Abstract
Background. Totally intrathoracic gastric volvulus is an uncommon presentation of hiatal hernia,
in which the stomach undergoes organoaxial torsion predisposing the herniated stomach
to strangulation and necrosis. This may occur as a surgical emergency, but some patients
present with only chronic, non-specific symptoms and can be treated electively. The
aim of this study is to describe a comprehensive approach to laparoscopic repair of
chronic intrathoracic gastric volvulus and to critically assess the pre-operative
work-up. Methods. Eight patients (median age, 71 years) underwent complete laparoscopic repair of chronic
intrathoracic gastric volvulus. Symptoms of epigastric pain and early satiety were
universally present. Five patients had reflux symptoms. The diagnostic evaluation
included a video esophagogram, upper endoscopy, 24-hour pH measurement, and esophageal
manometry in all patients. Operative results and postoperative outcome were recorded
and follow-up at 1 year included a barium swallow in all patients. Results. All patients had documented intrathoracic stomach. Five of 8 patients had a structurally
normal lower esophageal sphincter. All 4 patients with reflux esophagitis on upper
endoscopy had a positive 24-hour pH study, and 2 of these patients had a structurally
defective lower esophageal sphincter on manometry. None of the patients had preoperative
evidence of esophageal shortening. All procedures were completed laparoscopically.
The procedure included reduction of the stomach into the abdomen, primary closure
of the diaphragmatic defect, and the construction of a short, floppy Nissen fundoplication.
There were no major complications. One patient required repair of a trocar site hernia
6 months postoperatively. At 1-year follow-up, there were no radiologic recurrences
of the volvulus. One patient complained of temporary swallowing discomfort and another
had recurrent gastroesophageal reflux disease (GERD) symptoms caused by a breakdown
of the wrap. All other patients remained asymptomatic during follow-up. Conclusions. The repair of chronic gastric volvulus can be accomplished successfully with a laparoscopic
approach. A preoperative endoscopy and esophagogram are crucial to detect esophageal
stricture or shortening, and manometry is needed to access esophageal motility; pH
measurements do not affect operative strategy. The procedure should include a Nissen
fundoplication to treat preoperative GERD, to prevent possible postoperative GERD,
and to secure the stomach in the abdomen. The procedure is safe but technically challenging,
requiring previous laparoscopic foregut surgical expertise. (Surgery 2000;128:784-90.)
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Article info
Publication history
Accepted:
May 6,
2000
Footnotes
*Reprint requests: Namir Katkhouda, MD, Department of Surgery, Healthcare Consultation Center, 1510 San Pablo St, Los Angeles, CA 90033.
**Surgery 2000;128:784-90.
Identification
Copyright
© 2000 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
