1. Joint Hospital Grand Round Management of Chronic Gastric Volvulus Kenny K Y Yuen Tseung Kwan O Hospital 20th January, 2007 Kenny K Y Yuen Tseung Kwan O Hospital 20th January, 2007

2. Clinical scenario Clinical scenario History History Predisposing factors Predisposing factors Classifications Classifications Clinical presentations Clinical presentations Investigations Investigations Treatment Treatment Clinical scenario Clinical scenario History History Predisposing factors Predisposing factors Classifications Classifications Clinical presentations Clinical presentations Investigations Investigations Treatment Treatment

3. Clinical Scenario F/29 F/29 Intermittent epigastric pain for years Intermittent epigastric pain for years Cramping after heavy meal, relieved after vomiting Cramping after heavy meal, relieved after vomiting Weight loss 5 kg within 2-3 months Weight loss 5 kg within 2-3 months Upper endoscopy twisted stomach with difficulty in finding pylorus twisted stomach with difficulty in finding pylorus F/29 F/29 Intermittent epigastric pain for years Intermittent epigastric pain for years Cramping after heavy meal, relieved after vomiting Cramping after heavy meal, relieved after vomiting Weight loss 5 kg within 2-3 months Weight loss 5 kg within 2-3 months Upper endoscopy twisted stomach with difficulty in finding pylorus twisted stomach with difficulty in finding pylorus

5. Clinical Scenario Erect AXR Double air-fluid levels at LUQ Double air-fluid levels at LUQ Ba meal Stomach rotated > 180 o Stomach rotated > 180 o Body rotates towards the R hemidiaphragm Body rotates towards the R hemidiaphragm Greater curve laying same level as the fundus Greater curve laying same level as the fundus Organoaxial gastric volvulus Organoaxial gastric volvulus No hiatus hernia No hiatus hernia No gastric outlet obstruction No gastric outlet obstruction Erect AXR Double air-fluid levels at LUQ Double air-fluid levels at LUQ Ba meal Stomach rotated > 180 o Stomach rotated > 180 o Body rotates towards the R hemidiaphragm Body rotates towards the R hemidiaphragm Greater curve laying same level as the fundus Greater curve laying same level as the fundus Organoaxial gastric volvulus Organoaxial gastric volvulus No hiatus hernia No hiatus hernia No gastric outlet obstruction No gastric outlet obstruction

7. DefinitionDefinition Gastric volvulus is rotation of all or part of the stomach more than 180°, which may lead to a closed-loop obstruction and possible strangulation Gastric volvulus is rotation of all or part of the stomach more than 180°, which may lead to a closed-loop obstruction and possible strangulation

8. 1579 1866 1895 1904 1920 1930 1968 AmbrosePare Berti Berg Borchardt Roselet Buchanan Tanner History of Gastric Volvulus Described GV during autopsy Described GV during autopsy GV after sword wound GV after sword wound 1st successful operation 1st successful operation Classical triad Classical triad Described radiologically Described radiologically Clarify anatomical variation Clarify anatomical variation Etiology & methods of repair Etiology & methods of repair

9. Anatomy Anatomy

10. Predisposing factors Primary Primary –Laxity of the supporting ligaments –Especially elongation of the gastrosplenic and/or gastrocolic ligaments –one-third of cases Primary Primary –Laxity of the supporting ligaments –Especially elongation of the gastrosplenic and/or gastrocolic ligaments –one-third of cases

11. Predisposing factors Secondary Secondary Diaphragmatic defect –eventration –paraesophageal hiatal hernia –Bochdalek hernia –trauma –paralysis Congenital bands or adhesions Intestinal malrotation Pyloric stenosis with gastric distension Colon distension Secondary Secondary Diaphragmatic defect –eventration –paraesophageal hiatal hernia –Bochdalek hernia –trauma –paralysis Congenital bands or adhesions Intestinal malrotation Pyloric stenosis with gastric distension Colon distension

12. Predisposing factors Diaphragmatic defects - 43% Diaphragmatic defects - 43% Gastric ligaments - 32% Gastric ligaments - 32% Abnormal attachments, adhesions, or bands - 9% Abnormal attachments, adhesions, or bands - 9% Asplenism - 5% Asplenism - 5% Small and large bowel malformations - 4% Small and large bowel malformations - 4% Pyloric stenosis - 2% Pyloric stenosis - 2% Colonic distension - 1% Colonic distension - 1% Rectal atresia - 1% Rectal atresia - 1% Diaphragmatic defects - 43% Diaphragmatic defects - 43% Gastric ligaments - 32% Gastric ligaments - 32% Abnormal attachments, adhesions, or bands - 9% Abnormal attachments, adhesions, or bands - 9% Asplenism - 5% Asplenism - 5% Small and large bowel malformations - 4% Small and large bowel malformations - 4% Pyloric stenosis - 2% Pyloric stenosis - 2% Colonic distension - 1% Colonic distension - 1% Rectal atresia - 1% Rectal atresia - 1%

13. ClassificationsClassifications Onset - Acute Vs Chronic Onset - Acute Vs Chronic Location – subdiaphragmatic / primary Vs supradiaphragmatic / secondary Location – subdiaphragmatic / primary Vs supradiaphragmatic / secondary Axis of rotation – organoaxial/ mesenteroaxial / combined / unclassified Axis of rotation – organoaxial/ mesenteroaxial / combined / unclassified Etiology – type 1(idiopathic) Vs type 2 (congenital or acquired) Etiology – type 1(idiopathic) Vs type 2 (congenital or acquired) Onset - Acute Vs Chronic Onset - Acute Vs Chronic Location – subdiaphragmatic / primary Vs supradiaphragmatic / secondary Location – subdiaphragmatic / primary Vs supradiaphragmatic / secondary Axis of rotation – organoaxial/ mesenteroaxial / combined / unclassified Axis of rotation – organoaxial/ mesenteroaxial / combined / unclassified Etiology – type 1(idiopathic) Vs type 2 (congenital or acquired) Etiology – type 1(idiopathic) Vs type 2 (congenital or acquired)

14. ClassificationsClassifications Subdiaphragmatic, or primary Subdiaphragmatic, or primary – not associated with diaphragmatic defects – one third of cases Supradiaphragmatic, or secondary Supradiaphragmatic, or secondary – associated with diaphragmatic defects – two thirds of cases Subdiaphragmatic, or primary Subdiaphragmatic, or primary – not associated with diaphragmatic defects – one third of cases Supradiaphragmatic, or secondary Supradiaphragmatic, or secondary – associated with diaphragmatic defects – two thirds of cases

15. ClassificationsClassifications Organoaxial volvulus Organoaxial volvulus Rotates about the cardiopyloric axis results in an upside down stomach with the greater curve on top Obstruction may occur at the gastroesophageal junction and the pyloroantral area. 59% Mainly adult Organoaxial volvulus Organoaxial volvulus Rotates about the cardiopyloric axis results in an upside down stomach with the greater curve on top Obstruction may occur at the gastroesophageal junction and the pyloroantral area. 59% Mainly adult

16. ClassificationsClassifications Mesenteroaxial volvulus Mesenteroaxial volvulus Anterior rotation about an axis perpendicular to the cardiopyloric axis Greater curve remains on the bottom 29% Mainly children Mesenteroaxial volvulus Mesenteroaxial volvulus Anterior rotation about an axis perpendicular to the cardiopyloric axis Greater curve remains on the bottom 29% Mainly children

17. Clinical Presentation Borchardt s classical triad (1904): Borchardt s classical triad (1904): –epigastric pain and distention –Non-productive vomiting –difficulty with nasogastric tube insertion Borchardt s classical triad (1904): Borchardt s classical triad (1904): –epigastric pain and distention –Non-productive vomiting –difficulty with nasogastric tube insertion

18. Presenting symptom AcuteChronicTotal Abdominal pain 24630 Vomiting17320 UGIB/anaemia9211 Abdominal distension 505 Gastro-esophageal reflux 527 Dysphagia437 Respiratory symptoms/ chest pain 707 Postprandial discomfort 303 Altered bowel habit 202 Excess flatulence 202 Acute confusion 101 Dehydration101 Teague et al, BMJ 2000

19. InvestigationsInvestigations Barium study high sensitivity and specificity high sensitivity and specificity criterion standard for diagnosis criterion standard for diagnosis upside-down configuration of the stomach upside-down configuration of the stomach esophagogastric junction is lower than normal. esophagogastric junction is lower than normal. marked gastric dilatation and the slow passage of contrast past the site of twisting marked gastric dilatation and the slow passage of contrast past the site of twisting Barium study high sensitivity and specificity high sensitivity and specificity criterion standard for diagnosis criterion standard for diagnosis upside-down configuration of the stomach upside-down configuration of the stomach esophagogastric junction is lower than normal. esophagogastric junction is lower than normal. marked gastric dilatation and the slow passage of contrast past the site of twisting marked gastric dilatation and the slow passage of contrast past the site of twisting

20. InvestigationsInvestigations X-Ray findings suggestive of gastric volvulus should be confirmed with a barium study findings suggestive of gastric volvulus should be confirmed with a barium study Erect film: two air-fluid levels on the fundus - inferior, antrum - superior Erect film: two air-fluid levels on the fundus - inferior, antrum - superior Supine film: a beak where the esophagogastric junction is seen on normal images Supine film: a beak where the esophagogastric junction is seen on normal imagesX-Ray findings suggestive of gastric volvulus should be confirmed with a barium study findings suggestive of gastric volvulus should be confirmed with a barium study Erect film: two air-fluid levels on the fundus - inferior, antrum - superior Erect film: two air-fluid levels on the fundus - inferior, antrum - superior Supine film: a beak where the esophagogastric junction is seen on normal images Supine film: a beak where the esophagogastric junction is seen on normal images

21. InvestigationsInvestigations Endoscopy Both diagnostic and therapeutic Both diagnostic and therapeutic Mainly for therapeutic Mainly for therapeutic CT / MRI / USG Not diagnostic Not diagnostic Consider in patient cannot tolerate endoscopy or fluoroscopy Consider in patient cannot tolerate endoscopy or fluoroscopyEndoscopy Both diagnostic and therapeutic Both diagnostic and therapeutic Mainly for therapeutic Mainly for therapeutic CT / MRI / USG Not diagnostic Not diagnostic Consider in patient cannot tolerate endoscopy or fluoroscopy Consider in patient cannot tolerate endoscopy or fluoroscopy

22. InvestigationsInvestigationsInvestigationOrderedDiagnosticSuggestive No yield Barium meal 251474 CXR190514 Upper endoscopy 18567 AXR8034 Manometry/pH4004 Chest CT scan 2011 Colonoscopy1001 USG1001 Teague et al, BMJ 2000

23. TreatmentTreatment Aims: Aims: – Reduction of volvulus – Gastric fixation – Repair of predisposing factors Open Vs Endoscopic Vs Laparoscopic Vs Combined endoscopic and laproscopic Open Vs Endoscopic Vs Laparoscopic Vs Combined endoscopic and laproscopic Aims: Aims: – Reduction of volvulus – Gastric fixation – Repair of predisposing factors Open Vs Endoscopic Vs Laparoscopic Vs Combined endoscopic and laproscopic Open Vs Endoscopic Vs Laparoscopic Vs Combined endoscopic and laproscopic

24. Treatment – open surgery Open Surgery (traditional treatment >10 years ago) Diaphragmatic hernia repair Diaphragmatic hernia repair Division of bands Division of bands Gastropexy Gastropexy Partial gastrectomy (in case of necrosis) Partial gastrectomy (in case of necrosis) Gastropexy with division of gastrocolic ligament (Tanner s Operation) Gastropexy with division of gastrocolic ligament (Tanner s Operation) Gastrojejunostomy Gastrojejunostomy Fundoantral gastrogastrostomy (Opolzer s Operation) Fundoantral gastrogastrostomy (Opolzer s Operation) Repair of eventration of diaphragm Repair of eventration of diaphragm Open Surgery (traditional treatment >10 years ago) Diaphragmatic hernia repair Diaphragmatic hernia repair Division of bands Division of bands Gastropexy Gastropexy Partial gastrectomy (in case of necrosis) Partial gastrectomy (in case of necrosis) Gastropexy with division of gastrocolic ligament (Tanner s Operation) Gastropexy with division of gastrocolic ligament (Tanner s Operation) Gastrojejunostomy Gastrojejunostomy Fundoantral gastrogastrostomy (Opolzer s Operation) Fundoantral gastrogastrostomy (Opolzer s Operation) Repair of eventration of diaphragm Repair of eventration of diaphragm

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

26. Treatment – alpha 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 endoscope into the antrum and uncoiling of the loop and reduction of the volvulus Tsang et al. 1995

27. Treatment - J-type 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 turned to right and partially locked. Endoscopy is rotated through 180 o in anti- clockwise direction and withdrawn Bhasin et al. 1990

28. Treatment - laparoscopic 3-ports / 4-ports / 5-ports 3-ports / 4-ports / 5-ports Reduction of Volvulus Reduction of Volvulus Anchoring fundus of stomach to the diaphragm Anchoring fundus of stomach to the diaphragm Greater curve of the stomach to anterior abdominal wall Greater curve of the stomach to anterior abdominal wall +/- repair of diaphragmatic defect +/- repair of diaphragmatic defect +/- fundoplication or/and esocardiopexy – prevent post-operative GERD +/- fundoplication or/and esocardiopexy – prevent post-operative GERD +/- gastrostomy +/- gastrostomy 3-ports / 4-ports / 5-ports 3-ports / 4-ports / 5-ports Reduction of Volvulus Reduction of Volvulus Anchoring fundus of stomach to the diaphragm Anchoring fundus of stomach to the diaphragm Greater curve of the stomach to anterior abdominal wall Greater curve of the stomach to anterior abdominal wall +/- repair of diaphragmatic defect +/- repair of diaphragmatic defect +/- fundoplication or/and esocardiopexy – prevent post-operative GERD +/- fundoplication or/and esocardiopexy – prevent post-operative GERD +/- gastrostomy +/- gastrostomy

29. Treatment - laparoscopic 2 vertical lines – fundus anchored to diaphragm X – anterior gastropexy stitches A – camera, B – liver retractor, C,D,E - operating ports

30. Treatment - laparoscopic Esocardiopexy Phrenofundopexy Anterior gastropexy

31. Management - combined Described by Arben Beqiri (1997): Described by Arben Beqiri (1997): –Use endoscopic T-fasteners instead of PEG for anchoring –Laparoscopy - reduction of volvulus –Endoscopy - placement of T-fasteners –Less time consuming Described by Arben Beqiri (1997): Described by Arben Beqiri (1997): –Use endoscopic T-fasteners instead of PEG for anchoring –Laparoscopy - reduction of volvulus –Endoscopy - placement of T-fasteners –Less time consuming

32. TreatmentTreatment Follow-up Clinical Clinical –reflux symptoms –recurrent of symptoms - detection of recurrence –removal of PEG tube Imaging – Post OT contrast study Imaging – Post OT contrast study (no consensus of interval - Day 2 to 3 months) (no consensus of interval - Day 2 to 3 months)Follow-up Clinical Clinical –reflux symptoms –recurrent of symptoms - detection of recurrence –removal of PEG tube Imaging – Post OT contrast study Imaging – Post OT contrast study (no consensus of interval - Day 2 to 3 months) (no consensus of interval - Day 2 to 3 months)

33. TreatmentTreatment No RCT No RCT –rare disease (2.6/million/year) Largest series – Teague et al in 2000 Largest series – Teague et al in 2000 –36 patients were recruited Results: Results: –Diagnostic investigation: Ba contrast (21/25) and upper endoscopy (18/21) –Conservative Tx (5), open surgery (13), laparoscopic (18) – no major complications and death –Median hospital stay: shorter in laparoscopic group than open group 6 Vs 14, p< 0.05 No RCT No RCT –rare disease (2.6/million/year) Largest series – Teague et al in 2000 Largest series – Teague et al in 2000 –36 patients were recruited Results: Results: –Diagnostic investigation: Ba contrast (21/25) and upper endoscopy (18/21) –Conservative Tx (5), open surgery (13), laparoscopic (18) – no major complications and death –Median hospital stay: shorter in laparoscopic group than open group 6 Vs 14, p< 0.05

34. Clinical Scenario Laparoscopic approach Laparoscopic approach 3-ports 3-ports Organoaxial type Organoaxial type No diaphragmatic hernia and eventration of diaphragm No diaphragmatic hernia and eventration of diaphragm Gastropexy Gastropexy – 0-Ethibon – 2 anchoring fundus to the diaphragm – 2 anchoring greater curve to the anterior abdominal wall Laparoscopic approach Laparoscopic approach 3-ports 3-ports Organoaxial type Organoaxial type No diaphragmatic hernia and eventration of diaphragm No diaphragmatic hernia and eventration of diaphragm Gastropexy Gastropexy – 0-Ethibon – 2 anchoring fundus to the diaphragm – 2 anchoring greater curve to the anterior abdominal wall

41. Clinical Scenario Follow up: Follow up: –Resume diet in D3 –Contrast study in D2 stomach in normal position no gross abnormal configuration of stomach Follow up: Follow up: –Resume diet in D3 –Contrast study in D2 stomach in normal position no gross abnormal configuration of stomach

42. Clinical Scenario

43. ConclusionConclusion Chronic gastric volvulus is a rare disease Chronic gastric volvulus is a rare disease Require high index of suspicion in diagnosis Require high index of suspicion in diagnosis Pain and vomiting are the main symptoms Pain and vomiting are the main symptoms Barium meal is the most diagnostic tool Barium meal is the most diagnostic tool Can be safely treated by laparoscopic approach Can be safely treated by laparoscopic approach Chronic gastric volvulus is a rare disease Chronic gastric volvulus is a rare disease Require high index of suspicion in diagnosis Require high index of suspicion in diagnosis Pain and vomiting are the main symptoms Pain and vomiting are the main symptoms Barium meal is the most diagnostic tool Barium meal is the most diagnostic tool Can be safely treated by laparoscopic approach Can be safely treated by laparoscopic approach

44. The End Thank you The End Thank you