Gastric Volvulus Treatment & Management

Updated: May 06, 2019
  • Author: William W Hope, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Treatment

Approach Considerations

In general, the treatment of an acute gastric volvulus remains emergency surgical repair. [37] 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  with chronic gastric volvulus who were managed conservatively reported a high recurrence rate but very few serious complications. [38]

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 at high risk for surgery. [39] This strategy may allow the patient to be adequately resuscitated and medically optimized before definitive surgical repair.

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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 esophagogastric junction (EGJ) is obstructed. [26]

Care should be taken in placing the nasogastric tube. Aggressive tube placement may cause perforation; this is especially true in the pediatric population and therefore generally is not advocated. [9]

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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, [40] which include the following:

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

Minimally invasive approaches

A growing number of reports have described 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. [19, 18, 41, 42, 43, 44]

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. [19, 18, 41]

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. [45]

Operative 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 [41]

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 [18]
  • 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 [18]
  • Use caution when dissecting the right crus because the left gastric vessel may herniate with the stomach across the edge of the crus [18]
  • 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 [18, 41]

Postoperative care

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. [39, 32, 46, 47, 48, 49, 50, 51] However, the majority of cases describing endoscopic management pertain to chronic gastric volvulus. [32, 49, 50, 51]

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. [39, 32, 46] 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. [49, 51]

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. [39, 32] A growing number of reports have described the use of a combination of laparoscopy and endoscopy in the treatment of gastric volvulus. [41, 52, 53] In the future, laparoscopy and endoscopy will increasingly be used to treat gastric volvulus.

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Complications

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. [54]  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%. [55]

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. [19]  Palanivelu et al reported that 14 patients who underwent laparoscopic suture gastropexy for gastric volvulus had no perioperative complications or mortality. [18]

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