A rare case of post-splenectomy gastric volvulus managed by laparoscopic anterior gastropexy.

We report an extremely rare case of recurrent gastric volvulus after open splenectomy for hereditary spherocytosis. The initial episode was managed by endoscopic derotation. Later, for recurrent symptoms, she was successfully managed by laparoscopic anterior gastropexy.

INTRODUCTION

Gastric volvulus is characterized by an abnormal rotation of the stomach of more than 180° and it clinically presents as epigastric pain, distension and inability to vomit. Rarely it may present as acute abdomen secondary to rapid development of strangulation, incarceration, or perforation.[1] Gastric volvulus is generally secondary to diaphragmatic or para esophageal hernia.[2] Rarely, the laxity of supporting ligaments makes the stomach more prone to rotation and consequently leading to volvulus. Splenectomy for massive splenomegaly requires division of gastric ligaments and the residual dead space provide room for gastric rotation. However, to our knowledge, no case of post splenectomy gastric volvulus has been reported till date in the modern literature. Herein, we report a case of post splenectomy mesentero-axial gastric volvulus that was treated successfully with laparoscopic anterior gastropexy.

INDEX CASE

A 53-year-old female underwent open splenectomy for hereditary spherocytosis. Post-operatively, she developed retching followed by bilious vomiting. Contrast-enhanced computed tomography (CECT) of the abdomen showed a partial mesenteroaxial gastric volvulus [Figure 1]. Upper gastrointestinal endoscopy (UGIE) confirmed a shelf-like projection in the body of the stomach with tortuous distal stomach. Endoscopic derotation and nasojejunal intubation were done. She required readmission, after the 10th day of discharge, for recurrent vomiting and abdominal pain. Barium meal studies showed pylorus lying anterosuperior to the fundus, consistent with the diagnosis of mesenteroaxial gastric volvulus.

Figure 1

Contrast-enhanced computed tomography abdomen showing folding of pyloro-antral region over the gastric fundus

Laparoscopic anterior gastropexy was planned. The patient was placed in reverse Trendelenburg position with lower limbs in abduction; the trocars were positioned similar to that used for fundoplication except that they were placed 4–5 cm below the subcostal margin: 10-mm trocar in the umbilicus, 10-mm working trocars in the left hypochondrium, 5 mm in the left flank and 5-mm trocar in the right hypochondrium. The stomach was very elongated with the folding of the antro-pyloric region over the fundus of the stomach suggesting a mesenteroaxial volvulus. Laparoscopic anterior gastropexy was performed by percutaneous transfascial fixation of the greater curvature at five points with 1/0 prolene suture [Figure 2]. All the sutures were left in situ over the skin and tightened after deflation of the pneumoperitoneum. Post-operative period was uneventful.

Figure 2

Intraoperative photograph after the application of interrupted transfascial fixation sutures

Post-operative barium study showed a correctly positioned stomach with the free passage of contrast across the antro-pyloric region. At 6-month follow-up, the patient is doing well.

DISCUSSION

Gastric volvulus is an uncommon disorder characterised by rotation of a part or whole of the stomach in elderly adults. Volvulus can occur either along the longitudinal axis (organo-axial) or along the transverse axis (mesenteroaxial) of the stomach. It is mostly secondary to a diaphragmatic or a paraesophageal hernia.[123] Weak supporting ligaments mainly the gastrocolic and gastrosplenic ligaments or their disruption following upper abdominal surgery allow abnormal mobility of greater curvature of the stomach and pyloric antrum predisposing gastric volvulus. Splenectomy is a risk factor for the development of gastric volvulus in dogs.[4] However, this association has not been described in human being. After extensive English literature search, we could find only one report of post-operative gastric volvulus occurring after distal pancreatectomy and splenectomy for pancreatic tumour.[3]

Acute gastric volvulus presents as a surgical emergency with severe epigastric pain, inability to vomit and epigastric distension[1] while the chronic gastric volvulus is often associated with intermittent post-prandial epigastric pain, vomiting and epigastric distension.[12] Barium studies, CECT and UGIE, during the volvulus episode, clinch the diagnosis.[2] In the index case, both CECT and UGIE had confirmed the diagnosis. CECT is also beneficial in identifying the predisposing factors such as the diaphragmatic, hiatal hernia.[12]

Gastric volvulus treatment has evolved from open surgery to various endoscopic and laparoscopic techniques.[25] Endoscopic techniques are suitable for stable patients with partial volvulus without gastric ischemia or diaphragmatic defect. Endoscopic derotation with or without percutaneous endoscopic gastrostomy or stent is recommended, especially, in elderly patients, to prevent recurrence.[2]

With advanced laparoscopic techniques, the treatment of gastric volvulus has moved away from earlier open gastropexy to anterior gastropexy with or without gastrostomy.[25] Laparoscopy also offers the added advantage of repairing the concomitant hiatal or diaphragmatic hernia. Minimally invasive approach provides less pain and enhanced recovery, hence, is beneficial even in situations such as gastric ischemia and high-risk elderly patients.[5]

In conclusion, post-splenectomy recurrent gastric volvulus is an extremely rare phenomenon. The diagnosis is confirmed by CECT, endoscopy or barium contrast studies. Laparoscopic anterior gastropexy is an effective alternative treatment of recurrent gastric volvulus.

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Conflicts of interest

There are no conflicts of interest.