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Gastric Volvulus Treatment & Management

  • Author: William W Hope, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Apr 02, 2015
 

Approach Considerations

In general, the treatment of an acute gastric volvulus remains emergency surgical repair. In patients who are not surgical candidates (secondary to comorbidities or an inability to tolerate anesthesia), endoscopic reduction may be attempted.

Chronic gastric volvulus may be treated on a nonemergency basis, and surgical treatment is increasingly being performed via a laparoscopic approach. A review of patients managed conservatively with chronic gastric volvulus were reported to have a high recurrence rate but very few serious complications.[33]

Surgical contraindications

Contraindications for surgical treatment involve conditions or comorbidities in which the patient cannot tolerate general anesthesia. The surgeon should also exercise clinical judgment and make sure that the patient is optimized and resuscitated before the operation.

Some authors have advocated consideration of emergency endoscopic reduction in the setting of acute gastric volvulus in patients who are high risk for surgery.[34] This strategy may allow the patient to be adequately resuscitated and medically optimized before definitive surgical repair.

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Surgical Intervention

Emergency surgical intervention is indicated for acute gastric volvulus, which 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 are best accomplished with surgical therapy. Tanner described the surgical options for repair,[35] which include the following:

  • Diaphragmatic hernia repair
  • Simple gastropexy
  • Gastropexy with division of the gastrocolic omentum
  • Partial gastrectomy
  • Fundoantral gastrogastrostomy
  • Repair of eventration of the diaphragm

Minimally invasive approaches

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.[17, 16, 36, 37, 38]

With advances in laparoscopic surgery, most cases of acute and chronic gastric volvulus can now be approached laparoscopically. In the absence of peritonitis or an unstable patient, most cases can be adequately treated in this way. No randomized trials have compared open and laparoscopic surgery in the setting of gastric volvulus, but several reports have reported outcomes for laparoscopically treated acute and chronic gastric volvulus that are comparable or superior to the traditional outcomes obtained with open surgery.[17, 16, 36]

In a case series that included 11 high-operative-risk patients with obstructive gastric volvulus, Yates et al found that laparoscopic reduction of gastric volvulus and anterior abdominal wall sutured gastropexy enabled all 11 patients to remain free of gastric obstructive symptoms and recurrent episodes of volvulus.[39]

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.

The surgical strategy includes the following:

  • 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 an attempt to decrease the rate of reherniation has also been reported [36]

Technical points related to laparoscopic surgery include the following:

  • 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 (eg, laparoscopic antireflux surgery)
  • Keep the pneumoperitoneum pressure lower than normal (10-12 mm Hg) to facilitate easy reduction of hernia contents [16]
  • The stomach is visualized, and its viability is confirmed; when manipulating the stomach, avoid excess traction, which may lead to perforation
  • Dissect and excise the sac, and carefully separate it from the pleura to avoid pneumothorax [16]
  • Use caution when dissecting the right crus because the left gastric vessel may herniate with the stomach across the edge of the crus [16]
  • The stomach is grasped with a nontraumatic grasper and is 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 [16, 36]

Postoperative details

Gastric decompression is maintained until the return of bowel function. Pulmonary toilet and early ambulation are important postoperative measures.

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Endoscopic Treatment

Although the treatment of gastric volvulus is surgical, advances in laparoscopic surgery have also been accompanied by advances in therapeutic endoscopy, with several reports of endoscopic treatment of acute gastric volvulus.[34, 29, 40, 41, 42, 43, 44, 45] However, the majority of cases describing endoscopic management pertain to chronic gastric volvulus.[29, 43, 44, 45]

Endoscopic 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 surgical procedure to be performed on an elective basis and permitting medical optimization before surgery.[34, 29, 40] Failure to reduce the twist or evidence of strangulation necessitates surgery.

After 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.[43, 45]

Secondary to the high mortality associated with emergency operative repair of acute gastric volvulus and the typical poor clinical picture associated with patients, emergency endoscopic reduction of the acute volvulus is likely to be a growing consideration in the future.[34, 29] A growing number of reports have described the use of a combination of laparoscopy and endoscopy in the treatment of gastric volvulus.[36, 46, 47] In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus.

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Complications of Surgery

Operative complications are similar to those seen in other conditions requiring major abdominal surgery; they vary according to the series and the type of surgical procedure performed.

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.[48] In a study of 138 patients with hiatal hernia, 10 of the 21 patients who had gastric volvulus required emergency surgery; mortality was 40%, and the incidence of major morbidity was also 40%.[49]

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.[17] Palanivelu et al reported that 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus had no perioperative complications or mortality.[16]

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Resuscitation and Medical Optimization

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 this may be difficult if the gastroesophageal junction is obstructed.[23]

Care should be taken in placing the nasogastric tube, as aggressive placement may cause perforation; this is especially true in the pediatric population and is therefore generally not advocated.[10]

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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 East Area Health Education Center

William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cr bars<br/>Received research grant from: Ethicon, cr bard, we gore<br/>Received income in an amount equal to or greater than $250 from: Cr bard, wl gore <br/>Received grant/research funds from Ethicon for research; Received grant/research funds from CR Bard for consulting.

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.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

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.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS, is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Table 1. Anatomic Defects Associated With Gastric Volvulus
Congenital defects Diaphragmatic defects: 43%
Gastric ligaments: 32%
Abnormal attachments, adhesions, or bands: 9%
Asplenism: 5%
Small and large bowel malformations: 4%
Pyloric stenosis: 2%
Colonic distention: 1%
Rectal atresia: 1%
Complicating gastroesophageal surgery
Neuromuscular disorders Poliomyelitis
Source: Miller DL, Pasquale MD, Seneca RP. Gastric volvulus in the pediatric population. Arch Surg. Sep 1991;126(9):1146-9.[10]
Table 2. Causes of Secondary Gastric Volvulus in Adults
Diaphragmatic Defects Gastroesophageal Surgery Neuromuscular Disorder Increased Intra-abdominal Pressure Conditions Leading to Diaphragmatic Elevation
Hiatal hernia



Posttraumatic



Nissen fundoplication



Total esophagectomy



Highly selective vagotomy



Coronary artery bypass graft



Motor neuron disease



Poliomyelitis



Myotonic dystrophy



Abdominal tumors Phrenic nerve palsy



Left lung resection



Intrapleural adhesions



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