Management of Chronic Gastric Volvulus -

Management of Chronic Gastric Volvulus -

Joint Joint Hospital Hospital Grand Grand Round Round Management Management of of Chronic Chronic Gastric Gastric Volvulus Volvulus Kenny Kenny K K YY Yuen Yuen Tseung Tseung Kwan Kwan O O Hospital Hospital 20th 20th January, January, 2007 2007 Clinical Clinical scenario scenario History History

Predisposing Predisposing factors factors Classifications Classifications Clinical Clinical presentations presentations Investigations Investigations Treatment Treatment Clinical Clinical Scenario Scenario F/29 F/29 Intermittent Intermittent epigastric epigastric pain pain for for years years Cramping Cramping after after heavy heavy meal, meal, relieved relieved aft aft er

er vomiting vomiting Weight Weight loss loss 5 5 kg kg within within 2-3 2-3 months months Upper Upper endoscopy endoscopy twisted twisted stomach stomach with with difficulty difficulty in in finding finding pylo pylo rus rus Clinical Clinical Scenario Scenario Erect Erect AXR AXR Double

Double air-fluid air-fluid levels levels at at LUQ LUQ Ba Ba meal meal Stomach Stomach rotated rotated > > 180 180oo Body Body rotates rotates towards towards the the R R hemidiaphragm hemidiaphragm Greater Greater curve curve laying laying same same level level as as the the fund fund us us Organoaxial

Organoaxial gastric gastric volvulus volvulus No No hiatus hiatus hernia hernia No No gastric gastric outlet outlet obstruction obstruction Definition Definition Gastric Gastric volvulus volvulus is is rotation rotation of of all all o o rr part part of of the the stomach stomach more more than than 18 18 0,

0, which which may may lead lead to to a a closed-loop closed-loop obstruction obstruction and and possible possible strangulati strangulati on on 1579 Ambrose Pare GV after sword wound History History of of Gastric Gastric Volvulus Volvulus 1866 Berti 1895 Described

Berg GV 1904 during autopsy 1st Borchardt successful operation Classic al triad 1920 Roselet 1930 Described radiological Buchanan ly Clarify anatomical variation Etiology & methods of repair 1968 Tanner Anatomy Anatomy Predisposing

Predisposing factors factors Primary Primary Laxity Laxity of of the the supporting supporting ligaments ligaments Especially Especially elongation elongation of of the the gastrosplen gastrosplen ic ic and/or and/or gastrocolic gastrocolic ligaments ligaments one-third one-third of of cases cases Predisposing Predisposing factors factors Secondary Secondary Diaphragmatic

Diaphragmatic defect defect eventration eventration paraesophageal paraesophageal hiatal hiatal hernia hernia Bochdalek Bochdalek hernia hernia trauma trauma paralysis paralysis Congenital Congenital bands bands or or adhesions adhesions Intestinal Intestinal malrotation malrotation Pyloric Pyloric stenosis

stenosis with with gastric gastric distension distension Colon Colon distension distension Predisposing Predisposing factors factors Diaphragmatic Diaphragmatic defects defects -- 43% 43% Gastric Gastric ligaments ligaments -- 32% 32% Abnormal Abnormal attachments, attachments, adhesions, adhesions, or or band band ss -- 9% 9% Asplenism Asplenism -- 5% 5% Small

Small and and large large bowel bowel malformations malformations -- 4% 4% Pyloric Pyloric stenosis stenosis -- 2% 2% Colonic Colonic distension distension -- 1% 1% Rectal Rectal atresia atresia -- 1% 1% Classifications Classifications Onset Onset -- Acute Acute Vs Vs Chronic Chronic Location Location subdiaphragmatic subdiaphragmatic // prim prim ary

ary Vs Vs supradiaphragmatic supradiaphragmatic // seconda seconda ry ry Axis Axis of of rotation rotation organoaxial/ organoaxial/ mes mes enteroaxial enteroaxial // combined combined // unclassified unclassified Etiology Etiology type type 1(idiopathic) 1(idiopathic) Vs Vs type type 2 2 (congenital (congenital or or acquired) acquired) Classifications Classifications Subdiaphragmatic Subdiaphragmatic,, or

or primary primary not not associated associated with with diaphragmatic diaphragmatic defe defe cts cts one one third third of of cases cases Supradiaphragmatic Supradiaphragmatic,, or or secondar secondar y y associated associated with with diaphragmatic diaphragmatic defects defects two

two thirds thirds of of cases cases Classifications Classifications Organoaxial Organoaxial volvul volvul us us Rotates Rotates about about the the cardi cardi opyloric opyloric axis axis results results in in an an upside upside down down stoma stoma ch ch with with the

the greater greater cu cu rve rve on on top top Obstruction Obstruction may may occur occur at at the the gastroesophage gastroesophage al al junction junction and and the the pyl pyl oroantral oroantral area. area. 59% 59% Mainly Mainly adult adult Classifications Classifications

Mesenteroaxial Mesenteroaxial vo vo lvulus lvulus Anterior Anterior rotation rotation about about an an axis axis perpendicular perpendicular to to the the cardiopyloric cardiopyloric aa xis xis Greater Greater curve curve remains remains on on the the bottom bottom 29% 29% Mainly Mainly children

children Clinical Clinical Presentation Presentation Borchardts Borchardts classical classical triad triad (1904): (1904): epigastric epigastric pain pain and and distention distention Non-productive Non-productive vomiting vomiting difficulty difficulty with with nasogastric nasogastric tube tube insertion insertion Presenting symptom Acute Chronic Total Abdominal pain

24 6 30 Vomiting 17 3 20 UGIB/anaemia 9 2 11 Abdominal distension 5 0 5 Gastro-esophageal reflux

5 2 7 Dysphagia 4 3 7 Respiratory symptoms/ chest pain 7 0 7 Postprandial discomfort 3 0 3

Altered bowel habit 2 0 2 Excess flatulence 2 0 2 Acute confusion 1 0 1 Dehydration 1 0 1 Teague et al, BMJ 2000

Investigations Investigations Barium Barium study study high high sensitivity sensitivity and and specificity specificity criterion criterion standard standard for for diagnosis diagnosis upside-down upside-down configuration configuration of of the the sto sto mach mach esophagogastric esophagogastric junction junction is is lower lower th th an

an normal. normal. marked marked gastric gastric dilatation dilatation and and the the slo slo w w passage passage of of contrast contrast past past the the site site oo ff twisting twisting Investigations Investigations X-Ray X-Ray findings findings suggestive suggestive of of gastric gastric volvulus volvulus shoul shoul

d d be be confirmed confirmed with with aa barium barium study study Erect Erect film: film: two two air-fluid air-fluid levels levels on on the the fundus fundus -- inferior, inferior, antrum antrum -- superior superior Supine Supine film: film: aa beak beak where where the the esophagogastri esophagogastri cc junction junction is is seen seen on

on normal normal images images Investigations Investigations Endoscopy Endoscopy Both Both diagnostic diagnostic and and therapeutic therapeutic Mainly Mainly for for therapeutic therapeutic CT CT // MRI MRI // USG USG Not Not diagnostic diagnostic Consider Consider in in patient patient cannot cannot tolerate tolerate endoscop endoscop

yy or or fluoroscopy fluoroscopy Investigations Investigations Investigation Ordere d Diagnosti c Suggestiv No e yield Barium meal 25 14 7 4 CXR 19

0 5 14 Upper endoscop 18 y 5 6 7 AXR 8 0 3 4 Manometry/pH 4 0

0 4 Chest CT scan 2 0 1 1 Colonoscopy 1 0 0 1 USG 1 0 0

1 Teague et al, BMJ 2000 Treatment Treatment Aims: Aims: Reduction Reduction of of volvulus volvulus Gastric Gastric fixation fixation Repair Repair of of predisposing predisposing factors factors Open Open Vs Vs Endoscopic Endoscopic Vs Vs Laparoscopic Laparoscopic Vs Vs Combined

Combined endoscopic endoscopic and and laproscopic laproscopic Treatment Treatment open open surgery surgery Open (traditional treatment treatment >10 >10 years years ag ag Open Surgery Surgery (traditional o) o) Diaphragmatic Diaphragmatic hernia hernia repair repair Division Division of of bands bands Gastropexy Gastropexy Partial Partial gastrectomy

gastrectomy (in (in case case of of necrosis) necrosis) Gastropexy Gastropexy with with division division of of gastrocolic gastrocolic ligam ligam ent ent ((Tanners Tanners Operation Operation)) Gastrojejunostomy Gastrojejunostomy Fundoantral Fundoantral gastrogastrostomy gastrogastrostomy ((Opolzers Opolzers O O peration peration)) Repair Repair of of eventration eventration of of diaphragm diaphragm

TreatmentTreatment- endoscopic endoscopic Endoscopic Endoscopic reduction reduction Alpha-loop Alpha-loop maneuver maneuver Tat-Kin Tat-Kin Tsang Tsang et et al al ,1995 ,1995 J-type J-type maneuver maneuver D.K. D.K. Bhasin Bhasin et et al, al, 1990 1990 +/+/- gastrostomy gastrostomy for for the the fixation fixation of of stomach stomach tt

oo the the abdominal abdominal wall wall Treatment Treatment alpha alpha loop loop A,B,C Survey of the stomach and gastric volvulus and formation of alpha-loop D,E,F, Completed formation of alpha-loop with the advancement of tip pf the en doscope into the antrum and uncoiling of the loop and reduction of the volvulus Tsang et al. 1995 Treatment Treatment -- J-type J-type maneuver maneuver A,B Formation of the J by turn extremely up and to the right to locate the lumen C,D,E Endoscopy is maneuvered into the duodenal cap. Tip of the endoscopy is tur ned to right and partially locked. Endoscopy is rotated through 180o in anti-clockwise direction and withdrawn Bhasin et al. 1990 Treatment Treatment -- laparoscopic laparoscopic 3-ports 3-ports // 4-ports 4-ports // 5-ports

5-ports Reduction Reduction of of Volvulus Volvulus Anchoring Anchoring fundus fundus of of stomach stomach to to the the diaphrag diaphrag m m Greater Greater curve curve of of the the stomach stomach to to anterior anterior abd abd ominal ominal wall wall +/+/- repair repair of of diaphragmatic diaphragmatic defect defect

+/+/- fundoplication fundoplication or/and or/and esocardiopexy esocardiopexy pr pr event event post-operative post-operative GERD GERD +/+/- gastrostomy gastrostomy Treatment Treatment -- laparoscopic laparoscopic 2 vertical lines fundus anchored to diaphragm X anterior gastropexy stitches A camera, B liver retractor, C,D,E - operating ports Treatment Treatment -- laparoscopic laparoscopic Esocardiope xy Phrenofundopexy Anterior gastropexy

Management Management -- combined combined Described Described by by Arben Arben Beqiri Beqiri (1997): (1997): Use Use endoscopic endoscopic T-fasteners T-fasteners instead instead of of PE PE G G for for anchoring anchoring Laparoscopy Laparoscopy -- reduction reduction of of volvulus volvulus Endoscopy Endoscopy -- placement placement of of T-fasteners T-fasteners Less

Less time time consuming consuming Treatment Treatment Follow-up Follow-up Clinical Clinical reflux reflux symptoms symptoms recurrent recurrent of of symptoms symptoms -- detection detection of of recurrence recurrence removal removal of of PEG PEG tube tube Imaging

Imaging Post Post OT OT contrast contrast study study (no (no consensus consensus of of interval interval -- Day Day 22 to to 33 months) months) Treatment Treatment No No RCT RCT rare (2.6/million/year) rare disease disease (2.6/million/year) Largest Largest series series Teague Teague et et al al in in 2000 2000

36 36 patients patients were were recruited recruited Results: Results: Diagnostic Diagnostic investigation: investigation: Ba Ba contrast contrast (21/25) (21/25) an an d d upper upper endoscopy endoscopy (18/21) (18/21) Conservative Conservative Tx Tx (5), (5), open open surgery surgery (13), (13), laparosc laparosc opic opic (18) (18) no no major major complications

complications and and death death Median Median hospital hospital stay: stay: shorter shorter in in laparoscopic laparoscopic gr gr oup oup than than open open group group 6 6 Vs Vs 14, 14, p< p< 0.05 0.05 Clinical Clinical Scenario Scenario Laparoscopic Laparoscopic approach approach 3-ports 3-ports Organoaxial Organoaxial type

type No No diaphragmatic diaphragmatic hernia hernia and and eventrat eventrat ion ion of of diaphragm diaphragm Gastropexy Gastropexy 00-Ethibon Ethibon 2 2 anchoring anchoring fundus fundus to to the the diaphragm diaphragm 2 2 anchoring anchoring greater greater curve curve to to the

the anterio anterio rr abdominal abdominal wall wall Clinical Clinical Scenario Scenario Follow Follow up: up: Resume Resume diet diet in in D3 D3 Contrast Contrast study study in in D2 D2 stomach stomach in in normal normal position position no no gross gross abnormal abnormal configuration configuration of

of stomach stomach Clinical Clinical Scenario Scenario Conclusion Conclusion Chronic Chronic gastric gastric volvulus volvulus is is aa rare rare disease disease Require Require high high index index of of suspicion suspicion in in diagnos diagnos is is Pain Pain and and vomiting vomiting are are the the main

main symptom symptom ss Barium Barium meal meal is is the the most most diagnostic diagnostic tool tool Can Can be be safely safely treated treated by by laparoscopic laparoscopic app app roach roach The The End End Thank Thank you you

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