Adult primary gastric volvulus, a report of two cases

Abstract

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.

Keywords: Gastric volvulus; gastropexy; laparoscopic surgery; percutaneous endoscopic gastrostomy (PEG).

Figure 1

Contrast-enhanced abdominal CT findings (A,B), radiogram (C) and a schematic diagram of stomach for 1st case. The schematic diagram is drawn based on the findings. (A) CT scan at the abdominal esophageal level. The stomach is markedly distended and filled with gas and fluid. The gastric antrum and the gastroesophageal junction intersect so as to overlap each other. (B) the coronal CT scan, which demonstrates that the spleen is close to the fundus of the stomach and its position is definitely shifted to inferior-right side. In the image of (C), GI endoscope is inserted to duodenal bulb. The tube of the endoscope is bended so as to make a spiral.

Figure 2

Laparoscopic gastropexy to avoid the reoccurrence of gastric volvulus for 1st case. The upper, middle, gastric bodies and the antrum were secured to the anterior abdominal wall with two interrupted absorbable sutures, respectively.

Figure 3

Contrast-enhanced abdominal CT findings (A,B,C) and schematic diagram of stomach for 2nd case. The schematic diagram is drawn based on the findings. (A) CT scan at the abdominal esophageal level. The stomach is grossly enlarged and filled with gas and fluid. The gastric antrum was displaced so as to overlap with gastroesophageal junction, the formation of gastric volvulus; (B) is also CT scan and the scan level is inferior to abdominal esophageal level, which demonstrates that position of the spleen and fundus are definitely shifted to inferior side; (C) is the coronal CT scan. This image demonstrates that abdominal esophagus is abnormally close to duodenum and position of the spleen and fundus are definitely shifted to inferior side.

Figure 4

Laparoscopic gastropexy for 2nd case. The upper and middle gastric bodies are secured to anterior abdominal wall and the gastric antrum is also secured to the ligamentum teres hepatis with absorbable sutures.

Figure 5

CT examination showed that partial gastric volvulus occurred due to the dislodgement of the suture at the antrum. CT scan levels are as follows. (A) Ventral level; (C) dorsal level; (B) intermediate level between (A) and (C). Schematic diagram shows the situation of the stomach derived from CT images.