Laparoscopic Repair of Gastric Volvulus

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ABSTRACT

Background and Objectives: Acute and chronic gastricvolvulus usually present with different symptoms andaffect patients primarily after the fourth decade of life.Volvulus can be diagnosed by an upper gastrointestinalcontrast study or by esophagogastroduodenoscopy.There are three types of gastric volvulus: 1) organoaxial(most common type); 2) mesenteroaxial; and 3) a com-bination of the two. If undetected or if a delay in diag-nosis and treatment occurs, serious complications candevelop.

Methods: We present four cases of surgical repair oforganoaxial volvulus consisting of laparoscopic reduc-tion of the volvulus with excision of the hernia sac andreapproximation of the diaphragmatic crura. A Nissenfundoplication, to prevent reflux, was performed, andthe stomach was pexed to the anterior abdominal wall bylaparoscopic placement of a gastrostomy tube, thus pre-venting recurrent volvulus.

Results: There were no operative complications, and allfour patients tolerated the procedure well. The patientswere discharged one to three days postoperatively andwere asymptomatic within two months.

Conclusion: With the advancement of laparoscopicNissen fundoplication and laparoscopic repair of parae-sophageal and hiatal hernias, minimally invasive surgicalrepair is possible. Based on our experience, we advo-cate the laparoscopic technique to repair gastric volvu-lus.

Key Words: Laparoscopy, Volvulus, Gastric volvulus.

INTRODUCTION

Gastric volvulus affects patients of all ages but most oftenoccurs after the fourth decade of life. If undetected, gas-tric volvulus can lead to ulceration, perforation, hemor-rhage or ischemia and full-thickness necrosis. Symptomsare variable and can range from anemia and weight lossto severe epigastric and/or chest pain sometimes associ-ated with unproductive vomiting or upper gastrointesti-nal bleeding. Suspicion is heightened by a large air fluidlevel in the lower chest seen on chest x-ray; diagnosis ismade with an upper gastrointestinal contrast study oresophagogastroduodenoscopy (EGD). With theadvancement of laparoscopic Nissen fundoplication andlaparoscopic repair of paraesophageal and hiatal hernias,minimally invasive surgical repair is possible. We de-scribe four cases of organoaxial volvulus that wererepaired laparoscopically.

CASE REPORTS

Case 1

A 40-year-old woman was hospitalized with recurrentsymptoms of left chest pain and emesis and was foundto be anemic. Cardiac work-up was negative. A chestradiograph showed a large paraesophageal hernia.Endoscopy revealed Cameron erosions as a probablesource of her anemia. Her symptoms were believed toresult from a chronic intermittent gastric volvulus, sincemore than half of her stomach was within the lefthemithorax. Intraoperative findings revealed a large left-sided paraesophageal hernia with the esophagogastricjunction at the diaphragmatic hiatus and an organoaxialvolvulus. The volvulus was reduced, the hernia sac wasexcised, and the crura were reapproximated. A floppyNissen fundoplication was performed along with laparo-scopic placement of a gastrostomy tube. There were nooperative or postoperative complications. The patientwas discharged on postoperative day 1, tolerating a fullliquid diet; and she was asymptomatic after six weeks, atwhich time the gastrostomy tube was removed, and shewas discharged from further folllow-up.

Case 2A 71-year-old man presented to us after a brief episode

Department of Surgery, Mount Carmel Health System, Columbus, Ohio.

Address reprint request to: Philip D. Price, MD, 750 Mount Carmel Mall, Suite 200,Columbus, Ohio 43222, USA. Telephone: (614) 228-0768, Fax: (614) 228-7381.

© 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published bythe Society of Laparoendoscopic Surgeons, Inc.

Luke T. Channer, MD, Gregory T. Squires, MD, Phillip D. Price, MD

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226 JSLS (2000)4:225-230

of acute left chest pain associated with dyspnea. The car-diac work-up was negative. A chest radiograph showeda large hiatal hernia, and an upper GI showed anintrathoracic stomach with an organoaxial volvulus. Thehernia and volvulus were reduced laparoscopically withcomplete excision of the hernia sac, and a standard flop-py Nissen fundoplication with concomitant gastrostomytube placement was performed. There were no operativeor postoperative complications, and the patient was dis-charged on postoperative day 2, tolerating a full liquiddiet. The gastrostomy tube was removed eight weeksafter surgery at which time he was asymptomatic and dis-charged from follow-up.

Case 3

An 84-year-old man with significant coronary artery dis-ease had been admitted several times for evaluation ofatypical left-sided chest pain. Upper GI and CT scan ofthe lower chest and abdomen showed a paraesophagealhernia. An esophageal manometry study was normal, butthe lower esophageal sphincter could not be evaluatedsecondary to an organoaxial volvulus. The volvulus wasreduced via a laparoscopic approach with complete exci-sion of the hernia sac, and a floppy Nissen fundoplicationwas performed. A redundant gastrosplenic ligament wasnoted at the time of surgery. There were no intraopera-tive complications. However, the postoperative coursewas complicated by new onset cardiac dysrhythmia,which was controlled by medication but prolonged hispostoperative stay. He was discharged on postoperativeday 7, tolerating a full liquid diet. The patient wasasymptomatic at his 8-week follow-up visit and was, thus,discharged from care.

Case 4

A 61-year-old man was transferred from an outlying hos-pital with an upper GI bleed. He also complained of left-sided chest pain; after a negative cardiac work-up, a chestradiograph showed a markedly elevated left hemidi-aphragm. The patient underwent an EGD evaluation thatrevealed an organoaxial volvulus. The volvulus wasreduced endoscopically, and further evaluation withendoscopy revealed ischemic ulceration of the stomach.A follow-up upper GI study showed that the stomach hadre-volvulized in the organoaxial position (Figure 1).Laparoscopic reduction and Nissen fundoplication withconcomitant laparoscopic gastrostomy tube placementwere performed. A postoperative upper GI confirmednormal gastric position (Figure 2). There were no oper-

ative or postoperative complications, and the patient wasdischarged on postoperative day 3, tolerating a full liquiddiet. The patient was asymptomatic at his eight-weekfollow-up examination, at which time the gastrostomytube was removed, and he was discharged from follow-up.

OPERATIVE TECHNIQUE

Using standard laparoscopic Nissen fundoplication portplacement, all four cases of organoaxial gastric volvuluswere reduced without difficulty. The etiologies of thesefour cases were 1) left diaphragmatic eventration, 2) mas-sive hiatal hernia, and 3) two paraesophageal hernias.The hernia sac was carefully dissected out of the medi-astinum and excised completely. The short gastric ves-sels and any adhesions were divided with a harmonic

Figure 1. Organoaxial volvulus as shown by upper GI contraststudy following reduction by endoscopy. Note position of thenasogastric tube as it courses through the esophagus and makesa 180° turn back into the thoracic cavity.

scalpel (Ethicon, Johnson & Johnson Corp., Somerville,NJ). The diaphragmatic crura were reapproximated pos-teriorly. The Nissen fundoplication was wrapped over acombination of a 40 french lighted bougie and an 18french nasogastric orogastric tube for a total of 58 french.The stomach was evaluated intraoperatively and, if itwould continue to volvulize, a gastrostomy tube wasplaced laparoscopically to fix the stomach to the anteri-or abdominal wall. Gastrostomy tube placement wasperformed in three of the four patients and was fastenedusing T-fasteners (Ross Products Division, AbbottLaboratories, Columbus, OH).

The average operative time was 171 minutes (2 hours, 51minutes), with a range of 138-210 minutes. The averageblood loss was 113 cc with a range of 0-200 cc. The

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patients were started on a clear, non-carbonated liquiddiet as soon as they were able to tolerate a diet, usually6-12 hours postoperatively. They were then quicklyadvanced to a full liquid diet and maintained on this for2-3 weeks after discharge, at the discretion of the attend-ing surgeon (P.D.P.). This was done to avoid the post-operative dysphagia seen frequently after fundoplicationand to eliminate the possibility of food bolus impactionduring the early postoperative period. We hoped thiswould help prevent retching and/or vomiting that couldpotentially disrupt the repair, which by its very nature isunder more tension than routine laparoscopic fundopli-cation. There were no intraoperative complications, andthree of the four patients were discharged within 1-3days postoperatively. As mentioned previously, onepatient had a cardiac dysrhythmia that precluded an earlydischarge.

DISCUSSION

Adults with acute gastric volvulus typically present withsevere epigastric pain and distention, unproductive vom-iting and difficulty with nasogastric tube insertion. Thistriad of symptoms is known as Borchardt’s triad.1 Carteret al2 added additional clinical features that include thefollowing: 1) minimal abdominal findings when volvu-lus is intrathoracic; 2) gas-filled viscus in the lower chestor upper abdomen as seen on chest radiograph (Figures3 and 4); and 3) obstruction seen on upper GI contraststudies at the site of the volvulus.

A chronic gastric volvulus can present with atypical chestpain, anemia (most likely due to Cameron erosions),weight loss, dyspnea and reflux. When the stomach is inthe normal anatomic position, it is anchored by the gas-trocolic, gastrosplenic, gastrohepatic and gastroduodenalligaments. The gastrosplenic and/or gastrocolic liga-ments can become stretched, attenuated, and redundantand, following certain operative procedures, transected.When this occurs, the stomach can then rotate more than180° and form a volvulus.3

A primary gastric volvulus occurs spontaneously as aresult of ligamentous lengthening. More commonly, sec-ondary volvulus occurs due to diaphragmatic defects orother intra-abdominal factors such as left diaphragmaticeventration, adhesions, gastric ulceration and gastric orduodenal carcinoma. The three types of gastric volvulusare organoaxial, mesenteroaxial and a combination ofthese two. The most common type, organoaxial volvu-

Figure 2. The stomach as shown with upper GI contrast studyafter laparoscopic reduction, Nissen fundoplication and gastros-tomy tube placement. The balloon of the G-tube can be visual-ized within the gastric lumen, and the fundal wrap can be seenin its superior position.

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lus, rotates along the cardiopyloric axis with two sites ofobstruction. When associated with a large diaphragmat-ic defect, the greater curvature rotates upward into thedefect, creating an “upside down” stomach (Figure 5).This type is most commonly associated with a large hiatalhernia and left diaphragmatic eventration. The mesen-teroaxial volvulus, accounting for approximately one-third of gastric volvuli, occurs when the stomach rotatesaround a transverse axis at the pyloroantral area result-ing in the pyloric/antral portions becoming anterior to

Figure 3. Chest radiograph showing air-filled viscus in anintrathoracic position behind the cardiac silhouette (blackarrows).

Figure 4. Lateral chest radiograph showing the same air-filledradiograph showing the same air-filled viscus in an intrathoracicposition behind the heart (white arrows).

Figure 5. The stomach as it appears after upper GI contraststudy showing an organoaxial volvulus (“upside-down stom-ach”). Note position of the nasogastric tube as it courses throughthe gastroesophageal junction below the diaphragm and turns180° back into the thoracic cavity.

the stomach. The combination volvulus is rarely encoun-tered.

The basic surgical dictum for the treatment of gastricvolvulus includes decompression of the stomach withreduction of the volvulus, gastropexy and correction ofthe intra-abdominal factors predisposing to volvulus.Sometimes decompression of the stomach with a naso-gastric tube will result in reduction of the volvulus, asreported by Llaneza and Salt.4 Reduction of the volvuluscan be performed by endoscopy or by gentle traction onthe stomach during surgery. Gastric resection would benecessary only if full-thickness necrosis were present.

Many variations of gastropexy, some with multiple pointsof fixation, have been reported in the literature. Simplegastric fixation to the anterior abdominal wall, gastrosto-my tube placement or suturing the lesser curvature to theligamentum teres or the free edge of the liver can accom-plish gastropexy. Other variations include posterior fix-ation of the greater curvature to the parietal peritoneumand colonic mesentery or fixation of the fundus to theundersurface of the diaphragm. Definitive proceduresinclude gastropexy with colonic displacement (Tanner’sprocedure),5 fundoantral gastrostomy (Oozler’s opera-tion), gastrojejunostomy and gastrocolic disconnection.

There has been debate in the literature concerning theindications of an additional anti-reflux procedure whenrepairing a diaphragmatic defect. Paraesophageal her-nias, which have a normally located esophagus and func-tioning esophagogastric junction, are often thought to bethe common diaphragmatic defect associated with gastricvolvulus. On the contrary, Pearson observed that only 1of 53 patients with massive incarcerated hiatal hernias atlaparotomy actually had a true paraesophageal hernia,and 43 of 53 had symptomatic reflux.6 Pearson believesan anti-reflux procedure should be performed routinelyin such cases. We agree with this, since Nissen fundo-plication usually stops recurrent volvulus secondary tothe wrap and pexy of the wrap and/or stomach.

Endoscopic treatment of chronic and acute gastric volvu-lus is well documented in the literature. Until Tsang andWalker described the alpha-loop maneuver, the J-typemaneuver was the most commonly described in theendoscopy literature.7 The newer maneuver involvesforming an alpha-loop in the proximal stomach, thenadvancing the tip of the endoscope into the antrum andduodenum. The endoscope is then torqued in a clock-

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wise manner to uncoil the alpha-loop and reduce thegastric volvulus. Tsang and Walker reduced seven of theeight cases of acute gastric volvulus using the alpha-loopmaneuver, followed by surgical repair 1 to 38 days later.7

Gastrostomy tube placement can be employed to pex thestomach and decrease the incidence of recurrent volvu-lus. Eckhauser and Ferron used dual percutaneousendoscopic gastrostomy (PEG) tubes placed anteriorly inthe antrum and anterolaterally in the body of the stom-ach for a patient with idiopathic mesenteroaxial gastricvolvulus.8 A solitary PEG tube could potentially create anew point of fixation for a recurrent volvulus. Bhasinendoscopically reduced the volvulus in 10 patients withchronic gastric volvulus without performing any PEGplacement.9 With follow-up from 5 to 26 months, threecases eventually recurred and required surgical treat-ment. This experience led Bhasin to recommend surgi-cal treatment for secondary volvulus, failed endoscopicreduction and recurrent volvulus.

Laparoscopic and endoscopic techniques have also beencombined. Koger and Stone10 reported laparoscopicreduction of an acute organoaxial gastric volvulus due toa paraesophageal hernia. This was followed by broadgastropexy using three pull-type PEG tubes along thegreater curvature of the fundus, body and antrum.10 ThePEG tubes were removed two months postoperatively,and a follow-up upper GI showed adequate fixation ofthe stomach. Other variations of laparoscopic gas-tropexy have been performed using T-fasteners (RossProducts Division, Abbott Laboratories, Columbus,Ohio),11 as well as intracorporeal suturing.12 The naturalprogression in the treatment of gastric volvulus has ledto a total laparoscopic approach without compromisingthe basic tenets of the standard laparotomy repair.

CONCLUSION

Experience from our four cases of gastric volvulus hasshown that a laparoscopic approach with excision of thehernia sac, reapproximation of the diaphragmatic crura,an anti-reflux procedure and laparoscopic gastrostomytube placement, when indicated, has been tolerated byall of our patients. The laparoscopic gastrostomy tubesecures the stomach intra-abdominally and helps preventmigration of the stomach to an intrathoracic position.Complete excision of the hernia sac can help eliminateone cause for recurrence, as described by Williamsonand Ellis.13 As the advancement of laparoscopic tech-

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niques continues, there will be less need for a combinedendoscopic reduction and laparoscopic gastropexy,which remains a viable option in the high-risk patient.This combined approach ignores one of the basic tenetsin the treatment of gastric volvulus by failing to repair thediaphragmatic defect, leaving the potential for recurrenthernia as well as recurrent volvulus. Certainly, endo-scopic maneuvers to reduce an acute volvulus, such asthe alpha-loop or J-type techniques, are vital in the treat-ment of these patients. We strongly recommend repair ofthe diaphragmatic defect along with an anti-reflux proce-dure. Care should be taken to evaluate the stomach inits intra-abdominal position. If it is likely that recurrentvolvulus will occur, the stomach should be pexed to theanterior abdominal wall with a gastrostomy tube. Sincethere is a low morbidity associated with a minimally inva-sive surgical approach to gastric volvulus, we advocatelaparoscopic reduction and repair of this rare clinical con-dition.

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3. Dalgaard JB. Volvulus of the stomach. Acta Clin Scand.1952;103:131.

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7. Tsang TK, Walker R. Endoscopic reduction of gastric volvu-lus: the alpha-loop maneuver. Gastro Endosc. 1985;42(3):244-248.

8. Eckhauser ML, Ferron JP. The use of dual percutaneousendoscopic gastrostomy (DPEG) in the management of chronic intermittent gastric volvulus. Gastrointest Endosc.1985;31(5):340-342.

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12. Umehara Y, Kimura T, Okubo T, et al. Laparoscopic gas-tropexy in a patient with chronic gastric volvulus. Surg LaparoscEndosc. 1992;2:261-264.

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Acknowledgments: The authors wish to thank Janet L. Tremaine,ELS, for editorial assistance and Christine Merrill for preparationof the photographs.