1. Dr. Sudarshan Under Guidance of Dr. B. L. Yadav Assistant Professor, Upgraded Department of Surgery

2. History Name: Bhori singh Age & sex: 45 yrs ,male Resident :Baroli ,BharatpurDOA:05/01/2013Clinical presentation Pain abdomen: last 3 days Abdominal distention: last 3 days Not passing flatus motion: last 2 days No h/o fever No h/o vomiting 3. Cont.. Past history: No h/o similar complaint No h/o previous surgery No h/o DM, TB, COPD, Hypertension , Bronchial Asthma Personal history Smoker Tobacco chewer Non alcoholic Normal bowel bladder habits 4. Examination Conscious Oriented Afebrile Pulse-92/min B.P-100/70 mmHg No pallor No L.N Pathy No icterus No clubbing No pedal oedema 5. P/A Inspection: Abdomen distended with fullness present in upper abdomen No visible pulsation , peristalsis Palpation: Abdomen is tense, tender Guarding present No Rigidity Percussion: Tympanic note present Normal liver dullness and span No shifting dullness Auscultation: Bowel sounds absent 6. Investigations HB- 11.6 gm/dl TLC- 1400 /mm3 PLT- 1.35 lakh/ml Serum urea/creatinine- 87/2.0 mg/dl S.Total bilirubin-1.2 mg/dl Direct- 0.5 mg/dl Indirect- 0.7 mg/dl SGOT/SGPT- 70/18 Serum amylase-175.0 u/lt Serum electrolytes- wnl X-Ray FPA- Multiple air fluid level with large single stomach gas shadow 7. Provisional diagnosis: Acute intestinal obstruction Perforation peritonitisPlan: Exploratory Laparotomy 8. Procedure performed Exploratory laparotomy with Gastropexy 9. Per operative photos cranialR Lcaudal 10. Cont CRANIALRL 11. Cont.. cranialRL 12. Cont..CranialCaudal 13. Contd..Stomach Fixed to Diaphragm & AnteroLateral Abdominal Wall With Silk 14. Post operative follow up Vitals monitoring Input /output monitoring Chest physiotherapy Skin stitches removal-7th post op. day Discharge-8th post op. day 15. Discussion DefinitionGastric volvulus or volvulus of stomach a twisting of all or part of the Stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possibletissue death. 16. Cont.. Very uncommon clinical entity First described by Berti in 1866 Seen in both children and elderly people Rare below fifth decades of life 17. Classification of gastric volvulus On the basis of: 1)OnsetAcute Chronic 2)Axis of rotation Organoaxial Mesentroaxial Combined 18. Gastric volvulus 1. Organoaxial(along longitudinal axis-MC) a)Acute presentation b)associated with diaphragmatic defects c)more common in adults d)vascular compromise more common 2. Mesentroaxial (along vertical axis) a) recurrent episodes of pain abdomen b) Diaphragmatic defects are not seen c) more common in children 3. Combined 19. Diagrammatic representationOrganoaxialMesentroaxial 20. Aetiology Type 1 or Idiopathic gastric volvuluscomprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic*, gastrocolic*, gastrophrenic and gastrohepatic* ligaments. 21. Cont.. Type 2 or secondaryType 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 Diaphragmatic defect Eventration Paraoesophagial hiatal defect Trauma Paralysis Congenital bands and adhesions Intestinal malrotation Pyloric stenosis and gastric distension Colon distention 22. AETIOLOGY 23. Clinical features Pain abdomen (acute in onset) Recurrent retching with little vomitus Inability to pass a Ryles tubeOTHERS Abdominal pain Vomiting Upper GI bleed Dysphagia Gastro oesophageal reflux Respiratory symptoms Altered bowel habitBorchardts Triad 24. Investigations X Ray FPA- Gas filled viscus in chest and or upper abdomen, multiple air fluid levels, Barium contrast studies :sensitive and specific Upper GI Endoscopy: both diagnostic and therapeutic USG CT scan abdomen and MRI 25. X-ray findings in gastric volvulus 26. Contd 27. Barium meal: Organoaxial volvulusBefore surgeryAfter surgery 28. Mesentricoaxial Gastric volvulus 29. Endoscopy view: 30. USG: Peanut sign in a case of chronic gastric volvulus. The ultrasonographic features consist of a constrictedsegment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut. In several case reports, however, the ultrasonographic evaluation of gastric volvulus showed normal findings. 31. CT image: 32. Advantage of CT Scan detection of gastric pneumatosis andpneumoperitoneum, suggestive of necrosis and perforation, respectively detection of predisposing factors, e.g. diaphragmatic defects or hernias, dense adhesions detection of other abnormalities associated with gastric volvulus, viz. wandering spleen, intrathoracic kidney, malrotation with asplenia excluding other extra-gastric or vascular causes of gastric ischaemia 33. Limitation of Techniques Plain radiography may demonstrate findings that areindistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax. Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion. 34. Treatment Aims:1) Reduction of volvulus 2) Gastric fixation 3) Repair of predisposing factor Apporach:Open Endoscopic Laproscopic Combined (endoscopic + laproscopic) 35. Cont.. Open surgery: Diaphragmatic hernia repair Division of bands Gastropexy Partial gastrectomy(In case of necrosis) Gastrojejunostomy Repair of eventration of diaphragm 36. Surgical procedures Anterior suture gastropexyThe stomach along the gastro colic omentum is suspended to the anterior abdominal wall Partial gastrectomy Indicated if a portion of the stomach is gangrenous 37. Cont.. Endoscopic : Reduction Alpha loop maneuver J type maneuver With or without gastrostomy(for fixation of stomach) (PEG) 38. PEG Tube 39. Cont.. Laproscopic Reduction of volvulus Anchoring fundus of stomach to diaphragm andgreater curvature of stomach to anterior abdominal wall Repair of diaphragmatic defects fundoplication 40. Cont.. Combined approach Described by Arben Beqiri in 1997 Less time consuming Endoscopic T-fasteners are used instead of PEG foranchoring stomach 41. T-fastener system 42. Method for providing apposition of two bodily walls a) forming a puncture site through the two walls; b) inserting an access cannula into the puncture site; c) passing a guide tube through the access cannula, the guide tube retroflexing after passing beyond a distal end of the access cannula; d) positioning a distal end of the guide tube proximate one of the bodily walls; e) passing a flexible puncturing device through the guide tube and puncturing the two bodily walls at a second location; f) connecting a fastener to the puncturing device; g) retracting the puncturing device to draw the fastener through the two bodily walls at the second location; and h) securing the fastener to maintain apposition of the two walls at the second location. 43. Follow up Clinical: Reflux symptoms Recurrence Removal of PEG Tube Imaging: Contrast study 44. Complications of volvulus Strangulation Necrosis Perforation of stomach Gastrointestinal haemorrhage Cardiopulmonary failure 45. Complications related to PEG Tube Wound infection Peritonitis Peristomal leakage Dislodgement Bowel perforation Gastrocolic fistula 46. Association Wandering spleen Congenital diaphragmatic hernia Diaphragmatic eventration 47. Chronic gastric volvulus Patient presents with recurrent episodes of vagueabdominal pain and discomfort Bloating Surgery is only indicated if the episodes of pain are severe and disabling T/t of choice- conservative Operation of choice-anterior gastropexy