eMedicine Specialties > General Surgery > Abdomen

Gastric Volvulus: Treatment

Author: William W Hope, MD, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South Eastern Area Health Education Center
Coauthor(s): Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System; Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Contributor Information and Disclosures

Updated: Jul 21, 2009

Treatment

Medical Therapy

Although the treatment of gastric volvulus is surgical, endoscopic reduction can be attempted in selected patients. There are some reports of endoscopic reduction in acute gastric volvulus,17,31,32,33  but the majority of cases describing endoscopic management pertain to chronic gastric volvulus.28,34,35,36 Such 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 prior to surgery.17,28,31 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.34,36

Surgical Therapy

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.37
 
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.27,38,39,40

Preoperative Details

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 may be difficult if the gastroesophageal junction is obstructed.21  Care should be taken when placing the nasogastric tube, as aggressive placement may cause perforation; this is especially true in the pediatric population and therefore is generally not advocated.10  

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
    • 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.39
  • Technical points related to the laparoscopic approach include:
    • 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.38
    • 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.38
    • Use caution when dissecting the right crus, as the left gastric vessel may herniate with the stomach across the edge of the crus.38
    • 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.38,39

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).6,7 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.41 Haas et al reported on 138 patients with hiatal hernia, of which 21 had gastric volvulus. Ten of these 21 patients required emergent surgery.42 The authors reported a 40% mortality rate and a 40% major morbidity rate.

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.27 Palanivelu et al reported on 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus, reporting no perioperative complications or mortality.38

More on Gastric Volvulus

Overview: Gastric Volvulus
Workup: Gastric Volvulus
Treatment: Gastric Volvulus
Follow-up: Gastric Volvulus
References
Further Reading
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Keywords

gastric volvulus, volvulus, abnormal rotation of the stomach, closed loop obstruction, incarceration, strangulation, diaphragmatic defects, paraesophageal hernias, upside-down stomach, severe epigastric pain, nonproductive retching, endoscopic reduction, percutaneous endoscopic gastrostomy, gastrectomy, anterior gastropexy

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Contributor Information and Disclosures

Author

William W Hope, MD, Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South Eastern Area Health Education Center
William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System
Disclosure: Nothing to disclose.

Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Richard W Golub, MD, FACS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Association for Surgical Education, Crohns and Colitis Foundation of America, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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