology 34 : 53 61, 1940 17) Borchardt M : Zur pathologie und Therapie des Magenvolvulus. Arch Klin Chir 74 : 243 260, 1904 18) Tsang TK, Walker R, Yu DJ : Endoscopic reduction of gastric volvulus : the alpha-loop maneuver. Gastrointest Endosc 42 : 244 248, 1995 19)Dallemagne B, Weerts JM, Jehaes C, et al : Laparoscopic Nissen fundoplication : preliminary report. Surg Laparosc Endosc 1 : 138 143, 1991 20) Fukase K, Iseki M, Morikawa T, et al : Total Gastrectomy for Acute Organoaxial Gastric Volvulus. Jpn J Gastroenterol Surg 44 : 963-969, 2011 21) Oku T, Waga E, Wada Y, et al : Two cases of effective minimally invasive therapies for upside down stomach. Jpn J Gastroenterol 102 : 1194-1200, 2005 22)Allen MS, Trastek VF, Deschamps C, et al : Intrathoracic stomach. Presentation and results of operation. J Thorac Cardiovasc Surg 105 : 253-258, 1993 1185