Surgical management of hiatus hernia with chronic gastric volvulus: report of two cases

Totally intrathoracic gastric volvulus is an uncommon presentation of hiatus hernia. We report herein two patients of hiatus hernia repair with mesenteroaxial gastric volvulus who presented as so-called upside-down stomach, which resulted in excellent clinical outcomes. The two patients underwent an attempted laparoscopic floppy Nissen fundoplication. In patient 1, the duodenum severely adhered to the hernia sac and converted to an open Nissen fundoplication. The operating time for patient 1 and patient 2 was 224 and 232 min, respectively. No postoperative morbidities occurred. At a follow-up of 18 and 2 months, the two patients had not had a relapse or any of their prior symptoms. The repair of an esophageal hiatus hernia with chronic gastric volvulus can be accomplished successfully and safely with an open or laparoscopic approach. Because this condition occurs more frequently in the elderly, an attempt to perform laparoscopic surgery may contribute to minimal invasive treatment.     

Gastric volvulus after laparoscopic fundoplication: a rare complication after Heller-Dor operation for achalasia

A laparoscopic Heller-Dor operation is a safe and effective procedure for esophageal achalasia. We experienced postoperative gastric volvulus after performing a laparoscopic Heller-Dor operation. This was successfully treated with laparoscopic-assisted gastropexy. A 56-year-old Japanese woman had complained of dysphagia for 3 years. She was diagnosed as having achalasia and then underwent a laparoscopic Heller-Dor operation. She complained of nausea and abdominal fullness on postoperative day 5 and gastrography revealed organoaxial gastric volvulus. We performed a reoperation using a laparoscopic-assisted approach. Because of preexisting gastric ptosis, the stomach was unusually movable. In addition, a rotational torque due to the fundoplication might have caused the volvulus. We performed an anterior gastropexy. The patient’s dysphagia disappeared after the second surgery, and recurrent volvulus has not been observed for 13 months. In cases with an unusually movable stomach, the addition of gastropexy may be effective in preventing postoperative gastric volvulus, which is rare but may possibly occur after laparoscopic fundoplication.     

Laparoscopic gastropexy for chronic gastric volvulus

Gastric volvulus is an infrequently encountered clinical entity characterized by abnormal rotation of the stomach. Surgical treatment by anterior gastropexy is indicated for acute and chronic gastric volvulus. Recently, laparoscopic surgery has been used in abdominal surgery. We report the case of a patient with chronic gastric volvulus who was treated by laparoscopic gastropexy and evaluated by upper gastrointestinal series and endoscopic appearance of the stomach. The laparoscopic approach is safe and effective for patients and is considered applicable to surgery for other upper gastrointestinal disorders requiring organ fixation.     

Laparoscopic repair of hiatal hernia with mesenterioaxial volvulus of the stomach

Although mesenterioaxial gastric volvulus is an uncommon entity characterized by rotation at the transverse axis of the stomach, laparoscopic repair procedures have still been controversial. We reported a case of mesenterioaxial intrathoracic gastric volvulus, which was successfully treated with laparoscopic repair of the diaphragmatic hiatal defect using a polytetrafluoroethylene mesh associated with Toupet fundoplication. A 70-year-old Japanese woman was admitted to our hospital because of sudden onset of...     

Laparoscopic gastropexy for chronic intermittent gastric volvulus.

The traditional surgical treatment of chronic gastric volvulus involves laparotomy for derotation of the stomach and its fixation to the patients. We describe a 36-year-old man with organoaxial gastric volvulus who was treated successfully with laparoscopic gastropexy. He is asymptomatic four months later.     

Endoscopic treatment of acute gastric volvulus causing cardiac tamponade

Acute gastric volvulus occurs when the stomach, or part of the stomach, rotates more than 180 degrees, creating a closed-loop obstruction, which eventually leads to ischemia and strangulation. Acute gastric volvulus may occur in association with a diaphragmatic defect, diaphragmatic elevation of any cause, tumors of the pancreas and stomach, trauma, and congenital abnormalities of mesenteric fixation. We describe an unusual case of an acute gastric volvulus causing cardiac tamponade, which was successfully treated by endoscopic reduction of the gastric volvulus.     

Rare Case of Internal Hernia with a New Type of Hepatodiaphragmatic Interposition of the Stomach and Colon

We report a new type of retroperitoneal internal hernia with hepatodiaphragmatic interposition of the stomach and colon. The hernia neck was formed in the lesser omentum, and the hernia sac consisted of the lesser omentum and retroperitoneum. The herniated organs (the stomach and colon) were incarcerated in the right extraperitoneal subphrenic space from the left dorsal side of the sulcus vena cava. This is the first reported case of this type.     

Laparoscopic management of totally intra-thoracic stomach with chronic volvulus

AIM:To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus(IGV)and to assess the preoperative work-up.METHODS:A retrospective review of a prospectively collected database of patient medical records identified14 patients who underwent a laparoscopic repair of IGV.The procedure included reduction of the stomach into the abdomen,total sac excision,reinforced hiatoplasty with mesh and construction of a partial fundoplication.All perioperative data,operative details and complications were recorded.All patients had at least 6 mo of follow-up.RESULTS:There were 4 male and 10 female patients.The mean age and the mean body mass index were 66years and 28.7 kg/m2,respectively.All patients presented with epigastric discomfort and early satiety.There was no mortality,and none of the cases were converted to an open procedure.The mean operative time was235 min,and the mean length of hospitalization was 2 d.There were no intraoperative complications.Four minor complications occurred in 3 patients including pleuraleffusion,subcutaneous emphysema,dysphagia and delayed gastric emptying.All minor complications resolved spontaneously without any intervention.During the mean follow-up of 29 mo,one patient had a radiological wrap herniation without volvulus.She remains symptom free with daily medication.CONCLUSION:The laparoscopic management of IGV is a safe but technically demanding procedure.The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery.     

Gastric volvulus and obstruction in paraesophageal hiatus hernia

Patients with a paraesophageal hiatus hernia are usually asymptomatic. If gastric volvulus and obstruction of the herniated stomach should occur, however, symptoms rapidly ensue and surgery is mandatory for patient survival. We have presented 4 such cases which illustrate the clinical spectrum of this complication and the necessity for rapid diagnosis and definitive surgery.     

Laparoscopic Nissen fundoplication using laparosonic coagulating shears: report of a case

A 64-year-old man was admitted to Gunma University Hospital because of gastroesophageal reflux disease and hiatus hernia. Endoscopic examination showed a linear ulcer and mucosal redness in the lower esophagus. Gastrointestinal contrast study revealed a large esophageal hiatal sliding hernia. Laparoscopic Nissen fundoplication was then performed. Short gastric vessels were divided and lesser omentum was ablated with laparosonic coagulating shears, and the fundus of the stomach was used to construct the wrap around the esophagus. Three hundred and sixty degree fundoplication was undertaken using four sutures to secure the wrap. The patient is well and is currently free from reflux symptoms. Laparoscopic Nissen fundoplication is effective in the control of gastroesophageal reflux in the patient with hiatus hernia. This case report demonstrates that the use of laparosonic coagulating shears is effective for the division of the short gastric vessels.     

Recurrent gastric volvulus resolved surgically after therapeutic percutaneous endoscopic gastrostomy in Duchenne muscular dystrophy

A 20-year-old man with Duchenne muscular dystrophy (DMD) with recurrent gastric volvulus underwent percutaneous endoscopic gastrostomy (PEG). Four months later, he developed vomiting and consciousness disturbance. CT revealed gastric volvulus recurrence along the gastrostomy axis. Endoscopic repositioning failed and fistula perforation necessitated emergency surgery. The upper position of the stomach was twisted counter-clockwise and revolved on the gastrostomy axis sliding between the lower stomach and abdominal wall. The fistula showed necrotic perforation and was thus resected. The anterior stomach wall was fixed to the abdominal wall at 3 triangular points. Thereafter, gastric volvulus did not recur. PEG is reportedly effective for preventing gastric volvulus, but there are rare cases of postgastrostomy recurrence. This successfully managed case provides valuable clinical insights.     

Laparoscopic resection of submucosal tumor on posterior wall of gastric fundus

AIM: Laparoscopic resection of tumors on the posterior wall of gastric fundus, especially when they are next to the esophagocardiac junction (ECJ), is both difficult and time-consuming. Furthermore, it can lead to inadvertent esophagus stenosis and injury to the spleen. In order to overcome these difficulties, laparoscopically extraluminal resection of gastric fundus was designed to manage submucosal tumors located on the posterior wall of gastric fundus and next to ECJ. METHODS: From January 2001 to September 2003, laparoscopically extraluminal resection of gastric fundus was successfully carried out on 15 patients. There were 11 males and 4 females with an average age of 58 years (range, 38 to 78 years). The mean diameter of the tumors was 4.8 cm. The distance of the tumor border from ECJ was about 1.5-2.5 cm. The four-portal operation procedures were as follows: localization of the tumor, dissection of the omentum, mobilization of the gastric fundus and the upper polar of spleen, exposure of ECJ, and resection of the gastric fundus with Endo GIA. RESULTS: The laparoscopic operation time averaged (66.2+/-10.4) min, the average amount of bleeding was (89.4+/-21.7) mL. The mean post-operative hospital stay was (5.3+/-1.1) d. Within 36 h post-operation, 73.3% of all the patients recovered their gastrointestinal function and began to eat something and to walk. In all the operations, no apparent tumor focus was left and no complication or conversion to open surgery occurred. CONCLUSION: Our newly designed procedure, laparoscopically extraluminal resection of the gastric fundus, can avoid contamination of the abdominal cavity, injury to the spleen and esophageal stenosis. The procedure seems to be both safe and effective.     

腹腔镜袖状胃切除术中大网膜复位的应用及效果

目的探讨腹腔镜袖状胃切除术（LSG）中大网膜复位的应用及效果。 方法回顾性分析2015年1月至2017年12月在暨南大学附属第一医院肥胖与代谢病外科行LSG加大网膜复位术的264例肥胖症患者的临床资料,记录患者的体质量指数（BMI）、年龄、性别、合并症及术后并发症。 结果共行LSG加大网膜复位术264例,其中女性199例,男性65例,平均年龄（29.72±9.79）岁,平均BMI为（36.39±5.22）kg/m²,其中单孔手术18例,同时行胆囊切除术的病例数为17例。有2名患者出现少量呕血,保守治疗后好转。观察到1例发生胃漏,未见扭转和狭窄,无死亡病例。 结论残胃扭转是袖状胃术后胃功能性狭窄的原因之一。LSG中通过大网膜复位可稳定残胃大弯侧,防止胃扭转。     

A rare type of lesser sac hernia.

We report herein the case of a female who developed a lesser sac hernia which was a rare type and was strangulated by a hole in the posterior layer of the lesser omentum. In our patient, abdominal computed tomography showed a loop of distended intestines among the liver, gallbladder and stomach. To our knowledge, there has been no previous report of transomental hernia exactly like our present case.     

A case of Bochdalek hernia in an adult with volvulus of the stomach and hypopotassemia

Gastric volvulus is a rare disease. We recently encountered a gastric volvulus associated with Bochdalek hernia and severe hypopotassemia. A 32-year-old woman experienced epigastric pain and recurrent vomiting. The changes of the electrocardiogram in this patient (K1.8mEq/l) were inverted T wave and ST depression. She was diagnosed as having gastric volvulus associated with Bochdalek hernia by chest X-ray films, contrast radiography of the upper digestive tract and thoraco-abdominal CT scans. Symptoms did not disappear with the administration of conservative therapy. At laparotomy, the stomach was rotated around its mesenteric axis in the sagittal plane. After operative repair, symptoms disappeared, and serum potassium level returned to normal. Gastric volvulus is rather easily diagnosed if its existence is kept in mind.     

Laparoscopic subtotal gastrectomy for gastric carcinoma treatment

Laparoscopic surgery of the stomach is not well accepted in patients with malignant disease. This paper shows the first experiences with this procedure at the Clinical Hospital and Medical School, Split, in two patients with early stage gastric carcinoma. The first patient was a 57 year old man who had had some gastric symptoms for a while. The other patient was a 73 year old man who had ulcer disease 52 years ago. Laparoscopic subtotal gastrectomy with omentectomy and Roux-en-Y reconstruction of the alimentary tract was performed on both patients. Pathohystological analysis of the resected part of the stomach showed the early stage gastric adenocarcinoma without metastases to the lymph nodes around the stomach or any pathological changes in the omentum for both of the patients. There were no complications during postoperative period. The first patient was released from the hospital after 8 and other after 9 days. All oncological principles were satisfied with laparoscopic subtotal resection with good and fast postoperative recovery without complications.     

LAPAROSCOPIC COMPOSITE‐MESH REPAIR OF AN ADULT MORGAGNI HERNIA

Congenital Morgagni hernia is a rare clinical condition. We present a 72‐year‐old man with epigastric discomfort and hematemesis who was diagnosed with hernia of Morgagni with an incarceration of the stomach and colon. The patient was treated electively by laparoscopic composite‐mesh repair without excising the hernial sac or approximating the edges of the defect, which was 10 × 6 cm in diameter. He was discharged on the seventh postoperative day without any complications. At a 1‐year follow‐up examination he had no recurrence nor clinical symptoms, although the large hernial sac contained fluid. Laparoscopic composite‐mesh repair is a less‐invasive and tension‐free method for Morgagni hernia that results in an excellent clinical outcome.     

Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett's esophagus

Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE(LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach(LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of thearch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 m L of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.     

Hydropneumopericardium Presenting as an Acute Coronary Syndrome: A Rare Complication of Paraesophageal Hernia

Hydropneumopericardium is a very rare complication of long-standing paraesophageal hernia, occurring as a result of rupture of the intrathoracic gastric volvulus into the pericardium. A chronic paraesophageal hernia that is complicated by gastric volvulus can develop into such surgical emergencies as acute gastric obstruction, strangulation, perforation, and rupture into adjacent structures. Subsequent hydropneumopericardium constitutes an acute emergency that requires immediate surgical treatment and pericardial drainage. Herein, we discuss what we believe to be the 1st reported case of hydropneumopericardium that presented as an acute coronary syndrome in a patient who had a chronic paraesophageal hernia (as a result of rupture of the gastric volvulus into the pericardium). The 80-year-old patient did not survive the condition.Key words: Aged, 80 and over; diagnosis, differential; hernia, paraesophageal; pneumopericardium/complications/diagnosis/etiology/mortality/physiopathology/surgery/therapy; stomach volvulus/complicationsHydropneumopericardium is a very rare complication of long-standing paraesophageal hernia, occurring as a result of rupture of the intrathoracic gastric volvulus into the pericardium. A chronic paraesophageal hernia can be complicated by gastric volvulus and can present as various surgical emergencies, including acute gastric obstruction, strangulation, perforation, and rupture into adjacent structures.^1,2 Subsequent hydropneumopericardium constitutes an acute emergency that requires immediate surgical treatment and pericardial drainage. The mortality rate of this condition has been reported to be as high as 58%.³ Here, we present the case of an 80-year-old woman whose hydropneumopericardium presented as an acute coronary syndrome (ACS).     

Gastric volvulus caused by paraesophageal hernia complicating mid-trimester pregnancy

A 36-year-old woman, who was 19 weeks pregnant presented with epigastric pain and a one-week history of repeated vomiting. Endoscopy revealed twisted stomach. CT scan of the chest showed figure of eight stomach consistent with gastric volvulus. Confirmation of diagnosis was made by laparatomy in which reduction of the oedematous stomach and excision of ischemic omental patch and repair of a huge paraesophageal hernia were performed. Two days after operation, abortion took place. Few days later, rapid deterioration in renal and hepatic function occurred followed by maternal death.