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International Journal of Surgery Case Reports 114 (2024) 109095

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International Journal of Surgery Case Reports


journal homepage: www.elsevier.com/locate/ijscr

Case report

Chronic gastric volvulus with diaphragmatic eventration: Case presentation


Maria Adriano Costa *, Sofia Dias da Silva, Ana C. Moreira, Teresa Santos, Joana Noronha,
Rui Moreira
General Surgery Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Gastric volvulus is a rare clinical entity which occurs due to the rotation of the
Stomach volvulus stomach and can have life-threatening complications. This condition can have an acute or chronic presentation
Gastropexy and its symptoms will vary according to the degree of obstruction and rapidity of onset.
Laparoscopy
Case presentation: We report a case of a 84-year-old male with history of frequent periods of constipation and lack
Diaphragmatic eventration
Case report
of appetite who presented to the emergency room with left-sided abdominal pain and distension and persistent
nausea, without the ability to vomit. Abdominal radiograph, computed tomography scan of the abdomen,
contrast-enhanced examination and upper endoscopy were consistent with a gastric volvulus secondary to dia­
phragmatic eventration. The patient's symptoms resolved after nasogastric tube placement and fluid resuscita­
tion. However, he was proposed to a laparoscopic anterior gastropexy to prevent symptom recurrence. He
remains asymptomatic after 3 years of follow-up.
Clinical discussion: The diagnosis of gastric volvulus is based mainly on clinical presentation and abdominal
imaging. The main principles of surgical intervention include stomach decompression with volvulus reduction,
followed by gastropexy and correction of any predisposing intra-abdominal factors.
Conclusion: Definitive treatment of both acute and chronic gastric volvulus includes a surgical approach. Lapa­
roscopic anterior gastropexy has been found to be a viable alternative in these patients.

1. Introduction Gastric volvulus surgical treatment is traditionally based on an open


approach [4,5]. However, the recent use of laparoscopic techniques has
Gastric volvulus is a rare clinical entity, which occurs due to the shown to be a safe and feasible approach to treat this condition [2].
rotation of the stomach and can have life-threatening complications [1]. Here, we report a case of an 84-year-old male with chronic gastric
Indeed, a rotation of the stomach of >180◦ causes complete gastric volvulus and diaphragmatic eventration who was successfully treated by
outlet obstruction, which can result in strangulation, ischemia, perfo­ a multidisciplinary team with laparoscopic anterior gastropexy in a
ration or even abdominal sepsis if not promptly recognized [1,2]. public hospital. This case portrays that laparoscopic surgery is a safe and
This condition can have an acute or chronic presentation and its effective approach in patients with gastric volvulus and describes the
symptoms will vary according to the degree of obstruction and rapidity operative technique performed that lacks standardization in the current
of onset [2], but typically include abdominal pain and recurrent vom­ literature.
iting [3]. This work has been reported in line with the updated SCARE
The gastric volvulus can be further classified according to its axes of guidelines [6].
rotation: organo-axial (longitudinal axis), mesentero-axial (transverse
axis) and combined type [1]; and to its etiology: primary volvulus and 2. Case report
secondary volvulus, with the latter being responsible for about two
thirds of the cases (association with paraesophageal hernia, diaphrag­ We report a case of a 84-year-old male with history of frequent pe­
matic hernia, eventration of the diaphragm and anatomic abnormalities riods of constipation and lack of appetite who presented to the emer­
of other organs) [4]. gency room (ER) with left-sided abdominal pain and distension for 5

* Corresponding author at: Rua da Aviação Naval, 11A, 4◦ D, 3810-055 Aveiro, Portugal.
E-mail addresses: [email protected] (M.A. Costa), [email protected] (S.D. da Silva), [email protected].
pt (A.C. Moreira), [email protected] (T. Santos), [email protected] (J. Noronha).

https://doi.org/10.1016/j.ijscr.2023.109095
Received 25 October 2023; Received in revised form 22 November 2023; Accepted 27 November 2023
Available online 28 November 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M.A. Costa et al. International Journal of Surgery Case Reports 114 (2024) 109095

days. He also mentioned persistent nausea, without the ability to vomit, gastric antrum and in the transition between the gastric fundus and
dysphagia, as well as no passing of stool or gas since the day before. The corpus. No macroscopic signs of diaphragmatic defects or hiatal hernia
patient denied the experience of fever, chills, abdominal surgery or were found. Nine seromuscular silk sutures 2/0 were performed after
trauma. Besides, he had already visited the emergency room two times pneumoperitoneum pressure reduction to 6 mmHg (one between the
in the previous week with similar symptoms that improved after anal­ gastric fornix and the left diaphragm, six in the greater curvature and
gesics and laxatives. two near the lesser curvature to the anterior abdominal wall) (Fig. 5). At
His past medical history was significant for type 2 diabetes mellitus, the end of the procedure, air insufflation trough nasogastric tube
atrial fibrillation, hypertension, pulmonary embolism, deep venous revealed that the stomach remained in the correct position.
thrombosis, tuberculous pericarditis and left diaphragmatic eventration. A postoperative gastrointestinal transit study confirmed that the
The list of chronic medication included apixaban, bisoprolol, cande­ stomach had returned to the anatomical position (Fig. 4). He was dis­
sartan, furosemide, insulin detemir and folic acid supplements. charged four days after surgery. The patient remains asymptomatic after
On physical examination, the patient presented a distended and 3 years of follow-up.
tympanic abdomen with tenderness upon palpation of the left quad­
rants, but no signs of peritonitis. Arterial blood gas analysis in room air 3. Discussion
with compensated respiratory alkalosis (pH: 7.384, pCO2: 32.9 mmHg,
pO2: 82.1 mmHg, HCO3− : 19.3 mmol/L). The laboratory workup was Gastric volvulus is an uncommon condition that was first described
significant for leukocytosis, with neutrophilia [leukocyte count: 11.2 × by Berti in 1866 [7]. It is an abnormal rotation of one part of the stomach
109/L (normal range: 4.1–11.1 × 109/L), neutrophil count: 8.96 × 109/L around the other that can result in three categories of gastric volvulus
(2–7.5 × 109/L)] and slight elevation of C-reactive protein: 4,73 mg/dL according to their axes of rotation [1]: organo-axial, mesentero-axial
(<0.5 mg/dL). and a combined type.
A plain abdominal radiograph revealed an air bubble sign in the left Indeed, the stomach is normally fixed in its anatomical position by
upper abdomen with elevation of the hemidiaphragm (Fig. 1). A naso­ four main ligaments, namely the gastrocolic, gastrohepatic, gastro­
gastric tube was placed, after several failed attempts, with drainage of phrenic, and gastrosplenic ligaments. These ligaments together with the
air and bilioenteric fluid, with subsequent improvement of his symptoms gastroesophageal junction and pylorus offer support and prevent mal­
(Fig. 2). rotation [1]. A primary gastric volvulus results from an absence or laxity
The patient was then hospitalized for further investigation, clinical of those ligaments [8]. On the other hand, a secondary gastric volvulus
condition stabilization and optimization. develops as a consequence of other anatomical defects, such as dia­
Computed tomography (CT) scan of the abdomen was suggestive of phragmatic eventration, traumatic injury to diaphragm, para-
left diaphragmatic eventration, but with no unequivocal signs of gastric esophageal hernia, phrenic nerve palsy, malrotation of gut, asplenia or
volvulus (Fig. 3). Contrast-enhanced examination was performed on the wandering spleen [1,8].
following day and revealed partial gastric rotation accordant to mes­ Patients with gastric volvulus may have an acute or chronic pre­
enteroaxial gastric volvulus with contrast progression to the duodenum sentation according to the speed of onset and degree of obstruction [1].
(Fig. 4). Upper endoscopy also showed signs of stomach torsion. Acute gastric volvulus may present with the Borchardt's triad, which
The patient was started on an oral diet three days after admission and occurs in about 70 % of cases, and includes severe epigastric pain,
had intestinal transit. However, it was decided to plan surgical treat­ retching without vomiting and difficulty or inability to pass a nasogas­
ment due to the high probability of symptom recurrence. tric tube [2,4,9]. Another acute symptom is hematemesis probably
The patient underwent an elective laparoscopic anterior gastropexy caused by mucosal sloughing, due to ischemia or mucosal tear after
for chronic gastric volvulus on day 8. A pneumoperitoneum of 12 mmHg retching [1]. Chronic gastric volvulus may present with nonspecific
was created through Veress needle insertion on Palmer's point. A 10-mm symptoms such as intermittent epigastric pain, early satiety, abdominal
trocar was placed in the supraumbilical area for camera passage. fullness after meals, chest discomfort, pyrosis and dysphagia [1,9].
Another 10-mm trocar was placed in the left hypochondrium and three The diagnosis of gastric volvulus demands for a high index of sus­
5-mm trocars in the subxiphoid area, right hypochondrium and left flank picion due to the rarity of the condition and its vague and nonspecific
under direct visualization. The stomach was in the normal position with symptoms.
no signs of ischemia, but showed signs of wall thickening, mainly in the An erect abdominal radiograph may display double air-fluid levels in

Fig. 1. (A, B): Plain abdominal radiograph revealing an air bubble sign in the left upper abdomen with elevation of the hemidiaphragm.

2
M.A. Costa et al. International Journal of Surgery Case Reports 114 (2024) 109095

Fig. 2. (A, B): Plain abdominal radiograph after placement of a nasogastric tube, with drainage of air and bilioenteric fluid.

Fig. 3. (A, B): Computed tomography scan of the abdomen with no unequivocal signs of gastric volvulus; (B): Coronal plane showing diaphragmatic eventration.

Fig. 4. (A): Pre-operative contrast-enhanced examination revealing partial gastric rotation accordant to mesenteroaxial gastric volvulus; (B): Post-operative contrast-
enhanced examination with correct stomach position and normal contrast progression.

the antrum and fundus or a single air bubble [1]. A barium study may torsion of the stomach with two bubbles and a transition line [3,4], but it
show the stomach lying horizontal and upside down [4]. CT scan of the is often not sufficient to determine the presence or degree of mucosal
abdomen may be useful to demonstrate the abnormal position and ischemia [3]. Indeed, early upper endoscopy is necessary in patients

3
M.A. Costa et al. International Journal of Surgery Case Reports 114 (2024) 109095

Fig. 5. Laparoscopic anterior gastropexy (A): Suture between the gastric fornix and the left diaphragm; (B): Suture between greater curvature and the anterior
abdominal wall; (C): Suture between the areas near the lesser curvature to the anterior abdominal wall; (D): Diagram of suture placement.

with gastric volvulus and it helps determining the presence of gastric recognized to prevent complications. Definitive treatment of both acute
wall ischemia [3]. and chronic gastric volvulus includes a surgical approach. Indeed,
The management of an acute gastric volvulus includes fluid resus­ laparoscopic anterior gastropexy has been found to be a viable alter­
citation, correction of electrolyte imbalances and urgent decompression native in these patients, particularly in the elderly due to minimal
and de-rotation, that can be initially achieved by nasogastric tube morbidity and shorter hospital stay compared to the open approach and
placement [10]. Upper endoscopy can also help in gastric decompres­ other more invasive surgical techniques. This case highlights the
sion by guiding the nasogastric tube placement and stomach de-rotation increasing role of minimal invasive surgical techniques on the man­
by restoring the stomach to its normal anatomic position. However, it agement of gastric volvulus.
does not provide a definitive treatment [10].
A gastric volvulus requires operative intervention in its acute pre­ Ethical approval
sentation, as well as in the chronic variant if the patient becomes
symptomatic, in an effort to prevent complications [4]. Ethical approval is exempt/waived at our institution.
The main principles of surgical intervention include stomach
decompression, with volvulus reduction, followed by gastropexy and Funding
correction of any predisposing intra-abdominal factors [11]. Indeed,
gastric resection should be reserved only for the cases of stomach None.
strangulation and necrosis [11,12]. Historically, Tanner has described a
wide range of surgical techniques for volvulus correction: fundo-antral
Author contribution
gastrogastrostomy (Opolzer's operation), partial gastrectomy, division
of bands, gastrojejunostomy, repair of diaphragmatic hernia, simple
Maria Adriano Costa: Conceptualization, Methodology, Writing -
gastropexy, repair of eventration of the diaphragm and gastropexy with
Original Draft. Rui Moreira Supervision. Sofia Dias da Silva, Ana C
division of the gastrocolic omentum (Tanner's operation) [13]. There
Moreira, Teresa Santos, Rui Moreira, Joana Noronha: Writing - Re­
have been also reports of success in the treatment of gastric volvulus
view & Editing.
with single or dual percutaneous endoscopic gastrostomy placement
All authors read and approved the final manuscript.
(PEG), although it has significant morbidity and may result in gastric
rotations initiated by the PEG tubes [4,11].
Guarantor
There is limited literature comparing the laparoscopic and open
approaches, however there has been growing evidence that the laparo­
Maria Adriano Costa.
scopic surgery is safe and effective and results in fewer complications
and shorter hospital stay, which can be of major importance for the
elderly population [1,4,9,14]. Research registration number
In this article, we report a case of a patient with history of frequent
periods of constipation and lack of appetite for several years, that faced N/A.
an exacerbation with left-sided abdominal pain and distension as well as
persistent nausea. After reviewing the patient's previous medical re­ Patient consent
cords, which already showed evidence of diaphragmatic eventration and
analyzing the results of the imaging studies performed in the ER, it was Written informed consent was obtained from the patient for publi­
proposed the diagnosis of secondary chronic gastric volvulus. The pa­ cation of this case report and accompanying images. A copy of the
tient symptoms resolved after nasogastric tube placement and fluid written consent is available for review by the Editor-in-Chief of this
resuscitation. However, it was decided to plan a laparoscopic anterior journal on request.
gastropexy due to the high probability of symptom recurrence. In this
case, it was decided not to perform diaphragmatic plication for even­ Conflict of interest statement
tration correction, given the added technical complexity and the patient
comorbidities. None.
This case portrays that laparoscopic surgery is a safe and effective
approach in patients with gastric volvulus and describes the operative
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