Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective

The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).

Gastric volvulus and splenopancreatic torsion with wandering spleen: A case report

INTRODUCTION AND IMPORTANCE

Gastric volvulus is an uncommon potentially life-threatening medical condition characterized by rotation of the stomach or part of the stomach around its longitudinal or transverse axis. Acute gastric volvulus usually presents with the triads of epigastric pain, nonproductive retching, and inability to pass the nasogastric tube. Diagnosis is assisted with abdominal and chest x-ray and contrast studies.

CASE PRESENTATION

A 53-year-old female presented with abdominal pain of two days duration which started at the epigastric region and later on became diffuse all over the abdomen. She had associated frequent episodes of vomiting which were initially bilious followed by nonproductive retching and low-grade intermittent fever. Abdominal examination showed a distended, diffusely tender abdomen with an ill-defined epigastric mass. Abdominal X-ray showed central abdominal circular opacity continuous with stomach outline. Intraoperative findings revealed perforated gangrenous mesenteroaxial gastric volvulus and splenopancreatic torsion with wandering spleen. Proximal subtotal gastrectomy with esophagogastric anastomosis and splenopexy was performed. The patient was discharged on the 10th postoperative day and had an uneventful post-operative recovery.

CLINICAL DISCUSSION

Primary gastric volvulus is usually mesenteroaxial with the pylorus commonly rotating anteriorly. Primary gastric volvulus can be associated with congenital asplenia and wandering spleen as both conditions are characterized by absent or loose ligamentous attachments. This case was a mesenteroaxial volvulus with splenopancreatic torsion with a wandering spleen caused by abnormal ligamentous attachments.

CONCLUSION

A high index of suspicion for early diagnosis of gastric volvulus and timely intervention is required to improve treatment outcome.

Does Fixation of the Gastric Conduit Reduce the Incidence of Gastric Volvulus After Esophagectomy?

BACKGROUND

Acute volvulus of the gastric conduit is a rare complication after esophagectomy that warrants surgical intervention and is associated with increased morbidity and mortality. The aim of the study is to evaluate whether fixation of the gastric conduit would reduce the incidence of postoperative volvulus following esophagectomy.

METHODS

This single-center retrospective analysis of patients who underwent esophagectomy was conducted to determine the incidence of acute postoperative volvulus following a change in practice. All patients who underwent an esophagectomy from September 2013 to November 2022 were included. We compared postoperative outcomes of gastric conduit volvulus, reoperations, morbidity, and mortality among those who had fixation versus non-fixation of the conduit to the right pleural edge.

RESULTS

Two hundred and forty-two consecutive patients underwent minimally invasive esophagectomy (81% male, 41% were < 67 years old). The first 121 (50%) patients did not undergo fixation of the gastric conduit, while the subsequent 121 (50%) patients did undergo fixation. Comparing both groups, there were no significant differences in major complications, anastomotic leak, and 30-day and 90-day all-cause mortality. Four (2%) patients developed gastric conduit volvulus in the non-fixation group, requiring reoperative intervention. Following implementation of fixation, no patient experienced gastric volvulus.

CONCLUSION

Acute volvulus of the gastric conduit is a rare complication after esophagectomy. Early diagnosis and surgical intervention are critical. In this study, although not statistically significant, fixation of the gastric conduit did reduce the number of patients who experienced postoperative volvulus. Additional future studies are needed to validate this technique and the prevention of postoperative acute gastric conduit volvulus among a diverse patient population.

Fatal gastric volvulus: forensic pathology considerations and postmortem CT findings

Gastric volvulus is a rare cause of gastric obstruction, due to the rotation of the stomach by more than 180°. It is a rare but life-threatening medical emergency that is considered difficult to diagnose at the initial clinical presentation. Forensic pathologists may be presented with gastric volvulus in several ways, for instance, as a cause of sudden and unexpected death or in the context of suspected clinical errors. The post-mortem examination of gastric volvulus may be challenging, due to the specific technical issues it presents and the various mechanisms by which volvulus may cause death. We therefore present five cases of gastric volvulus that in combination represent almost the entire spectrum of presentations and post-mortem findings, to discuss how gastric volvulus may come to the attention of a forensic pathologist, the approach and findings at post-mortem examination (including post-mortem CT), and the variety of mechanisms by which gastric volvulus may result in death.

Comprehensive Review: Acute Esophageal Necrosis in the Setting of Gastric Volvulus

BACKGROUND AND AIMS

Acute esophageal necrosis (AEN) in the setting of gastric volvulus is a rare condition with only a handful of cases reported. Volvulus may contribute to AEN by limiting tissue perfusion and promoting massive reflux of gastric contents on compromised esophageal mucosa.

METHODS

We reviewed 225 original articles, literature reviews, case series, brief reports, case reports, and discuss six total cases of co-occurring esophageal necrosis and gastric volvulus.

RESULTS AND CONCLUSIONS

We present the first comprehensive analysis of all reported cases in the literature to date and formulate management strategies for the co-occurrence of AEN and volvulus. Management of AEN should be directed at correcting underlying medical conditions, providing hemodynamic support, initiating nil-per-os restriction, and administering high-dose proton pump inhibitor therapy. Surgical intervention is typically reserved for cases of esophageal perforation with mediastinitis and abscess formation.

Mesentero-axial gastric volvulus treated with laparoscopic gastropexy: a case report

BACKGROUND

Mesentero-axial gastric volvulus (MAGV) is an uncommon subtype of gastric volvulus (GV). However, reports of such cases in adult patients are very rare. We present an unusual case of idiopathic MAGV in an old woman.

CASE PRESENTATION

An 84-year-old woman was referred to the emergency department for vomiting and abdominal pain. An abdominal computed tomography scan revealed a mesentero-axial gastric volvulus, which could be corrected endoscopically, and the symptoms were relieved. Contrast-enhanced examination was performed before the elective surgery to confirm the presence of short-axis dorsal 180-degree volvulus. The patient underwent laparoscopic surgery on a wait-and-watch basis. After releasing the torsion, the stomach returned to normal position. The gastric fornix was sutured to the left diaphragm and the gastric body and antrum were sutured to the abdominal wall using non-absorbable thread. Symptoms did not flare after the surgery.

CONCLUSIONS

We experienced a rare case of adult MAGV presenting with incomplete obstruction. Laparoscopic gastropexy is useful when gastric decompression is achieved.

Gastric volvulus associated with shrinkage of a gastrointestinal stromal tumor by neoadjuvant imatinib: a case report

BACKGROUND

During neoadjuvant chemotherapy for giant gastrointestinal stromal tumors, changes in gastrointestinal stromal tumor size are rarely associated with events such as perforation and bleeding that require emergency surgery. Moreover, it is very rare for gastrointestinal stromal tumors to shrink and become mobile, resulting in gastric volvulus. Herein, we report a case of gastrointestinal stromal tumor shrinkage during neoadjuvant imatinib treatment, resulting in gastric volvulus that required surgery. To the best of our knowledge, this is the first reported occurrence of gastric volvulus during neoadjuvant imatinib treatment for a giant gastrointestinal stromal tumor.

CASE PRESENTATION

A 58-year-old Japanese woman who was diagnosed with a giant gastric gastrointestinal stromal tumor and administered neoadjuvant imatinib presented to our hospital with complaints of abdominal pain and retching. Enhanced computed tomography revealed that the gastrointestinal stromal tumor had shrunk and shifted in position, and the stomach had organoaxially twisted. Accordingly, the patient was diagnosed with gastric volvulus caused by a gastric gastrointestinal stromal tumor. Conservative treatment did not improve the volvulus; hence, laparotomy was performed. The tumor developed from the lesser curvature of the stomach and caused rotation of the gastric body. The local gastric wall was resected. Histopathological examination confirmed the diagnosis of gastrointestinal stromal tumor. The patient received adjuvant imatinib for 3 years and has been alive for 5 years without recurrence.

CONCLUSIONS

Gastric volvulus can be caused by the laxity of the ligaments that hold the stomach and gastric ptosis or esophageal hernia and diaphragmatic hernia; therefore, gastric gastrointestinal stromal tumors rarely cause gastric volvulus. However, a risk of torsion exists if the gastrointestinal stromal tumor develops extramural to lesser curvature and attains a certain size.

Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression

PURPOSE

The purpose of this study is to determine the incidence of gastric tube abnormalities after SG and its relationship with esophagitis progression.

METHODS

Retrospective study which included 459 patients in the postoperative period of SG who underwent an esophagogastroduodenoscopy in both pre- and postoperative periods. The main studied variables were presence of gastric tube abnormalities (dilation, neofundus, twist, and hiatal hernia) and esophagitis progression.

RESULTS

Among the 459 patients who underwent SG, 393 (85.6%) were women, and 66 (14.4%) men, with mean age of 40.4 years. Mean preoperative BMI was 39.70 kg/m². In total, 20.3% of the sample presented progression of esophagitis after surgery. Among the whole sample, 130 (28.3%) presented with an abnormality of the remnant gastric tube. The most common alteration was gastric dilation, which occurred in 16.1% of the patients, followed by gastric twist (10.7%), neofundus (7.4%), and hiatal hernia (0.2%). Patients who presented with any abnormality of the gastric tube were significantly prone to presenting esophagitis progression (p = 0.013). When analyzing each morphological abnormality isolated, there was no statistically significant correlation.

CONCLUSION

Abnormalities of the gastric tube are not uncommon after SG and seems to contribute partially to the relevant rates of GERD and esophagitis after this surgery.

An illustrative case to understand the pathophysiology of gastric volvulus

Purpose: To depict the characteristics of a special type of gastric volvulus caused by acute re-herniation of a previous hiatal hernia.Materials and methods: We present the case of a male patient with known history of a giant hiatal hernia who presented to our emergency department with a chief complaint of epigastric pain, oral intolerance and incoercible vomiting in the last 24 h. On suspicion of abdominal complication, an emergent computed tomography (CT) scan was performed.Results: Gastric volvulus secondary to downward re-herniation of the fundus into the abdominal cavity was the cause of this patient's symptoms. This mechanism, which was demonstrated by comparing the CT findings of the acute episode with previous imaging studies, reveals a largely unrecognized pathogenic mechanism of gastric volvulus.Conclusions: Acute gastric volvulus should be suspected in patients with hiatal hernia. CT allows its diagnosis and likely underlying pathophysiological mechanism.

Acute abdomen with gastric volvulus revealing an underlying pneumatosis cystoides intestinalis: a case report

Background

Pneumatosis intestinalis is an abnormal presence of free air outside the lumen of the intestines in many shapes. It is classified based on its etiology to primary or secondary, it affects adults as well as infants and can involve any part of the GI tract.

Case presentation

We report a case of a 55-year-old man with a past medical history of a surgically repaired perforated duodenal ulcer who presented with an acute abdominal pain, Flatulence and constipation. On examination of the abdomen; severe distension, tenderness and tympanicity on percussion were noted. An erect CXR was performed and showed bilateral sub-diaphragmatic air levels. We performed an abdominal Paracentesis under the right subcostal margin which led to evacuation of large amounts of air. Next, an investigational laparotomy showed that the reason was a gastric volvulus associated with an anterior and posterior gastric wall lacerations. The suitable surgical repair approach was taken, but another lesion was detected incidentally. A pneumatosis cystoides intestinalis (PCI) was extended along large length of the intestines in many shapes and without any symptoms or signs.

Conclusions

Pneumatosis cystoides intestinalis has been reported continuously in relation to peptic ulcer disease (PUD). We aim to report a new association of a gastric volvulus and PCI secondary to pyloric stenosis caused by a duodenal ulcer; which we believe can aid in the diagnosing of dangerous complications, of a rare disease.

Patients with gastric volvulus recurrence have high incidence of wandering spleen requiring laparoscopic gastropexy and splenopexy

PURPOSE

Though gastric volvulus in neonates and infants resolves by conservative therapy and aging, some cases require surgical intervention. This study aimed to review the cases of gastric volvulus requiring surgical intervention and evaluate their characteristics.

METHODS

We retrospectively reviewed gastric volvulus cases requiring surgical intervention. Surgical indication was persistent acute gastric volvulus and repeated hospitalization for gastric volvulus. We evaluated the characteristics of those cases requiring surgical intervention and the surgical results of laparoscopic gastropexy.

RESULTS

The median age of patients included was 4 years (range: 1-6 years). All eight cases of gastric volvulus requiring sugery had congenital spleen diseases. Six of the eight cases suffered from a wandering spleen, while two cases presented with situs inversus with asplenia. Both splenopexy (preperitoneal distension balloon [PDB] or blunt separaion methods) and gastropexy were performed in cases with wandering spleen. No postoperative complications were reported in any of the eight cases, except the recurrence of gastric volvulus due to suture shedding in one case.

CONCLUSION

Laparoscopic gastropexy for gastric volvulus and splenopexy for cases concomitant with wandering spleen were found to be effective surgical approaches. Both PDB and blunt separation methods for making extraperitoneal pockets for the spleen were employed successfully.

The Key Role of Upper Endoscopy in Diagnosing Gastric Herniation and Volvulus in Acute Gastrointestinal Obstruction

The diagnosis of gastric volvulus can be a clinical challenge as it is rare, and the symptoms are often nonspecific and intermittent. Upper endoscopy is a minimally invasive intervention that may be repeated more than once to provide key information and ultimately establish such a diagnosis. To emphasize the role of upper endoscopy in surgical cases with recurrent upper gastrointestinal obstructions, we present a case of intermittent gastric volvulus in a patient with a remote history of complex chest wall reconstruction for invasive breast cancer using an omental flap. She presented with substernal chest pain, belching, nausea, and vomiting. Although the initial imaging suggested duodenal obstruction, exploratory laparotomy and intraoperative upper endoscopy did not show any pathology in the stomach or duodenum. Repeat upper endoscopy due to recurrence of obstructive symptoms shortly after the initial exploratory laparotomy revealed a gastric volvulus. This resulted in abnormal duodenal orientation which caused intermittent duodenal obstruction while the pathology was in the stomach. Gastric volvulus may be spontaneously reducible, leading to discordance in findings during the clinical course. This could explain the absence of visible twisting on initial exploratory laparotomy in this patient and the subsequent findings of volvulus on upper endoscopy. Thus, it is important to consider gastric volvulus as a possible cause of symptoms despite initial negative findings as it is a dynamic process and may only be discovered through relook upper endoscopy and imaging.

A case report and literature review

INTRODUCTION AND IMPORTANCE

One of the most performed bariatric procedures, Laparoscopic sleeve gastrectomy (LSG) can be utilized not only as a primary bariatric procedure to achieve weight loss but also as a staged procedure, as it attains durable weight loss on long term follow up with remission of obesity-related comorbidities. There are several complications associated with LSG in the short and long terms, including hemorrhage, gastric leakage, and gastroesophageal reflux disease (GERD), yet gastric volvulus after sleeve gastrectomy is a rare entity.

CASE PRESENTATION AND CLINICAL DISCUSSION

We present a morbid obese female patient 32 years old -with no known medical comorbidity- presented to our bariatric outpatient clinic after laparoscopic sleeve gastrectomy with a chronic progressive history of vomiting, regurgitation, and heartburn of three months which started once/week then progress to 3 times/week duration. After a normal abdominal x-ray, Pelvi-abdominal ultrasound showed mild colonic gaseous distension. The CT virtual gastroscopy with 3D reconstruction revealed significant mid-body kinking with a wavy appearance. A decision was made on a multi-disciplinary approach to do a diagnostic laparoscopy for the patient with a revision of the previous sleeve gastrectomy. Upon entering the intra-abdominal there were extensive adhesions between the sleeved stomach, liver, and pancreas. Intra-operative upper endoscopy was done, and the scope didn't pass at the mid-portion of the sleeved stomach. Conversion to Roux-en-Y gastric bypass had been done with successful results.

CONCLUSION

Gastric volvulus after sleeve gastrectomy is a rare entity presenting vague symptoms and signs and requires a high index of suspicion from the physicians for the proper diagnosis.

Impact of surgical repair on type IV paraesophageal hernias (PEHs)

BACKGROUND

Paraesophageal hernias (PEHs; types II-III-IV) account for about 5% of all hiatal hernias (HHs). The peculiarity of PEHs is the presence of a herniated sac which contains a more or less important part of the stomach, along with other abdominal organs in type IV PEHs. Surgical treatment is more complex since it requires a reduction not only of the herniated content but also of the "container," namely the sac adherent to mediastinal structures. Since type III and IV PEHs are mostly grouped together as large PEHs, there is a lack of articles in the literature with regards to clear surgical outcomes, as well as management algorithms in type IV PEHs. This study aims to compare outcomes in type IV vs. type III PEHs after surgical repair.

METHODS

A retrospective study of patients who underwent laparoscopic PEH hernia repair (LPEHR) was conducted in a single institution between 2006 and 2020. Patient baseline characteristics and surgical outcomes were analyzed.

RESULTS

A total of 103 patients were included in the analysis. Patients presenting with type IV PEHs (12/103) were significantly older than patients with type III PEHs (91/104) (75.25 ± 7.15 vs. 66.91 ± 13.58 respectively (p = 0.039), and more fragile with a higher Charlson Comorbidity Index (CCI) (4.25 ± 1.48 vs. 2.96 ± 1.72, p = 0.016). Operative time was significantly longer (243 ± 101.73 vs. 133.38 ± 61.76, p = 0.002), and postoperative morbidity was significantly higher in type IV PEH repair (50% vs. 8.8% type III, p = 0.000).

CONCLUSION

Patients with type IV PEHs appear to be older and frailer. The higher incidence of postoperative complications in patients with type IV PEHs should advocate for a precise indication for surgical treatment, which should be performed in centers of expertise.

Acute gastric volvulus following rapid and incomplete chewing of vegetables: A case report

One of the rare but serious causes of acute abdomen is gastric volvulus. It is considered an emergent surgical condition when it takes place acutely due to the risk of gastric strangulation, gangrene, and perforation. In this study, we introduce a case of a previously healthy young adult patient who presented with sudden severe epigastric and left upper quadrant abdominal pain along with nausea and retching following insufficient mastication and rapid swallowing of large amounts of vegetables. Radiological studies with chest and abdominal X-rays were in favor of acute gastric outlet obstruction and finally, laparotomy confirmed the diagnosis of acute, primary mesenteroaxial gastric volvulus. We postulated a probable justifying mechanism of the presence of a flaccid gastrocolic ligament (found through the laparotomy) besides rapid entrance of great pieces of vegetables into the stomach precipitated instant gastric rotation.

Let's (Not) Twist Again: Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy in Paediatric Gastric Volvulus

INTRODUCTION

In the setting of intermittent abdominal pain accompanied by gastro-intestinal obstruction, gastric volvulus should be suspected.

AREAS COVERED

A 10-year-old girl was admitted to our hospital for intermitted abdominal pain associated with recurrent non-bilious vomiting and acute weight loss. The radiological images performed at the district general hospital were reported as negative. After careful review of the imaging, a gastric volvulus was suspected. Exploratory laparoscopy confirmed the diagnosis; laparoscopic-assisted percutaneous endoscopic gastrostomy was performed. The postoperative upper gastro-intestinal study showed stomach in its normal shape and position.

EXPERT COMMENTARY

Gastric volvulus is a potential life-threatening condition with a good outcome when promptly recognized. Laparoscopic-assisted percutaneous endoscopic gastrostomy is a safe and curative procedure in the case of suspected gastric volvulus, avoiding the need for a secondary procedure. In pediatric patients, it facilitates direct inspection of the stomach and abdominal cavity, reducing the need for a second procedure. This procedure may emerge as a 'gold standard' for gastric volvulus treatment.

A case report of gastric volvulus, a rare cause of acute abdomen

Gastric volvulus is an uncommon disorder with an unknown incidence, unless it stays in the back of the diagnostician's mind, diagnosis of gastric volvulus, which can have significant morbidity and mortality associated with it, can be easily missed and can present either in the acute or chronic setting with variable symptoms. When it occurs in the acute scenario, patients present with severe epigastric pain and retching without vomiting. Together with inability to pass nasogastric tube, they constitute Borchardt's triad. The presence of a hiatal hernia with persistent vomiting despite initial antiemetic treatment should trigger one to think of gastric volvulus, despite the patient appearing very stable.

We report a case which presented in our hospital with abdominal pain and vomiting. As Oesophagogastroduodenoscopy shows hiatal hernia and peptic ulcer.

Primary gastric volvulus occurs in the absence of any defect in the diaphragm or adjacent organ pathology and may be caused by weakening of gastric supports.

As conclusion; Gastric volvulus is a surgical case, requiring early diagnosis and aggressive management, as a delay results into complications like gangrene and perforation which substantially increase the morbidity and mortality in these patients, and contrast enhanced computed tomography (CECT) is the best modality for diagnosis of gastric volvulus.

Gastric remnant mesentero-axial volvulus following Roux-en-Y esophagojejunostomy: A rare complication

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Acute gastric volvulus is characterized by abnormal rotation of the stomach by more than 180°, creating a closed loop obstruction with the risk of strangulation, necrosis and perforation.

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Diagnosis of gastric volvulus is challenging due to non-specific presentation and rarity of this clinical condition.

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The diagnosis is even more challenging in patients with altered anatomy and requires high index of suspicion.

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Extensive gastric mobilization is a key step in several foregut and bariatric surgeries.

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This mobilization will leave the stomach with no attachments posteriorly and along the greater curvature, increasing the likelihood of volvulus.

Introduction

Acute gastric volvulus is a surgical emergency with a mortality as high as 15–20%. The rarity of gastric volvulus requires high index of clinical suspicion especially in the patients with altered anatomy, to allow immediate surgical intervention and reduce the morbidity and mortality.

Presentation of case

We present an unusual case of gastric remnant volvulus several months following Roux-en-Y esophagojejunostomy performed in an obese patient for severe, recurrent gastroesophageal reflux disease (GERD) and failed prior fundoplication. The patient was treated with gastropexy and Stamm gastrostomy tube.

Discussion

Gastric volvulus is a rare phenomenon, in which the stomach rotates around the short (mesentero-axial) or longitudinal (organo-axial) axes. Diagnosis of gastric volvulus is challenging due to non-specific presentation and rarity of this clinical condition. The diagnosis of volvulus in patients with altered anatomy is even more challenging, requiring a high index of suspicion, and heavily relies on cross sectional imaging.

Conclusion

Extensive gastric mobilization is a key step in several foregut and bariatric surgeries, this will leave the stomach with no attachments posteriorly and along the greater curvature and increases the likelihood of volvulus.

Gastric necrosis following a hiatal hernia: A case report

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Nasogastric tube decompression if the first-step treatment of gastric volvulus, which can be placed blindly or under endoscopic guidance.

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Prompt endoscopic or surgical assessment should be conducted when signs of sepsis, perforation, or ischemia are present.

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Definitive treatment for secondary volvulus is best achieved with hernia reduction, closing of the anatomical defect, and fundoplication.

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Primary volvulus can be treated with gastropexy alone.

Introduction

Gastric volvulus are rare. Complications can be life threatening, including necrosis and perforation. Assessment of mucosal viability is essential, and urgent surgical intervention is mandatory in case of vascular compromise.

Presentation of case

An 72-year-old female known for a paraesophageal hiatal hernia was admitted at our emergency department with acute abdominal pain. Blood count demonstrated leukocytosis and increased C-reactive protein. Abdominal computed tomography showed a mesenteroaxial gastric volvulus. Urgent upper endoscopy revealed mucosal ischemia, which prompted immediate laparotomy with partial gastrectomy, cruroplasty, and Dor fundoplication. Postoperative course was uneventful.

Discussion

Gastric volvulus is initially treated with nasogastric tube decompression, but definitive treatment is achieved surgically. When there is an associated hernia, closing the anatomical defect and fundoplication should be performed. Complication such as necrosis is associated with a high mortality, and requires urgent surgical repair.

Conclusion

Gastric volvulus can be life-threatening. Urgent endoscopic or surgical assessment should be conducted to assess mucosal viability.

Total gastrectomy in a case of complicated gastric volvulus: Case report and review of literature

INTRODUCCIóN: Gastric volvulus is characterized by a rotation, in its long or short axis, generating various degrees of obstruction, which can occur acutely or chronically.

CASE

A 45-year-old female. Refers to the performance of laparoscopic Nissen fundoplication 4 years ago. In December 2018, she presented a recurrence of the symptoms associated with reflux, for which a new laparoscopic fundoplication was performed (outside our medical unit) without eventualities or apparent complications. Six months later, he was admitted to our medical unit due to intolerance to the oral route. Thoraco-abdomino-pelvic tomography reports images suggestive of gastric volvulus and mixed hiatal hernia with protrusion of colon, stomach, duodenum, jejunum and mesenteric vessels, with data suggestive of complication or ischemia of these structures. An emergency operating room was requested to perform an exploratory laparotomy. Gastric volvulus, ischemia and gastric necrosis were observed in the cavity, for which a total gastrectomy and restitution of the intestinal transit were carried out by means of an esophagus-jejunum end-to-side Roux-en-Y anastomosis.

DISCUSSION

There is no scientific evidence or algorithms described for the management of this condition, according to the management described in the literature, decision-making by our team surgical procedure matches current recommendations.

CONCLUSION

In accordance with what is described in the literature, we consider it important to carry out a retrospective study that describes the bases for standardizing the management of this complication, and assessing models for conducting prospective multicenter studies that allow the creation of an algorithm and clinical guideline.

Intrathoracic gastric volvulus complicating a robotic left upper lobectomy: A case report and review of literature

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Intrathoracic gastric volvulus.

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Robotic Lobectomy unusual complication.

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Para esophageal hernias a cause for concern during robotic thoracic procedures.

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Gastric Ischemia.

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Etiology of gastric volvulus.

Unrecognized intrathoracic gastric volvulus can be a life-threatening condition, especially in elderly individuals undergoing major surgical procedures. We herein report the first case of a gastric volvulus after a robot-assisted left upper lobectomy for non-small-cell lung cancer in a patient with a known paraesophageal hernia. The operative procedure was performed by Dr Jacques Fontaine a senior thoracic surgeon at Moffitt Cancer Center in Tampa Florida a major academic institution. This operation was complicated by a large type-III hiatal hernia, with most of the stomach having herniated into the left pleural cavity and demonstrating organo-axial torsion one day after the indexed operation for the lung cancer. The patient required emergency surgery due to gastric ischemia. The patient underwent exploratory laparotomy with reduction of the volvulus and closure of the esophageal hiatus at that time. The patient was taken back to the operating room for a planned relook 24 h after the exploratory laparotomy to assess viability of the stomach. Unfortunately, the second look revealed necrotic areas of the stomach, which required to be resected. Given her age and poor nutritional status, we elected to place a feeding jejunostomy tube. Her postoperative course was marred by an abdominal wound infection treated with a wound vacuum-assisted closure device. Ultimately she was discharged home on POD#19 tolerating a regular diet. This case report highlights that in the elderly patients undergoing left lung resection with a known large hiatal hernia, the index of suspicion for herniation must be high and prompt recognition can avert mortality or morbidity.

Acute intrathoracic gastric volvulus with retrograde gastric intussusception: A case report of a rare surgical emergency with review of the literature

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The acute intrathoracic gastric volvulus is a rare condition.

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The gastrogastric intussusception is very very rare.

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The gastric volvulus and the gastrogastric intussusception are surgical emergencies.

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Any delay in diagnosis and treatment can prove fatal.

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Emergent laparotomy or laparoscopy is considered the correct treatment.

Introduction

The gastric volvulus is a rare condition in which the stomach, or part of it, rotates on its axis, for over 180°, constituting a surgical emergency. Even more rare is gastro-gastric intussusception. A delay in their diagnosis and treatment can have fatal consequences

Presentation of case

An 82-year-old woman was admitted to the Surgery Unit with a two-day history of abdominal pain associated at first with coffee vomiting and, subsequently, with unproductive retching and oligoanuria. Physical examination showed severe dehydration, fever, at the abdominal level, palpation caused a marked tenderness of all quadrants, with signs of peritonism.

Laboratory test showed showed neutrophilic hyperleukocytosis and high C reactive protein level. Abdominal computed tomography revealed an acute intrathoracic gastric volvulus and a gastrogastric intussuception. The patient was submitted to exploratory laparotomy, subtotal gastrectomy with Roux en Y anastomosis and simple plastic of the esophageal hiatus. At the end of the surgery, however, the patient died of your septic shock.

Discussion

The traditional treatment for a patient with acute gastric volvulus is an immediate surgical intervention to derotate the stomach and prevent vascular insufficiency.

In the presence of necrosis or gastric perforation, resection should be performed.

The few cases of gastrogastric intussusception described in the literature have been treated with sub-total gastrectomy and gastro-jejunal anastomosis. Any delay in diagnosis and treatment can prove fatal.

Conclusion

Intrathoracic Gastric Volvulus and, even more, retrograde gastrointestinal intussusception are very rare pathologies, difficult to diagnose.

Acute intrathoracic gastric volvulus: A rare delayed presentation of congenital diaphragmatic hernia: A case report

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Acute gastric volvulus occurs when the stomach undergoes torsion in the thoracic cavity.

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We describe an 8-year-old boy with diaphragmatic hernia complicated by gastric volvulus presented with acute epigastric pain and non-bilious vomiting.

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He underwent laparotomy. Reduction of the viscera to the abdominal cavity, gastropexy and repair of diaphragmatic defect were done.

Introduction

Acute intrathoracic gastric volvulus occurs when the stomach undergoes organoaxial rotation in the chest due presence of a diaphragmatic defect. Gastric volvulus associated with congenital diaphragmatic hernia is extremely rare and can be explained as 2 of the 4 ligaments supporting the stomach (gastrophrenic and gastrosplenic) which are connected to the left diaphragm may become elongated or absent. According to the current literature, only 27 pediatric cases have been reported so far.

Presentation of case

We describe an 8 years old boy who presented to our emergency department with acute epigastric pain and vomiting. The chest radiograph obtained in the emergency department demonstrated an elevated gastric air-fluid level in the left hemithorax. A computed tomography scan demonstrated a sizable left diaphragmatic defect admitting stomach, small bowel loops and transverse colon with organoaxial gastric volvulus. Emergent laparotomy was done for reduction of the viscera to the abdominal cavity and repair of the diaphragmatic defect. The patient showed an uneventful recovery without experience any pain or difficulty with eating.

Discussion

Acute gastric volvulus is a rare pathology defined as an abnormal rotation of the stomach for more than 180° leading to a closed-loop obstruction which may progress to ischemia and strangulation. A plain standing abdominal X-ray and an upper gastrointestinal contrast study are useful for diagnosis, but some authors recommend performing CT or MRI to confirm the diagnosis. The standard treatment for volvulus is open laparotomy with detorsion and anterior gastropexy.

Conclusion

The presented case highlights congenital diaphragmatic hernia associated with gastric volvulus is a serious condition with very high morbidity and mortality. It should be considered in the differential diagnosis of children with epigastric pain and uncontrolled non bilious vomiting. An upper gastrointestinal contrast study is useful for early diagnosis and surgical treatment should not be delayed awaiting further complementary imaging tests.

Adult primary gastric volvulus, a report of two cases

Gastric volvulus is the medical situation that a stomach is twisted beyond the physiological range. It is a rare disease which is hard to experience in routine medical examination. Principally surgical treatment is essential for the acute type. However, the conservative therapy should be attempted in some cases, such as decompression of a stomach with a nasogastric tube, endoscopic reduction and so forth. Concerning surgical operation, the base is reduction of the torsion and immobilization of stomach. Recently, laparoscopic surgery is performed for the case that the general condition is stable or chronically progressive in the early stages. Percutaneous endoscopic gastrostomy (PEG) had also been performed for gastric immobilization. However, the recurrences and problems of twisting around the gastrostomy site were reported in addition to the problem of cosmetic outcomes. Therefore, the case is decreasing. In this paper, we present two cases on adult primary gastric volvulus. For the first case, endoscopic reduction was not good enough to release the torsion state. Then laparoscopic gastropexy was performed successfully. For the second case, we succeeded in endoscopic reduction. Since the patient had already experienced gastric volvulus, laparoscopic surgery was performed. The upper and middle gastric bodies were secured to the anterior abdominal wall, and gastric antrum to the ligamentum teres hepatis with interrupted absorbable sutures respectively. However, partial gastric volvulus recurred after ten and a several days postoperatively due to cutting off of the suture at the antrum secured to the ligamentum teres hepatis at previous surgery. Then, PEG for 2 points of lower body and antrum were performed to secure the antrum. The gastrostomies were removed 6 months after the surgery. Immobilization by laparoscopic gastropexy and PEG are useful for gastric volvulus due to their significant merit of minimum invasiveness. Concerning gastropexy, the number of sutures is very important for the secured part not to be torn off.

Chronic gastric volvulus-Case report of an uncommon diagnosis

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Chronic gastric volvulus is an uncommon condition.

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The diagnosis of a chronic gastric volvulus requires a high index of suspicion.

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Surgical repair should be done to prevent an acute complication, associated with higher morbidity and mortality.

Introduction

Gastric volvulus is an uncommon condition that results from the torsion of the stomach upon its axis. Although rare, it can present as an acute medical emergency, therefore its diagnosis should not be overlooked. In this article we aim to present a case of a patient with chronic gastric volvulus operated in our hospital. We also aim to discuss this condition.

Presentation of case

We report the case of a 61  year old, healthy male, referred to surgical consultation complaining of epigastric discomfort and postprandial fullness. The diagnostic workup showed a mesentero-axial volvulus of the stomach. He was operated electively: reduction of volvulus, Nissen fundoplication and gastropexy was performed, with resolution of symptoms.

Discussion

There are several predisposing factors for the development of a gastric volvulus. It is classified according to the axis upon the rotation of the stomach occurs. The treatment of gastric volvulus may differ in the acute or chronic setting.

Conclusion

Diagnosis of a chronic gastric volvulus requires a high index of suspicion. Surgical repair should be done to prevent an acute complication.

Combined laparoscopic and thoracoscopic approach for tension gastrothorax in a foramen of Bochdalek hernia

INTRODUCTION

The incidence of Bochdalek hernias in adults is much more than previously reported. Though most of these are asymptomatic. Tension gastrothorax is a rare complication of these. Literature about the endoscopic management of a tension gastrothorax is extremely sparse. In this case report, we describe how we combined laparoscopy and thoracoscopy in an emergency setting to manage a case of tension gastrothorax with an underlying Bochdalek hernia defect in an adult.

PATIENT PROFILE

A 27 year old male presented to our emergency with tension gastrothorax and a gastric volvulus with an underlying Bochdalek hernia defect, exhibiting the classical Borchardt's triad. The patient underwent an emergency surgery, through a minimally invasive approach wherein the herniated contents were reduced, the gastric volvulus detorted and a repair of the diaphragmatic defect was performed. His post-operative course was uneventful.

DISCUSSION

Tension gastrothorax, is a diagnostic challenge as an air-fluid level in the thorax on radiology with worsening respiration causes as many as 38% of these cases to be misdiagnosed as tension pneumothorax, hydro-pneumothorax, hemothorax, empyema, effusion or pneumonia. Various techniques of decompression have been described in literature but, employing those, in case of a misdiagnosis may have catastrophic outcomes.

CONCLUSION

We strongly recommend employing a combined laparoscopic and thoracoscopic approach for an emergency repair of a tension gastrothorax in a hemodynamically stable patient as, it poses all the advantages of minimal access surgery and is available, at smaller centres, even in an emergency.

Management and outcomes of gastric volvulus in children: a systematic review

BACKGROUND

Gastric volvulus (GV) in children is a rare condition. This study reviewed management and outcomes of GV in the pediatric population.

METHODS

MEDLINE/PubMed, Embase, and Google Scholar databases were searched for studies in English regarding GV in patients < 18 years old between 2008 and 2017, selected by two reviewers. Results were presented as percentages and medians. Fisher's exact test was used to evaluate categorical variables, and Bonferroni correction was applied for multiple comparisons.

RESULTS

Ninety-seven papers with 125 patients were included. The median age was 24 months, with slightly female preponderance. Vomiting was the most common symptom and acute presentation occurred in the majority of cases. History of previous surgery/abdominal trauma was described in 12 and 3 children, respectively. Radiology was diagnostic for GV in most cases. The initial management was surgical in the majority of cases, with most of them including gastropexy, gastrostomy, or gastric resection. Mesenteroaxial GV was associated with acute presentation (P = 0.004) and the latter with ischemia (P < 0.01). Complications occurred in 23 (18.9%) children, esophageal stenosis being the most common. There were eight (6.4%) deaths, and only one recurrence 6 months after endoscopic management. The median follow-up period was 12 months. The inclusion of only case reports/case series, the incomplete reporting from papers, and the short follow-up were limitations of the study.

CONCLUSIONS

GV occurs at a median age of 24 months and requires high suspicion and prompt management, as mortality is considerable. The preferred surgical approach for GV includes variations of gastropexy. Esophageal stenosis is the most common morbidity post-GV management.

Recurrent gastric volvulus associated with a gastrointestinal stromal tumor: A case report

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A 7-cm gastrointestinal stromal tumor (GIST) caused recurrent abdominal pain, apparently through gastric volvulus (GV).

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The risk of GV based on the size and location of a tumor is unknown.

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Prompt surgical intervention is indicated in cases of recurrent GV.

Introduction

Gastric volvulus (GV) is defined as a rotation of the stomach along its short or long axis leading to variable degrees of gastric outlet obstruction. Rotation of the stomach >180° may cause closed loop obstruction and possible strangulation, which often causes acute abdominal pain. Strangulation and gangrene of the twisted stomach sometimes occurs, which demands immediate surgical intervention. We report a case of acute gastric volvulus due to a gastrointestinal stromal tumor (GIST), with multiple recurrences, that eventually required emergency gastrectomy.

Presentation of the case

A 71-year-old woman with a history of recurrent epigastric pain, nausea, and anorexia was diagnosed to have a 70-mm sized submucosal tumor (SMT) in the lesser curvature of the stomach. An elective gastrectomy was planned; however, before the procedure, she visited the emergency room with acute recurrent epigastric pain associated with postural variations. Computed tomography (CT) revealed a GV and the tumor had shifted to the greater curvature. An emergency gastrectomy was performed. The postoperative course was uneventful and pathological examination revealed features consistent with that of GIST.

Discussion

GV with GIST has rarely been reported and risk factors such as size or localization are unknown. In this case, GV was probably caused by GIST of the stomach, which was large and heavy enough to rotate the gastric body around the mesenteroaxis.

Conclusion

Surgical intervention without delay should be planned in similar scenarios accounting for the risk of GV in GIST.

Role of Diagnostic Preoperative Upper Gastrointestinal Endoscopy in Radiologically Confirmed Gastric Volvulus

BACKGROUND AND AIMS

Gastric volvulus (GV) is a life-threatening condition that warrants prompt diagnosis and treatment. GV is a radiologic diagnosis. The role of preoperative upper gastrointestinal endoscopy (UGIE) for individuals with radiologically confirmed GV is poorly defined. Our objective was to assess the diagnostic yield of UGIE in the preoperative evaluation of patients presenting with radiologically confirmed GV.

METHODS

Retrospective review of all adult patients undergoing surgery for GV between July 1996 and August 2016 has been carried out. We performed analyses evaluating diagnostic yield of preoperative UGIE and compared outcomes in patients who did and did not undergo preoperative UGIE. Outcomes were diagnostic yield of preoperative UGIE, length of hospital stay, postoperative complications, and mortality at 30 days and 1 year.

RESULTS

In the preoperative UGIE group, the diagnostic yield was 34.6% (27/78). The most common endoscopic findings were erosive esophagitis (13/27) and clean based gastric or duodenal ulcers (5/27). There were no cases of esophago-gastric malignancy. Three patients had ulcers with stigmata of recent bleeding, and three patients had features suggestive of gastric ischemia. Endoscopic findings did not influence surgical management. There was no statistically significant difference in mortality between patients who did and did not undergo preoperative UGIE, both at 30 days (0 vs. 2.5%) and 1 year (3.8 vs. 7.5%).

CONCLUSION

Among patients with radiologically confirmed GV, preoperative UGIE rarely demonstrates clinically significant findings and can potentially delay definitive surgical intervention.

Management of Acute Upper Gastrointestinal Disease While at Sea

Management of complex acute surgical pathology in austere environments necessitates rapid evaluation and resource appropriate management to avoid time-associated morbidity and potentially mortality. Obstructive upper gastrointestinal (UGI) pathologies can be particularly challenging and associated with significant morbidity. Herein, we present six patients with UGI obstructions encountered over the course of an 8-mo deployment onboard a US Navy Aircraft Carrier. Each patient presented to our medical department with signs and symptoms of obstructive UGI pathology including one gastric volvulus requiring operative management at sea, one with a new diagnosis of achalasia requiring transportation and continental United States outpatient evaluation, and four patients with food impaction requiring urgent endoscopic management. Although UGI pathology is seldom encountered at sea, definitive surgical interventions, including prompt evaluation and management of these acute pathologies, can be performed in an austere environment. We wish to call attention to these potential encounters in order that underway deployed medical units and supporting resources ashore are prepared and equipped to intervene on acute UGI obstructive pathology.

Gastric volvulus through Morgagni hernia and intestinal diverticulosis in an adult patient: a case report

BACKGROUND

Morgagni's hernia (MH) is a rare type of congenital diaphragmatic hernia with limited available literature. Late presentations are infrequent and the ones complicated due to gastric volvulus are even rarer. Another uncommon association of MH is with small bowel diverticulosis. We herein discussed a case of gastric volvulus as the content of MH, and small bowel diverticulosis present in a patient concomitantly.

CASE PRESENTATION

A 30 year old woman, who presented with a one year history of epigastric burning and indigestion, occasionally associated with pain and vomiting. On clinical examination, no clue to the diagnosis could be ascertained. Her chest and abdominal x-ray indicated an abnormal air-fluid level at right hemithorax, which prompted a Computed Tomography (CT) scan, showing organo-axial gastric volvulus. MH with gastric volvulus was observed during laparotomy and trans-thoracic reduction of the contents was performed, along with repair of the defect. Multiple intestinal diverticuli were also found and the largest diverticulum was excised.

CONCLUSIONS

Gastric volvulus through MH is a rare but potentially life-threatening condition. Non-specific symptoms like epigastric pain and vomiting can delay the diagnosis and management, however, advanced imaging techniques like CT scan can speed up this process. After the diagnosis is made, surgical repair should be attempted regardless of symptoms.

[Endoscopic management of gastric volvulus in a 8-years old girl]

INTRODUCTION

Gastric volvulus is a rare cause of acute abdomen in childhood, and it is usually a casual finding. We present the case of a girl with mesenteroaxial gastric volvulus, which was initially treated by endoscopic approach.

CLINICAL CASE

8 year-old patient, diagnosed of Down syndrome, who presented sudden and diffuse colic pain, associated with vomiting, sialorrhea and progressive compromise. She entered in bad general condition. At the physical examination it was highlighted a large abdominal mass. In the imaging study, a mesenteroaxial gastric volvulus and wandering spleen were confirmed. It was decided to perform an endoscopic gastric devolvulation under general anesthesia. Subsequently, gastropexy and splenopexy were performed by laparotomic approach. Evolution was uneventful, being discharged at the tenth postoperative day.

COMMENTS

Endoscopic gastric devolvulation is an effective procedure in patients with gastric volvulus, especially in cases of great compromise of the general state, in which a prolonged surgery could suppose a greater risk.

"Black Esophagus" and Gastric Volvulus Following Slipped Laparoscopic Adjustable Gastric Band

To review the entity "black esophagus" and sequela of a slipped laparoscopic adjustable band. The patient's history, physical examination, imaging, and endoscopic findings were reviewed. Detailed review of pathophysiology, presentation, diagnosis, management, and natural history was conducted. "Black esophagus," also known as acute esophageal necrosis (AEN), is a rare condition resulting in black discoloration of the mid to distal esophagus with less than a hundred reported cases. It has not been previously documented in bariatric surgery or following laparoscopic adjustable gastric banding. The volvulus was reduced at surgery, and the esophageal changes resolved without sequela. "Black esophagus" is an acute, ominous-appearing condition with a spectrum ranging from superficial mucosal disease to transmural involvement with perforation. Fortunately, esophageal resection is rarely required.

Acute Organoaxial gastric volvulus: A massive problem with a twist-case report

INTRODUCTION

Gastric volvulus (GV) is a rare and life threatening condition if not treated promptly or wrongly diagnosed. The main complication of gastric volvulus is foregut obstruction. The extreme rotation can cut off blood supply to the stomach and even distal organs, which can lead to ischemia and necrosis of the affected area.

PRESENTATION OF CASE

We report a case of a 41yo female that complained of severe abdominal pain, nausea and vomiting for approximately 3days after eating a large meal. The patient didn't have any flatus or bowel movements in the last 24h. CT of the abdomen and pelvis showed a dilatation of the stomach and esophageal hernia. Laparotomy confirmed an organoaxial volvulus at the level of the antrum and body of the stomach. Gastropexy was implemented and the stomach fixed to the posterior abdominal wall to prevent recurrence.

DISCUSSION

GV may have a significant related morbidity and mortality rate. It can be missed easily on diagnosis. The presence of vomiting not responding to initial antiemetic treatment, as well as, the presence of a hiatal hernia on the imaging studies should trigger our thinking of gastric volvulus, regardless of the stable appearance of the patient.

CONCLUSION

Chronic GV can manifests as atypical chest, abdomen and gastro intestinal symptoms. We recommend that everyone with these atypical symptoms seek medical attention to rule out GV. Early diagnosis and treatment will reduce the risk of developing chronic gastric volvulus to acute gastric volvulus.

A Case of Organo-Axial Gastric Volvulus Following Laparoscopic Fundoplication: a Case Report

Organo-axial gastric volvulus is a rare postoperative complication of stomach surgeries. A case is presented in which a 43-year-old patient developed acute gastric volvulus 14 months after a laparoscopic fundoplication, diagnosed by preoperative CT scan, and treated by reduction of the volvulus, closing the gap in the pars flaccida, and a sham gastro-jejunostomy, all done laparoscopically. This is being published to highlight one of the rare complications of gastric surgery, which can be treated successfully with the laparoscope.

[Gastric volvulus, an infrequent cause of acute abdominal pain]

Gastric volvulus (GV) is characterized by the abnormal rotation of a portion of the stomach around a horizontal or vertical axis that can cause obstruction, vascular disorder and even strangulation, and may evolve into necrosis or even perforation. It can be classified according to its aetiology into primary or secondary GV, according to its anatomy into axial organ or into axial mesenteric GV, and according to its presentation into chronic or acute GV. Both types of volvulus require treatment; however, in spite of the classic treatment being open surgery, there is no standard treatment, nor is there consensus on the alternative of choice at present. Minimally invasion techniques, whether endoscopic or laparoscopic, should be considered in patients of advanced age or high surgical risk, where what is sought is a reduction in perioperative morbidity and mortality.

Lethal mechanisms in gastric volvulus

A 55-year-old wheelchair-bound woman with severe cerebral palsy was found at autopsy to have marked distention of the stomach due to a volvulus. The stomach was viable, and filled with air and fluid and had pushed the left dome of the diaphragm upwards causing marked compression of the left lung with a mediastinal shift to the right (including the heart). There was no evidence of gastric perforation, ischaemic necrosis or peritonitis. Removal of the organ block revealed marked kyphoscoliosis. Histology confirmed the viability of the stomach and biochemistry showed no dehydration. Death in cases of acute gastric volvulus usually occurs because of compromise of the gastric blood supply resulting in ischaemic necrosis with distention from swallowed air and fluid resulting in perforation with lethal peritonitis. Hypovolaemic shock may also occur. However, the current case demonstrates an alternative lethal mechanism, that of respiratory compromise due to marked thoracic organ compression.

Chronic recurrent vomiting associated with primary gastric volvulus in infant: A case report and review of literature

Gastric volvulus is an uncommon entity found in the paediatric population. We are reporting a case of chronic gastric volvulus presented to us with the complaints of recurrent vomiting after each feed. The vomiting was projectile, nonbilious, and the content was milk. The patient was evaluated by clinical and radiological means in the form of the X-ray abdomen, ultrasound abdomen, upper gastrointestinal (GI) contrast study, and computed tomography scan of the abdomen. The upper GI contrast study was suggestive of gastric volvulus. The patient was operated and gastropexy was done. There was lax gastrocolic ligament with increased distance between stomach and transverse colon without any obvious gastric volvulus. Postsurgery, the patient was symptom-free.

Acute primary mesenteroaxial gastric volvulus in a 6 years old child; the contribution of ultrasonographic findings to the prompt diagnosis (a case report and review of the literature)

The aim of the present case study is to raise concern on the proper diagnostic approach of acute gastric volvulus (AGV) cases, in which, the key issue is the timely diagnosis and the prompt therapeutic intervention. After thorough and systematic research of the current literature, it is concluded that early diagnosis remains challenging, while there is no relevant publication with emphasis on the contribution of ultrasonography to the diagnostic documentation of AGV. A 6 years old boy was admitted to our Department due to repeatedly non bilious vomiting and food refusal during the last 72 hours before admission. Physical examination revealed the presence of a spherical, painful mass in the epigastrium, which did not recede a er placement of a nasogastric tube. Abdominal radiography showed the presence of a large gastric air bubble. Ultrasonography highlighted a distended and fluid-filled stomach, which was displaced in a cephalic position compared to esophagus and a pylorus pointing downward, in a cranial caudal orientation. Following barium meal examination confirmed the diagnosis of gastric volvulus. Patient underwent an urgent exploratory laparotomy, revealing the presence of acute mesenteroaxial gastric volvulus with a serosal ecchymosis in the major arc. After restoration of the gastric volvulus, thorough intraoperative investigation on the existence of a subject cause followed. Presence of relaxation of stomach's ligaments was finally documented. Fixation of the stomach' fundus to the diaphragm and anterior gastropexy were then conducted. Postoperative period was uneventful and the patient was discharged home on the 4th postoperative day. In conclusion, we believe that ultrasonography plays a significant role in the diagnostic approach of acute gastric volvulus, as it has the potential to detect findings suggestive of the diagnosis. Once the diagnosis is suspected on ultrasonography, contrast series should be performed, without further delay, in order to con rm the diagnosis.

Mesentero-axial gastric volvulus after removal of laparoscopic adjustable gastric band

Despite the decreasing popularity of gastric banding, a large number of patients still have a band in situ. Although immediate postoperative complications are relatively rare, long-term complications of gastric banding are more common but are not reported to occur after band removal. We report a case of gastric volvulus and subsequent ischaemic perforation in a patient shortly after band removal, resulting in emergency laparotomy and total gastrectomy. Severe continuing pain persisting after band deflation and even gastric band removal should be treated as an emergency and urgent investigation should not be delayed.

The management of gastric volvulus in elderly patients

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Endoscopy is necessary for management of gastric volvulus.

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Endoscopic reduction is effective as first aid for gastric volvulus.

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Endoscopic gastropexy is available for gastric volvulus in elderly patients.

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Laparoscopic gastropexy can be an alternative to hernia repair in poor condition.

Introduction

Gastric volvulus is torsion of the stomach and requires immediate treatment. The optimal treatment strategy for patients with gastric volvulus is not established, because of significant variations in the cause and clinical course of this condition.

Presentation of cases

We describe our experience with six elderly patients with gastric volvulus caused by different conditions using various approaches. This includes two patients managed with endoscopic reduction, followed by endoscopic or laparoscopic gastropexy.

Discussion

Endoscopy is a necessary first step to determine the optimal treatment strategy, and endoscopic reduction is often effective. The indications for surgical repair of gastric volvulus depend on the patient’s overall condition, and several options are available. In some elderly patients with severe comorbidities, major surgery may have an unacceptably high risk. We propose a novel treatment strategy for gastric volvulus in the elderly and a review of the literature.

Conclusion

Early endoscopy is necessary in patients with gastric volvulus. Endoscopic or laparoscopic gastropexy may be adequate therapy in selected elderly patients.

Gastric volvulus in children--a diagnostic problem: two case reports

Background

Gastric volvulus is a clinically significant cause of acute or recurrent abdominal pain and chronic vomiting in children. Since related clinical symptoms are nonspecific, clinicians often refer to radiologists for a diagnostic evaluation. Early diagnosis is crucial to prevent life-threatening complications of prolonged volvulus, such as intestinal ischemia, infarction, strangulation, necrosis, and perforation that may require immediate surgical treatment. In this report, we describe clinical and radiological criteria for diagnosis of gastric volvulus in children.

Case presentation

We describe two pediatric clinical cases. A 16-month-old female Caucasian child was admitted to our hospital for recurrent postprandial vomiting episodes, which started at 11 months old, associated with failure to thrive. A 9-month-old term-born baby boy was admitted for chronic, recurrent, postprandial vomiting, which started at 7 months of age, with progressive failure to thrive. A barium study allowed definitive diagnosis of chronic organoaxial gastric volvulus.

Conclusions

Gastric volvulus is an extremely rare disorder in the pediatric population. It can be considered a complex clinical condition with regard to the etiology and the management. A nonoperative approach is advisable in the absence of warning signs.

Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report

A 43-year-old female was referred to our hospital for sudden onset of abdominal pain, fullness, and vomiting. Physical examination revealed abdominal distension with mild epigastric tenderness. Abdominal radiography showed massive gastric distension and plain computed tomography (CT) a markedly enlarged stomach filled with gas and fluid. A large volume of gastric contents was suctioned out via a nasogastric (NG) tube. Contrast-enhanced CT showed a grossly distended stomach with displacement of the antrum above the gastroesophageal junction, and the spleen was dislocated inferiorly. Upper gastrointestinal (GI) series showed the greater curvature to be elevated and the gastric fundus to be lower than normal. Acute mesenteroaxial gastric volvulus was diagnosed. GI endoscopy showed a distortion of the gastric anatomy with difficulty intubating the pylorus. Various endoscopic maneuvers were required to reposition the stomach, and the symptoms showed immediate and complete solution. GI fluoroscopy was performed 3 days later. Initially, most of the contrast medium accumulated in the fundus, which was drawn prominently downward, and then began flowing into the duodenum with anteflexion. Elective laparoscopic surgery was performed 1 month later. The stomach was in its normal position, but the fundus was folded posteroinferiorly. The spleen attached to the fundus was normal in size but extremely mobile. We diagnosed a wandering spleen based on the operative findings. Gastropexy was performed for the treatment of gastric volvulus and wandering spleen. The patient remained asymptomatic, and there was no evidence of recurrence during a follow-up period of 24 months. This report describes a rare adult case of acute gastric volvulus associated with wandering spleen. Because delay in treatment can result in lethal complications, it is critical to provide a prompt and correct diagnosis and surgical intervention. We advocate laparoscopic surgery after endoscopic reduction because it is a safe and effective procedure with lower invasiveness.

Acute gastric volvulus in a patient with trisomy 21

Acute gastric volvulus is a torsion of the stomach by more than 180° and a life-threatening condition. We present a 50-year-old male patient with acute abdominal pain who has Down syndrome/trisomy 21. Computed tomography showed a significant distended stomach with features of a severe gastric volvulus. Emergency operation in form of reduction and gastropexy was performed. We are not aware of any similar cases published in the English literature, where as gastric volvulus occurred in a patient with Down syndrome.

Possibility of visualization of gastrothorax based on unenhanced postmortem computed tomography/PMCT

We present a fatal case of a gastrothorax due to an acute gastric volvulus resulting from a Bochdalek hernia. A 5-year-old boy without previous medical history was brought to our institution in a state of cardiopulmonary arrest and was subsequently pronounced dead. Postmortem computed tomography (PMCT) of the torso showed abdominal organs involving the lower section of the esophagus up to the entire stomach, the left side of the transverse colon, the entire spleen, and the tail of the pancreas herniated into the left thoracic cavity. The stomach was markedly expanded and a mesentero-axial (rotation along the short axis) volvulus was observed, displacing mediastinal structures to the right side and depressing the diaphragmatic contour. A PMCT of the thorax at the lung window setting revealed displacement of bilateral lungs. The bilateral lungs were severely atelectatic and congested. The PMCT findings mentioned above were consistent with the autopsy findings. PMCT can provide useful information for the diagnosis in cases we initially cannot predict any significant changes, for example, organ displacement.