http://emedicine.medscape.com/article/2054271-overview
http://emedicine.medscape.com/article/2054271-overview
Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of more than 180°, creating a closed-loop obstruction that can result in incarceration and strangulation. Berti first described gastric volvulus in a female autopsy patient in 1866.[1] Years later, in 1896, Berg performed the first successful operation for this condition.[2] In 1904, Borchardt described the classic triad associated with gastric volvulus: severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube.[3]
Because many cases of chronic volvulus are not diagnosed, the incidence and prevalence of gastric volvulus is unknown. Males and females are equally affected. About 10-20% of cases occur in children,[4] usually before age 1 year, but cases have been reported in children up to age 15 years.[5] Gastric volvulus in children is often secondary to congenital diaphragmatic defects. The condition is uncommon in adults younger than 50 years.[4]
Classification
The most frequently used classification system of gastric volvulus, proposed by Singleton,[6] relates to the axis around which the stomach rotates, including organoaxial, mesentericoaxial, and combined.
This is the most common type of gastric volvulus, occurring in approximately 59% of cases,[7] and it is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with organoaxial gastric volvulus and have been reported in 5-28% of cases.[8]
Patients with mesentericoaxial gastric volvulus usually present without diaphragmatic defects and usually have chronic symptoms.
Organoaxial type
In an organoaxial gastric volvulus, the stomach rotates around an axis that connects the gastroesophageal junction and the pylorus. The antrum rotates in opposite direction to the fundus of the stomach.This is the most common type of gastric volvulus, occurring in approximately 59% of cases,[7] and it is usually associated with diaphragmatic defects. Strangulation and necrosis commonly occur with organoaxial gastric volvulus and have been reported in 5-28% of cases.[8]
Mesentericoaxial type
The mesentericoaxial axis bisects the lesser and greater curvatures. The antrum rotates anteriorly and superiorly so that the posterior surface of the stomach lies anteriorly. The rotation is usually incomplete and occurs intermittently. Vascular compromise is uncommon. This etiology comprises approximately 29% of cases of gastric volvulus.[7]Patients with mesentericoaxial gastric volvulus usually present without diaphragmatic defects and usually have chronic symptoms.
Combined type
The combined type of gastric volvulus is a rare form in which the stomach twists mesentericoaxially and organoaxially. This type of gastric volvulus makes up the remainder of cases and is usually observed in patients with chronic volvulus.[9]Etiology
According to etiology, gastric volvulus can be classified as either type 1 (idiopathic) or type 2 (congenital or acquired).
Type 1 gastric volvulus is more common in adults but has been reported in children.
Table 1. Anatomic Defects Associated With Gastric Volvulus (Open Table in a new window)
Causes of type 2 gastric volvulus
The most common causes of gastric volvulus in adults are diaphragmatic defects. In cases of paraesophageal hernias, the gastroesophageal junction remains in the abdomen, whereas the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias. It has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, gastric volvulus may be a complication of liver transplantation and may be related to ligation of the hepatogastric ligament during the hepatectomy.[11]
Gastric volvulus after laparoscopic left adrenalectomy[12] or laparoscopic adjustable gastric band placement,[13] or related to eventration of the diaphragm[14] or to a large-cell neuroendocrine carcinoma in the stomach[15] have been reported. Table 2, below, summarizes the causes of secondary gastric volvulus in adults.
Type 1
Idiopathic gastric volvulus comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic, gastroduodenal, gastrophrenic, and gastrohepatic ligaments. This allows approximation of the cardia and pylorus when the stomach is full, predisposing to volvulus.Type 1 gastric volvulus is more common in adults but has been reported in children.
Type 2
Type 2 gastric volvulus is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach. Miller and colleagues reviewed the anatomic defects associated with type 2 gastric volvulus in the pediatric population,[10] as presented in Table 1, below.Table 1. Anatomic Defects Associated With Gastric Volvulus (Open Table in a new window)
| Congenital defects | Diaphragmatic defects: 43% |
| Gastric ligaments: 32% | |
| Abnormal attachments, adhesions, or bands: 9% | |
| Asplenism: 5% | |
| Small and large bowel malformations: 4% | |
| Pyloric stenosis: 2% | |
| Colonic distention: 1% | |
| Rectal atresia: 1% | |
| Complicating gastroesophageal surgery | — |
| Neuromuscular disorders | Poliomyelitis |
| Source: Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9.[10] | |
The most common causes of gastric volvulus in adults are diaphragmatic defects. In cases of paraesophageal hernias, the gastroesophageal junction remains in the abdomen, whereas the stomach ascends adjacent to the esophagus, resulting in an upside-down stomach. Gastric volvulus is the most common complication of paraesophageal hernias. It has also been reported to complicate gastroesophageal surgery, neuromuscular disorders, and intra-abdominal tumors. Rarely, gastric volvulus may be a complication of liver transplantation and may be related to ligation of the hepatogastric ligament during the hepatectomy.[11]
Gastric volvulus after laparoscopic left adrenalectomy[12] or laparoscopic adjustable gastric band placement,[13] or related to eventration of the diaphragm[14] or to a large-cell neuroendocrine carcinoma in the stomach[15] have been reported. Table 2, below, summarizes the causes of secondary gastric volvulus in adults.
Prognosis
The nonoperative mortality rate for gastric volvulus is reportedly as high as 80%.[16] Historically,
mortality rates of 30-50% have been reported for acute gastric
volvulus, with the major cause of death being strangulation, which can
lead to necrosis and perforation.[8, 9, 17] With
advances in diagnosis and management, the mortality rate from acute
gastric volvulus is 15-20% and that for chronic gastric volvulus is
0-13%.[16, 18]
History
Gastric
volvulus can manifest as an acute abdominal emergency or as a chronic
intermittent problem. The presenting symptoms depend on the degree of
twisting and the rapidity of onset.
Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus.[19]
Intra-abdominal gastric volvulus most commonly manifests as the sudden onset of severe epigastric or left upper quadrant pain. Intrathoracic gastric volvulus manifests as sharp chest pain radiating to the left side of the neck, shoulder, arms, and back.
This condition is often associated with cardiopulmonary compromise from gastric distention and may mimic an acute myocardial infarction.
Progressive distention and nonproductive retching follow the pain. Patients may have upper abdominal distention and tenderness if the stomach remains intra-abdominal; however, if becomes intrathoracic, there may be minimal abdominal findings.
Occasionally, some patients present with hematemesis secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.
Because of the nonspecific nature of the symptoms, however, patients are often investigated for other common disease entities such as cholelithiasis and peptic ulcer disease.
Upper GI series can be diagnostic during an acute attack.
Acute gastric volvulus
The Borchardt triad of pain, retching, and inability to pass a nasogastric tube is diagnostic of acute volvulus and reportedly occurs in 70% of cases.[10] Carter et al described 3 additional findings that are suggestive of gastric volvulus, including minimal abdominal findings when the stomach is in the thorax, gas-filled viscus in the lower chest or upper abdomen on chest radiograph, and obstruction at the site of the volvulus on upper gastrointestinal (GI) radiographic series.[8]Hiccups have been reported to be a subtle sign in the clinical diagnosis of gastric volvulus.[19]
Intra-abdominal gastric volvulus most commonly manifests as the sudden onset of severe epigastric or left upper quadrant pain. Intrathoracic gastric volvulus manifests as sharp chest pain radiating to the left side of the neck, shoulder, arms, and back.
This condition is often associated with cardiopulmonary compromise from gastric distention and may mimic an acute myocardial infarction.
Progressive distention and nonproductive retching follow the pain. Patients may have upper abdominal distention and tenderness if the stomach remains intra-abdominal; however, if becomes intrathoracic, there may be minimal abdominal findings.
Occasionally, some patients present with hematemesis secondary to mucosal ischemia and sloughing. This can rapidly progress to hypovolemic shock from loss of blood and fluids.
Chronic gastric volvulus
Patients typically with chronic gastric volvulus present with intermittent epigastric pain and abdominal fullness following meals. Patients may report early satiety, dyspnea, and chest discomfort. Dysphagia may occur if the gastroesophageal junction is distorted.Because of the nonspecific nature of the symptoms, however, patients are often investigated for other common disease entities such as cholelithiasis and peptic ulcer disease.
Upper GI series can be diagnostic during an acute attack.
Physical Examination
Physical
examination findings in patients with gastric volvulus can be
nonspecific and relate the chronicity of the volvulus. Epigastric
tenderness and distention can suggest gastric volvulus, and, in cases of
stomach necrosis or severe obstruction, peritonitis can be present.
Approach Considerations
Biochemical
tests are usually not diagnostic for gastric volvulus; however,
hyperamylasemia and elevated serum alkaline phosphatase have been
reported.[20] There has also been a report of hyperamylasemia in gastric volvulus leading to a missed diagnosis of pancreatitis.[21]
Imaging studies such as radiography (plain film and barium contrast) and computed tomography scanning confirm the diagnosis. Findings on endoscopy may be suggestive of gastric volvulus.
Imaging studies such as radiography (plain film and barium contrast) and computed tomography scanning confirm the diagnosis. Findings on endoscopy may be suggestive of gastric volvulus.
Chest and Abdominal Radiography
On
chest radiography, a retrocardiac, gas-filled viscus may be seen in
cases of intrathoracic stomach, which confirms the diagnosis.
Plain abdominal radiography reveals a massively distended viscus in the upper abdomen. In organoaxial volvulus, plain films may show a horizontally oriented stomach with a single air-fluid level[22] and a paucity of distal gas.[23] In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and 2 air-fluid levels on erect images, with the antrum positioned superior to the fundus.[9]
Upper gastrointestinal (GI) contrast radiographic studies (using barium or Gastrografin) are sensitive and specific if performed with the stomach in the "twisted" state[27] and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81-84% of patients.[17, 25, 28, 29]
Plain abdominal radiography reveals a massively distended viscus in the upper abdomen. In organoaxial volvulus, plain films may show a horizontally oriented stomach with a single air-fluid level[22] and a paucity of distal gas.[23] In mesenteroaxial volvulus, plain abdominal radiographic findings include a spherical stomach on supine images and 2 air-fluid levels on erect images, with the antrum positioned superior to the fundus.[9]
Upper GI contrast studies
The diagnosis of gastric volvulus is usually based on barium studies[24, 25] ; however, some authors recommend computed tomography (CT) scanning as the imaging modality of choice.[26, 27]Upper gastrointestinal (GI) contrast radiographic studies (using barium or Gastrografin) are sensitive and specific if performed with the stomach in the "twisted" state[27] and may show an upside-down stomach. Contrast studies have been reported to have a diagnostic yield in 81-84% of patients.[17, 25, 28, 29]
CT Scanning
Often
performed for an evaluation of acute abdominal pain, a computed
tomography (CT) scan can offer immediate diagnosis by showing 2 bubbles
with a transition line. Proponents of CT scanning in the diagnosis of
gastric volvulus report several benefits, including: (1) the ability to
rapidly diagnose the condition based on a few coronal reconstructed
images, (2) the ability to detect the presence or abscess of gastric
pneumatosis and free air, (3) the detection of predisposing factors (ie,
diaphragmatic or hiatal hernias), and (4) the exclusion of other
abdominal pathology.[27, 30]
Endoscopy
Upper
gastrointestinal (GI) endoscopy may be helpful in the diagnosis of
gastric volvulus. When this procedure reveals distortion of the gastric
anatomy with difficulty intubating the stomach or pylorus, it can be
highly suggestive of gastric volvulus.[27] In
the late stage of gastric volvulus, strangulation of the blood supply
can result in progressive ischemic ulceration or mucosal fissuring.[31]
Approach Considerations
In
general, the treatment of an acute gastric volvulus remains emergent
surgical repair. In patients who are not surgical candidates (secondary
to comorbidities or an inability to tolerate anesthesia), endoscopic
reduction may be attempted.
Chronic gastric volvulus may be treated nonemergently, and surgical treatment is increasingly being performed using a laparoscopic approach.
A review of patients managed conservatively with chronic gastric volvulus were reported to have a high recurrence rate but very few serious complications.[32]
Some authors have advocated consideration of emergent endoscopic reduction in the setting of acute gastric volvulus in patients who are high risk for surgery.[33] This strategy may allow the patient to be adequately resuscitated and medically optimized prior to definitive surgical repair.
Chronic gastric volvulus may be treated nonemergently, and surgical treatment is increasingly being performed using a laparoscopic approach.
A review of patients managed conservatively with chronic gastric volvulus were reported to have a high recurrence rate but very few serious complications.[32]
Surgical contraindications
Contraindications for surgical treatment involve conditions or comorbidities in which the patient cannot tolerate general anesthesia. The surgeon should also use clinical judgment and make sure the patient is optimized and resuscitated before the operation.Some authors have advocated consideration of emergent endoscopic reduction in the setting of acute gastric volvulus in patients who are high risk for surgery.[33] This strategy may allow the patient to be adequately resuscitated and medically optimized prior to definitive surgical repair.
Preoperative Management
Once
the diagnosis of gastric volvulus is confirmed, the patient is
resuscitated, medically optimized, and prepared for the operating room.
Analgesics and antiemetics should be initiated. In adults, early gastric
decompression with nasogastric tube placement is advocated, but this
may be difficult if the gastroesophageal junction is obstructed.[23]
Care should be taken when placing the nasogastric tube, as aggressive placement may cause perforation; this is especially true in the pediatric population and is therefore generally not advocated.[10]
Care should be taken when placing the nasogastric tube, as aggressive placement may cause perforation; this is especially true in the pediatric population and is therefore generally not advocated.[10]
Conservative Management
Although
the treatment of gastric volvulus is surgical, advances in laparoscopic
surgery have also occurred in conjunction with advances in therapeutic
endoscopy, with several reports of endoscopic treatment of acute gastric
volvulus.[33, 29, 34, 35, 36, 37, 38, 39] However, the majority of cases describing endoscopic management pertain to chronic gastric volvulus.[29, 37, 38, 39]
Endoscopic reduction can be attempted in patients with multiple comorbid conditions who are poor candidates for surgery. One potential benefit of endoscopic reduction is that it may act as a temporizing measure in chronic and acute gastric volvulus, allowing the surgery to be performed on an elective basis and to allow medical optimization before surgery.[33, 29, 34] Failure to reduce the twist or evidence of strangulation necessitates surgery.
Following endoscopic reduction, the use of single or double percutaneous endoscopic gastrostomy tube placement in an attempt to decrease the incidence of recurrence has been reported.[37, 39]
Increasingly, there have been reports of combined laparoscopic and endoscopic procedures in the treatment of gastric volvulus.[40, 41, 42]
In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus. Secondary to the high mortality associated with emergent operative repair of acute gastric volvulus and the typical poor clinical picture associated with patients, future considerations for treatment include emergent endoscopic reduction of the volvulus, allowing resuscitation and medical optimization prior to definitive operative repair.[33, 29]
With advances in laparoscopic surgery, most cases of acute and chronic gastric volvulus can now be approached laparoscopically. In the absence of peritonitis or an unstable patient, most cases can be adequately treated in this way. There have been no randomized trials comparing open and laparoscopic surgery in the setting of gastric volvulus, but there have been several reports showing comparable or improved outcomes for acute and chronic gastric volvulus, compared with the traditional outcomes obtained with open surgery.[17, 16, 40]
Endoscopic reduction
Endoscopic treatment can be accomplished by advancing the scope beyond the point of torsion and then rotating it to untwist the stomach. However, because of the chance of gastric perforation, endoscopic reduction should not be attempted in patients who appear clinically ill or are found to have vascular compromise during endoscopy.Endoscopic reduction can be attempted in patients with multiple comorbid conditions who are poor candidates for surgery. One potential benefit of endoscopic reduction is that it may act as a temporizing measure in chronic and acute gastric volvulus, allowing the surgery to be performed on an elective basis and to allow medical optimization before surgery.[33, 29, 34] Failure to reduce the twist or evidence of strangulation necessitates surgery.
Following endoscopic reduction, the use of single or double percutaneous endoscopic gastrostomy tube placement in an attempt to decrease the incidence of recurrence has been reported.[37, 39]
Increasingly, there have been reports of combined laparoscopic and endoscopic procedures in the treatment of gastric volvulus.[40, 41, 42]
In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus. Secondary to the high mortality associated with emergent operative repair of acute gastric volvulus and the typical poor clinical picture associated with patients, future considerations for treatment include emergent endoscopic reduction of the volvulus, allowing resuscitation and medical optimization prior to definitive operative repair.[33, 29]
Laparoscopic approach
There have been increased reports of the use of minimally invasive techniques, such as laparoscopy, for the treatment of gastric volvulus. These have the potential to decrease the morbidity associated with the open procedures.[17, 16, 40, 43]With advances in laparoscopic surgery, most cases of acute and chronic gastric volvulus can now be approached laparoscopically. In the absence of peritonitis or an unstable patient, most cases can be adequately treated in this way. There have been no randomized trials comparing open and laparoscopic surgery in the setting of gastric volvulus, but there have been several reports showing comparable or improved outcomes for acute and chronic gastric volvulus, compared with the traditional outcomes obtained with open surgery.[17, 16, 40]
Surgical Intervention
Emergent
surgical intervention is indicated for acute gastric volvulus and is
still considered a surgical emergency by many surgeons. With chronic
gastric volvulus, surgery is performed to prevent complications.
The principles associated with the treatment of gastric volvulus include decompression, reduction, and prevention of recurrence, which is best accomplished with surgical therapy.
Tanner described the surgical options for repair, including diaphragmatic hernia repair, simple gastropexy, gastropexy with division of the gastrocolic omentum, partial gastrectomy, fundoantral gastrogastrostomy, and repair of eventration of the diaphragm.[44]
Surgical strategy includes the following:
The principles associated with the treatment of gastric volvulus include decompression, reduction, and prevention of recurrence, which is best accomplished with surgical therapy.
Tanner described the surgical options for repair, including diaphragmatic hernia repair, simple gastropexy, gastropexy with division of the gastrocolic omentum, partial gastrectomy, fundoantral gastrogastrostomy, and repair of eventration of the diaphragm.[44]
Intraoperative details
Patients with signs of acute peritonitis are better explored through a midline incision. In all other cases, initial laparoscopic exploration should be attempted.Surgical strategy includes the following:
- Reduction of the volvulus
- Assessment of gastric viability, with resection of the gangrenous portions by segmental, subtotal, or total gastrectomy
- Prevention of recurrence by anterior gastropexy, which is most often accomplished with a gastrostomy tube or suture gastropexy
- A fundoplication can be added to the procedure if there is an indication of preoperative reflux. Fundoplication in the attempt to decrease the rate of reherniation has also been reported.[40]
- The surgeon's experience and comfort level with open and closed techniques should be used to determine the means of safe abdominal access
- Trocars must be placed high on the abdominal wall to allow instruments to reach into the chest; in general, the trocar strategy will be similar to that used for other foregut operations, such as in laparoscopic antireflux surgery
- Keep the pneumoperitoneum pressure lower than normal (10-12 mmHg) to facilitate easy reduction of hernia contents[16]
- The stomach is visualized, and its viability is confirmed; when manipulating the stomach, avoid excess traction, as this may lead to perforation
- Dissect and excise the sac, and carefully separate it from the pleura to avoid pneumothorax[16]
- Use caution when dissecting the right crus, as the left gastric vessel may herniate with the stomach across the edge of the crus[16]
- The stomach is grasped with a nontraumatic grasper and is then reduced and reoriented; repair of the hiatal hernia is then performed, with fixation of the stomach below the diaphragm
- Gastropexy with a gastrostomy tube is typically done to provide postoperative decompression, allow access for enteral feeding, and prevent recurrence[16, 40]
Postoperative details
Gastric decompression is maintained until the return of bowel function. Pulmonary toilet and early ambulation are important postoperative measures.Complications
Strangulation
and necrosis are the most feared complications of gastric volvulus;
they can be a life threatening and occur most commonly with organoaxial
gastric volvulus (5-28% of cases).[8, 9] Gastric
perforation occurs secondary to ischemia and necrosis and can result in
sepsis and cardiovascular collapse. Perforation can also complicate
endoscopic reduction.
Operative complications are similar to those seen in other conditions requiring major abdominal surgery; they range according to the series and type of surgery. Carlson et al performed a transabdominal open repair of intrathoracic chronic gastric volvulus in 44 patients, reporting a complication rate of 38%, including splenic injuries and wound complications, such as infection and dehiscence.[45] In a study of 138 patients with hiatal hernia, of which 21 had gastric volvulus, 10 of the 21 patients with gastric volvulus required emergent surgery.[46] The authors reported a 40% mortality rate and a 40% major morbidity rate.[46]
Teague et al reported no major complications and no mortality in 36 patients, 29 of whom presented acutely with hiatal hernia and 13 of whom underwent laparoscopic repair.[17] Palanivelu et al reported that 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus had no perioperative complications or mortality.[16]
Operative complications are similar to those seen in other conditions requiring major abdominal surgery; they range according to the series and type of surgery. Carlson et al performed a transabdominal open repair of intrathoracic chronic gastric volvulus in 44 patients, reporting a complication rate of 38%, including splenic injuries and wound complications, such as infection and dehiscence.[45] In a study of 138 patients with hiatal hernia, of which 21 had gastric volvulus, 10 of the 21 patients with gastric volvulus required emergent surgery.[46] The authors reported a 40% mortality rate and a 40% major morbidity rate.[46]
Teague et al reported no major complications and no mortality in 36 patients, 29 of whom presented acutely with hiatal hernia and 13 of whom underwent laparoscopic repair.[17] Palanivelu et al reported that 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus had no perioperative complications or mortality.[16]
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