Gastric volvulus and other types of volvulus

1. Gastric volvulus Dr. Sudarshan Under Guidance of Dr. B. L. Yadav Assistant Professor, Upgraded Department of Surgery

2. History Name: Bhori singh DOA:05/01/2013 Age & sex: 45 yrs ,male Resident : Baroli , Bharatpur Clinical presentation Pain abdomen: last 3 days Abdominal distention: last 3 days Not passing flatus motion: last 2 days No h/o fever No h/o vomiting

3. Cont.. Past history: No h/o similar complaint No h/o previous surgery No h/o DM, TB, COPD, Hypertension , Bronchial Asthma Personal history Smoker Tobacco chewer Non alcoholic Normal bowel bladder habits

4. Examination Conscious Oriented Afebrile Pulse-92/min B.P-100/70 mmHg No pallor No L.N Pathy No icterus No clubbing No pedal oedema

5. P/A Inspection: Abdomen distended with fullness present in upper abdomen No visible pulsation , peristalsis Palpation: Abdomen is tense, tender Guarding present No Rigidity Percussion : Tympanic note present Normal liver dullness and span No shifting dullness Auscultation: Bowel sounds absent

6. HB- 11.6 gm/dl TLC- 1400 /mm3 PLT- 1.35 lakh /ml Serum urea/ creatinine - 87/2.0 mg/dl S.Total bilirubin-1.2 mg/dl Direct- 0.5 mg/dl Indirect- 0.7 mg/dl SGOT/SGPT- 70/18 Serum amylase-175.0 u/ lt Serum electrolytes- wnl X-Ray FPA- Multiple air fluid level with large single stomach gas shadow Investigations

7. Provisional diagnosis: Acute intestinal obstruction Perforation peritonitis Plan: Exploratory Laparotomy

8. Procedure performed Exploratory laparotomy with Gastropexy

9. Per operative photos cranial caudal R L

10. Cont… R L CRANIAL

11. Cont.. R L cranial

12. Cont.. Cranial Caudal

13. Contd.. Stomach Fixed to Diaphragm & AnteroLateral Abdominal Wall With Silk

14. Post operative follow up Vitals monitoring Input /output monitoring Chest physiotherapy Skin stitches removal-7 th post op. day Discharge-8 th post op. day

15. Discussion Definition Gastric volvulus or volvulus of stomach a twisting of all or part of the Stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death.

16. Cont.. Very uncommon clinical entity First described by Berti in 1866 Seen in both children and elderly people Rare below fifth decades of life

17. Classification of gastric volvulus On the basis of: 1) Onset - Acute Chronic 2) Axis of rotation - Organoaxial Mesentroaxial Combined

18. Gastric volvulus 1. Organoaxial (along longitudinal axis-MC) a)Acute presentation b)associated with diaphragmatic defects c)more common in adults d)vascular compromise more common 2. Mesentroaxial (along vertical axis) a) recurrent episodes of pain abdomen b) Diaphragmatic defects are not seen c) more common in children 3. Combined

19. Diagrammatic representation Organoaxial Mesentroaxial

20. Aetiology Type 1 or Idiopathic gastric volvulus comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic *, gastrocolic *, gastrophrenic and gastrohepatic * ligaments.

21. Cont.. Type 2 or secondary Type 2 gastric volvulus is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach Diaphragmatic defect Eventration Paraoesophagial hiatal defect Trauma Paralysis Congenital bands and adhesions Intestinal malrotation Pyloric stenosis and gastric distension Colon distention

22. AETIOLOGY

23. Clinical features Pain abdomen (acute in onset) Recurrent retching with little vomitus Borchardts Inability to pass a Ryles tube Triad OTHERS Abdominal pain Vomiting Upper GI bleed Dysphagia Gastro oesophageal reflux Respiratory symptoms Altered bowel habit

24. Investigations X Ray FPA- Gas filled viscus in chest and or upper abdomen, multiple air fluid levels, Barium contrast studies : sensitive and specific Upper GI Endoscopy: both diagnostic and therapeutic USG CT scan abdomen and MRI

25. X-ray findings in gastric volvulus

26. Contd …

27. Barium meal : Organoaxial volvulus After surgery Before surgery

28. Mesentricoaxial Gastric volvulus

29. Endoscopy view:

30. USG: Peanut sign in a case of chronic gastric volvulus . The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut. In several case reports, however, the ultrasonographic evaluation of gastric volvulus showed normal findings.

31. CT image:

32. Advantage of CT Scan detection of gastric pneumatosis and pneumoperitoneum , suggestive of necrosis and perforation, respectively detection of predisposing factors, e.g. diaphragmatic defects or hernias, dense adhesions detection of other abnormalities associated with gastric volvulus , viz. wandering spleen, intrathoracic kidney, malrotation with asplenia excluding other extra-gastric or vascular causes of gastric ischaemia

33. Limitation of Techniques Plain radiography may demonstrate findings that are indistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax . Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion.

34. Treatment Aims: 1) Reduction of volvulus 2) Gastric fixation 3 ) Repair of predisposing factor Apporach : Open Endoscopic Laproscopic Combined (endoscopic + laproscopic )

35. Cont.. Open surgery: Diaphragmatic hernia repair Division of bands Gastropexy Partial gastrectomy (In case of necrosis) Gastrojejunostomy Repair of eventration of diaphragm

36. Surgical procedures Anterior suture gastropexy - The stomach along the gastro colic omentum is suspended to the anterior abdominal wall Partial gastrectomy – Indicated if a portion of the stomach is gangrenous

37. Cont.. Endoscopic : Reduction Alpha loop maneuver J type maneuver With or without gastrostomy (for fixation of stomach) ( PEG )

38. PEG Tube

39. Cont.. Laproscopic Reduction of volvulus Anchoring fundus of stomach to diaphragm and greater curvature of stomach to anterior abdominal wall Repair of diaphragmatic defects fundoplication

40. Cont.. Combined approach Described by Arben Beqiri in 1997 Less time consuming Endoscopic T-fasteners are used instead of PEG for anchoring stomach

41. T-fastener system

42. Method for providing apposition of two bodily walls a) forming a puncture site through the two walls; b) inserting an access cannula into the puncture site; c) passing a guide tube through the access cannula , the guide tube retroflexing after passing beyond a distal end of the access cannula ; d) positioning a distal end of the guide tube proximate one of the bodily walls; e) passing a flexible puncturing device through the guide tube and puncturing the two bodily walls at a second location; f) connecting a fastener to the puncturing device; g) retracting the puncturing device to draw the fastener through the two bodily walls at the second location; and h) securing the fastener to maintain apposition of the two walls at the second location.

43. Follow up Clinical: Reflux symptoms Recurrence Removal of PEG Tube Imaging: Contrast study

44. Complications of volvulus Strangulation Necrosis Perforation of stomach Gastrointestinal haemorrhage Cardiopulmonary failure

45. Complications related to PEG Tube Wound infection Peritonitis Peristomal leakage Dislodgement Bowel perforation Gastrocolic fistula

46. Association Wandering spleen Congenital diaphragmatic hernia Diaphragmatic eventration  

47. Chronic gastric volvulus Patient presents with recurrent episodes of vague abdominal pain and discomfort Bloating Surgery is only indicated if the episodes of pain are severe and disabling T/t of choice- conservative Operation of choice- anterior gastropexy