Joint Hospital Grand Round Management of Chronic Gastric Volvulus Kenny K Y Yuen Tseung Kwan O...
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Transcript of Joint Hospital Grand Round Management of Chronic Gastric Volvulus Kenny K Y Yuen Tseung Kwan O...
Joint Hospital Grand RoundJoint Hospital Grand RoundManagement of Management of
Chronic Gastric VolvulusChronic Gastric Volvulus
Joint Hospital Grand RoundJoint Hospital Grand RoundManagement of Management of
Chronic Gastric VolvulusChronic Gastric Volvulus
Kenny K Y YuenKenny K Y YuenTseung Kwan O HospitalTseung Kwan O Hospital
20th January, 200720th January, 2007
Kenny K Y YuenKenny K Y YuenTseung Kwan O HospitalTseung Kwan O Hospital
20th January, 200720th January, 2007
•Clinical scenarioClinical scenario
•HistoryHistory
•Predisposing factorsPredisposing factors
•ClassificationsClassifications
•Clinical presentationsClinical presentations
• InvestigationsInvestigations
•Treatment Treatment
•Clinical scenarioClinical scenario
•HistoryHistory
•Predisposing factorsPredisposing factors
•ClassificationsClassifications
•Clinical presentationsClinical presentations
• InvestigationsInvestigations
•Treatment Treatment
Clinical ScenarioClinical ScenarioClinical ScenarioClinical Scenario
• F/29F/29• Intermittent epigastric painIntermittent epigastric pain for years for years• CrampingCramping after heavy meal, relieved after after heavy meal, relieved after
vomitingvomiting• Weight lossWeight loss 5 kg within 2-3 months 5 kg within 2-3 monthsUpper endoscopyUpper endoscopy • twisted stomachtwisted stomach with difficulty in finding pyloru with difficulty in finding pyloru
ss
• F/29F/29• Intermittent epigastric painIntermittent epigastric pain for years for years• CrampingCramping after heavy meal, relieved after after heavy meal, relieved after
vomitingvomiting• Weight lossWeight loss 5 kg within 2-3 months 5 kg within 2-3 monthsUpper endoscopyUpper endoscopy • twisted stomachtwisted stomach with difficulty in finding pyloru with difficulty in finding pyloru
ss
Clinical ScenarioClinical ScenarioClinical ScenarioClinical Scenario
Erect AXRErect AXR • Double air-fluidDouble air-fluid levels at LUQ levels at LUQ Ba mealBa meal• Stomach Stomach rotated rotated > 180> 180oo
• Body rotates towards the R hemidiaphragmBody rotates towards the R hemidiaphragm• Greater curveGreater curve laying laying same levelsame level as the as the fundus fundus• OrganoaxialOrganoaxial gastric volvulus gastric volvulus• No hiatus hernia No hiatus hernia • No gastric outlet obstructionNo gastric outlet obstruction
Erect AXRErect AXR • Double air-fluidDouble air-fluid levels at LUQ levels at LUQ Ba mealBa meal• Stomach Stomach rotated rotated > 180> 180oo
• Body rotates towards the R hemidiaphragmBody rotates towards the R hemidiaphragm• Greater curveGreater curve laying laying same levelsame level as the as the fundus fundus• OrganoaxialOrganoaxial gastric volvulus gastric volvulus• No hiatus hernia No hiatus hernia • No gastric outlet obstructionNo gastric outlet obstruction
DefinitionDefinitionDefinitionDefinition
• Gastric volvulusGastric volvulus is rotation of all or pa is rotation of all or part of the stomach rt of the stomach more than 180°,more than 180°, whic which may lead to a h may lead to a closed-loop obstructioclosed-loop obstructionn and and possible strangulationpossible strangulation
• Gastric volvulusGastric volvulus is rotation of all or pa is rotation of all or part of the stomach rt of the stomach more than 180°,more than 180°, whic which may lead to a h may lead to a closed-loop obstructioclosed-loop obstructionn and and possible strangulationpossible strangulation
15791579
18661866
18951895
19041904
19201920
19301930
19681968
Ambrose Ambrose ParePare
BertiBerti
BergBerg
BorchardtBorchardt
RoseletRoselet
BuchananBuchanan
TannerTanner
History of Gastric VolvulusHistory of Gastric Volvulus
Described GV during autopsy
Described GV during autopsy
GV after sword woundGV after sword wound
1st successfuloperation
1st successfuloperation Classic
al triad
Classical triad Described
radiologically
Describedradiologically
Clarify anatomicalvariationClarify anatomicalvariation
Etiology & methods of repair
Etiology & methods of repair
AnatomyAnatomy AnatomyAnatomy
Predisposing factorsPredisposing factorsPredisposing factorsPredisposing factors
•Primary Primary – LaxityLaxity of the supporting ligaments of the supporting ligaments– Especially elongation of the Especially elongation of the gastrosplenicgastrosplenic a a
nd/or nd/or gastrocolicgastrocolic ligaments ligaments– one-third of casesone-third of cases
•Primary Primary – LaxityLaxity of the supporting ligaments of the supporting ligaments– Especially elongation of the Especially elongation of the gastrosplenicgastrosplenic a a
nd/or nd/or gastrocolicgastrocolic ligaments ligaments– one-third of casesone-third of cases
Predisposing factorsPredisposing factorsPredisposing factorsPredisposing factors
•SecondarySecondaryDiaphragmatic defectDiaphragmatic defect – eventration eventration – paraesophageal hiatal herniaparaesophageal hiatal hernia– Bochdalek herniaBochdalek hernia– trauma trauma – paralysisparalysisCongenital bands or adhesionsCongenital bands or adhesionsIntestinal malrotationIntestinal malrotationPyloric stenosis with gastric distensionPyloric stenosis with gastric distensionColon distensionColon distension
•SecondarySecondaryDiaphragmatic defectDiaphragmatic defect – eventration eventration – paraesophageal hiatal herniaparaesophageal hiatal hernia– Bochdalek herniaBochdalek hernia– trauma trauma – paralysisparalysisCongenital bands or adhesionsCongenital bands or adhesionsIntestinal malrotationIntestinal malrotationPyloric stenosis with gastric distensionPyloric stenosis with gastric distensionColon distensionColon distension
Predisposing factorsPredisposing factorsPredisposing factorsPredisposing factors
• Diaphragmatic defectsDiaphragmatic defects - - 43%43%• Gastric ligamentsGastric ligaments - - 32%32%• Abnormal attachments, adhesions, or bands - 9Abnormal 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 defectsDiaphragmatic defects - - 43%43%• Gastric ligamentsGastric ligaments - - 32%32%• Abnormal attachments, adhesions, or bands - 9Abnormal 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%
ClassificationsClassificationsClassificationsClassifications
• OnsetOnset - Acute Vs Chronic - Acute Vs Chronic • LocationLocation – subdiaphragmatic / primary – subdiaphragmatic / primary
Vs supradiaphragmatic / secondaryVs supradiaphragmatic / secondary• Axis of rotationAxis of rotation – organoaxial/ mesente – organoaxial/ mesente
roaxial / combined / unclassified roaxial / combined / unclassified • EtiologyEtiology – type 1(idiopathic) Vs type 2 (c – type 1(idiopathic) Vs type 2 (c
ongenital or acquired)ongenital or acquired)
• OnsetOnset - Acute Vs Chronic - Acute Vs Chronic • LocationLocation – subdiaphragmatic / primary – subdiaphragmatic / primary
Vs supradiaphragmatic / secondaryVs supradiaphragmatic / secondary• Axis of rotationAxis of rotation – organoaxial/ mesente – organoaxial/ mesente
roaxial / combined / unclassified roaxial / combined / unclassified • EtiologyEtiology – type 1(idiopathic) Vs type 2 (c – type 1(idiopathic) Vs type 2 (c
ongenital or acquired)ongenital or acquired)
ClassificationsClassificationsClassificationsClassifications
• SubdiaphragmaticSubdiaphragmatic, or , or primaryprimary– notnot associated associated with diaphragmatic defects with diaphragmatic defects – one third of casesone third of cases
• SupradiaphragmaticSupradiaphragmatic, or , or secondarysecondary– associatedassociated with diaphragmatic defects with diaphragmatic defects – two thirds of casestwo thirds of cases
• SubdiaphragmaticSubdiaphragmatic, or , or primaryprimary– notnot associated associated with diaphragmatic defects with diaphragmatic defects – one third of casesone third of cases
• SupradiaphragmaticSupradiaphragmatic, or , or secondarysecondary– associatedassociated with diaphragmatic defects with diaphragmatic defects – two thirds of casestwo thirds of cases
ClassificationsClassificationsClassificationsClassifications• Organoaxial volvulusOrganoaxial volvulus
Rotates Rotates about the cardiopabout the cardiopyloric axisyloric axis results in an u results in an upside down stomach witpside down stomach with theh the greater curve on tgreater curve on top op
Obstruction may occur at Obstruction may occur at the gastroesophageal juthe gastroesophageal junction and the pyloroannction and the pyloroantral area. tral area.
59%59%Mainly Mainly adultadult
• Organoaxial volvulusOrganoaxial volvulusRotates Rotates about the cardiopabout the cardiop
yloric axisyloric axis results in an u results in an upside down stomach witpside down stomach with theh the greater curve on tgreater curve on top op
Obstruction may occur at Obstruction may occur at the gastroesophageal juthe gastroesophageal junction and the pyloroannction and the pyloroantral area. tral area.
59%59%Mainly Mainly adultadult
ClassificationsClassificationsClassificationsClassifications
• Mesenteroaxial volvMesenteroaxial volvulusulusAnterior rotation about aAnterior rotation about a
n axis n axis perpendicular to perpendicular to the cardiopyloric axisthe cardiopyloric axis
Greater curve remains on Greater curve remains on the bottomthe bottom
29% 29% Mainly Mainly childrenchildren
• Mesenteroaxial volvMesenteroaxial volvulusulusAnterior rotation about aAnterior rotation about a
n axis n axis perpendicular to perpendicular to the cardiopyloric axisthe cardiopyloric axis
Greater curve remains on Greater curve remains on the bottomthe bottom
29% 29% Mainly Mainly childrenchildren
Clinical PresentationClinical PresentationClinical PresentationClinical Presentation
• Borchardt’s classical triad (1904):Borchardt’s classical triad (1904):– epigastric painepigastric pain and and distentiondistention– Non-productive vomitingNon-productive vomiting– difficultydifficulty with nasogastric tube insertion with nasogastric tube insertion
• Borchardt’s classical triad (1904):Borchardt’s classical triad (1904):– epigastric painepigastric pain and and distentiondistention– Non-productive vomitingNon-productive vomiting– difficultydifficulty with nasogastric tube insertion with nasogastric tube insertion
Presenting symptomPresenting symptom AcuteAcute ChronicChronic TotalTotal
Abdominal painAbdominal pain 2424 66 3030
VomitingVomiting 1717 33 2020
UGIB/anaemiaUGIB/anaemia 99 22 1111
Abdominal distensionAbdominal distension 55 00 55
Gastro-esophageal refluxGastro-esophageal reflux 55 22 77
DysphagiaDysphagia 44 33 77
Respiratory symptoms/ chest Respiratory symptoms/ chest painpain
77 00 77
Postprandial discomfortPostprandial discomfort 33 00 33
Altered bowel habitAltered bowel habit 22 00 22
Excess flatulenceExcess flatulence 22 00 22
Acute confusionAcute confusion 11 00 11
DehydrationDehydration 11 00 11Teague et al, BMJ 2000
InvestigationsInvestigationsInvestigationsInvestigations
Barium studyBarium study • high high sensitivitysensitivity and and specificityspecificity• criterion standardcriterion standard for diagnosis for diagnosis• upside-down configurationupside-down configuration of the stomac of the stomac
h h • esophagogastric junctionesophagogastric junction is is lowerlower than n than n
ormal. ormal. • marked marked gastric dilatationgastric dilatation and the and the slowslow papa
ssage of contrastssage of contrast past the site of twisting past the site of twisting
Barium studyBarium study • high high sensitivitysensitivity and and specificityspecificity• criterion standardcriterion standard for diagnosis for diagnosis• upside-down configurationupside-down configuration of the stomac of the stomac
h h • esophagogastric junctionesophagogastric junction is is lowerlower than n than n
ormal. ormal. • marked marked gastric dilatationgastric dilatation and the and the slowslow papa
ssage of contrastssage of contrast past the site of twisting past the site of twisting
InvestigationsInvestigationsInvestigationsInvestigations
X-RayX-Ray• findings findings suggestive suggestive of gastric volvulus should be of gastric volvulus should be
confirmed with a barium studyconfirmed with a barium study• Erect film:Erect film: two air-fluid levelstwo air-fluid levels on the fundus - inf on the fundus - inf
erior, antrum - superiorerior, antrum - superior• Supine film: a beak where the esophagogastric juSupine film: a beak where the esophagogastric ju
nction is seen on normal images nction is seen on normal images
X-RayX-Ray• findings findings suggestive suggestive of gastric volvulus should be of gastric volvulus should be
confirmed with a barium studyconfirmed with a barium study• Erect film:Erect film: two air-fluid levelstwo air-fluid levels on the fundus - inf on the fundus - inf
erior, antrum - superiorerior, antrum - superior• Supine film: a beak where the esophagogastric juSupine film: a beak where the esophagogastric ju
nction is seen on normal images nction is seen on normal images
InvestigationsInvestigationsInvestigationsInvestigations
Endoscopy Endoscopy • Both diagnostic and therapeuticBoth diagnostic and therapeutic• Mainly for Mainly for therapeutictherapeutic
CT / MRI / USGCT / MRI / USG • Not diagnosticNot diagnostic • Consider in patient cannot tolerate endoscopy Consider in patient cannot tolerate endoscopy
or fluoroscopyor fluoroscopy
Endoscopy Endoscopy • Both diagnostic and therapeuticBoth diagnostic and therapeutic• Mainly for Mainly for therapeutictherapeutic
CT / MRI / USGCT / MRI / USG • Not diagnosticNot diagnostic • Consider in patient cannot tolerate endoscopy Consider in patient cannot tolerate endoscopy
or fluoroscopyor fluoroscopy
InvestigationsInvestigationsInvestigationsInvestigationsInvestigationInvestigation OrdereOrdere
ddDiagnostiDiagnosticc
SuggestivSuggestivee
No No yieldyield
Barium mealBarium meal 2525 1414 77 44
CXRCXR 1919 00 55 1414
Upper endoscopyUpper endoscopy 1818 55 66 77
AXRAXR 88 00 33 44
Manometry/pHManometry/pH 44 00 00 44
Chest CT scanChest CT scan 22 00 11 11
ColonoscopyColonoscopy 11 00 00 11
USGUSG 11 00 00 11
Teague et al, BMJ 2000
TreatmentTreatmentTreatmentTreatment
• Aims:Aims:– Reduction Reduction of volvulus of volvulus – Gastric Gastric fixationfixation– RepairRepair of predisposing factors of predisposing factors
• OpenOpen Vs Vs EndoscopicEndoscopic Vs Vs LaparoscopicLaparoscopic Vs Vs Combined endoscopic and laproscopicCombined endoscopic and laproscopic
• Aims:Aims:– Reduction Reduction of volvulus of volvulus – Gastric Gastric fixationfixation– RepairRepair of predisposing factors of predisposing factors
• OpenOpen Vs Vs EndoscopicEndoscopic Vs Vs LaparoscopicLaparoscopic Vs Vs Combined endoscopic and laproscopicCombined endoscopic and laproscopic
Treatment – open surgery Treatment – open surgery Treatment – open surgery Treatment – open surgery
Open SurgeryOpen Surgery (traditional treatment >10 years ago)(traditional treatment >10 years ago)
• Diaphragmatic hernia repairDiaphragmatic hernia repair• Division of bandsDivision of bands• GastropexyGastropexy• Partial gastrectomy (in case of necrosis)Partial gastrectomy (in case of necrosis)• Gastropexy with division of gastrocolic ligamenGastropexy with division of gastrocolic ligamen
t (t (Tanner’s OperationTanner’s Operation))• GastrojejunostomyGastrojejunostomy• Fundoantral gastrogastrostomy (Fundoantral gastrogastrostomy (Opolzer’s OpOpolzer’s Op
erationeration))• Repair of eventration of diaphragmRepair of eventration of diaphragm
Open SurgeryOpen Surgery (traditional treatment >10 years ago)(traditional treatment >10 years ago)
• Diaphragmatic hernia repairDiaphragmatic hernia repair• Division of bandsDivision of bands• GastropexyGastropexy• Partial gastrectomy (in case of necrosis)Partial gastrectomy (in case of necrosis)• Gastropexy with division of gastrocolic ligamenGastropexy with division of gastrocolic ligamen
t (t (Tanner’s OperationTanner’s Operation))• GastrojejunostomyGastrojejunostomy• Fundoantral gastrogastrostomy (Fundoantral gastrogastrostomy (Opolzer’s OpOpolzer’s Op
erationeration))• Repair of eventration of diaphragmRepair of eventration of diaphragm
Treatment- endoscopicTreatment- endoscopicTreatment- endoscopicTreatment- endoscopic
Endoscopic reductionEndoscopic reduction
Alpha-loop maneuver Alpha-loop maneuver Tat-Kin Tsang et al ,1995Tat-Kin Tsang et al ,1995
J-type maneuverJ-type maneuver D.K. Bhasin et al, 1990D.K. Bhasin et al, 1990
• +/- +/- gastrostomygastrostomy for the fixation of stomach to t for the fixation of stomach to the abdominal wallhe abdominal wall
Endoscopic reductionEndoscopic reduction
Alpha-loop maneuver Alpha-loop maneuver Tat-Kin Tsang et al ,1995Tat-Kin Tsang et al ,1995
J-type maneuverJ-type maneuver D.K. Bhasin et al, 1990D.K. Bhasin et al, 1990
• +/- +/- gastrostomygastrostomy for the fixation of stomach to t for the fixation of stomach to the abdominal wallhe abdominal wall
Treatment – alpha loopTreatment – alpha loopTreatment – alpha loopTreatment – 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
Treatment - J-type maneuverTreatment - J-type maneuverTreatment - J-type maneuverTreatment - 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 180o in anti-clockwise direction and withdrawn Bhasin et al. 1990
Treatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopic
• 3-ports / 4-ports / 5-ports 3-ports / 4-ports / 5-ports • ReductionReduction of Volvulus of Volvulus• AnchoringAnchoring fundus of stomach to the fundus of stomach to the diaphragmdiaphragm • Greater curveGreater curve of the stomach to of the stomach to anterior abdomianterior abdomi
nal wallnal wall• +/- repair of +/- repair of diaphragmatic defectdiaphragmatic defect• +/-+/- fundoplication fundoplication or/and or/and esocardiopexyesocardiopexy – – prevepreve
nt post-operative GERDnt post-operative GERD• +/- +/- gastrostomygastrostomy
• 3-ports / 4-ports / 5-ports 3-ports / 4-ports / 5-ports • ReductionReduction of Volvulus of Volvulus• AnchoringAnchoring fundus of stomach to the fundus of stomach to the diaphragmdiaphragm • Greater curveGreater curve of the stomach to of the stomach to anterior abdomianterior abdomi
nal wallnal wall• +/- repair of +/- repair of diaphragmatic defectdiaphragmatic defect• +/-+/- fundoplication fundoplication or/and or/and esocardiopexyesocardiopexy – – prevepreve
nt post-operative GERDnt post-operative GERD• +/- +/- gastrostomygastrostomy
Treatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopic
2 vertical lines – fundus anchored to diaphragmX – anterior gastropexy stitches
A – camera, B – liver retractor, C,D,E - operating ports
Treatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopicTreatment - laparoscopic
EsocardiopexyEsocardiopexy PhrenofundopexyPhrenofundopexy
Anterior gastropexyAnterior gastropexy
Management - combinedManagement - combinedManagement - combinedManagement - combined
•Described by Arben Beqiri (1997):Described by Arben Beqiri (1997):– Use Use endoscopicendoscopic T-fastenersT-fasteners instead of PEG fo instead of PEG fo
r anchoringr anchoring– Laparoscopy - reduction of volvulus Laparoscopy - reduction of volvulus – Endoscopy - placement of T-fastenersEndoscopy - placement of T-fasteners– Less time consumingLess time consuming
•Described by Arben Beqiri (1997):Described by Arben Beqiri (1997):– Use Use endoscopicendoscopic T-fastenersT-fasteners instead of PEG fo instead of PEG fo
r anchoringr anchoring– Laparoscopy - reduction of volvulus Laparoscopy - reduction of volvulus – Endoscopy - placement of T-fastenersEndoscopy - placement of T-fasteners– Less time consumingLess time consuming
TreatmentTreatmentTreatmentTreatment
Follow-upFollow-up • Clinical Clinical
– reflux symptomsreflux symptoms– recurrent of symptoms - detection of recurrence recurrent of symptoms - detection of recurrence – removal of PEG tuberemoval of PEG tube
• Imaging Imaging – Post OT contrast study– Post OT contrast study (no consensus of interval - Day 2 to 3 months)(no consensus of interval - Day 2 to 3 months)
Follow-upFollow-up • Clinical Clinical
– reflux symptomsreflux symptoms– recurrent of symptoms - detection of recurrence recurrent of symptoms - detection of recurrence – removal of PEG tuberemoval of PEG tube
• Imaging Imaging – Post OT contrast study– Post OT contrast study (no consensus of interval - Day 2 to 3 months)(no consensus of interval - Day 2 to 3 months)
TreatmentTreatmentTreatmentTreatment
• No RCTNo RCT – rare disease rare disease (2.6/million/year)(2.6/million/year)
• Largest series – Teague Largest series – Teague et alet al in 2000 in 2000 – 36 patients were recruited36 patients were recruited
• Results:Results:– DiagnosticDiagnostic investigation: investigation: Ba contrastBa contrast (21/25) and (21/25) and upup
per endoscopyper endoscopy (18/21) (18/21)– Conservative Tx (5), open surgery (13), laparoscopic Conservative Tx (5), open surgery (13), laparoscopic
(18) – (18) – no major complications and deathno major complications and death– Median hospital stay: Median hospital stay: shorter in laparoscopicshorter in laparoscopic group group
than open group 6 Vs 14, than open group 6 Vs 14, p< 0.05p< 0.05
• No RCTNo RCT – rare disease rare disease (2.6/million/year)(2.6/million/year)
• Largest series – Teague Largest series – Teague et alet al in 2000 in 2000 – 36 patients were recruited36 patients were recruited
• Results:Results:– DiagnosticDiagnostic investigation: investigation: Ba contrastBa contrast (21/25) and (21/25) and upup
per endoscopyper endoscopy (18/21) (18/21)– Conservative Tx (5), open surgery (13), laparoscopic Conservative Tx (5), open surgery (13), laparoscopic
(18) – (18) – no major complications and deathno major complications and death– Median hospital stay: Median hospital stay: shorter in laparoscopicshorter in laparoscopic group group
than open group 6 Vs 14, than open group 6 Vs 14, p< 0.05p< 0.05
Clinical ScenarioClinical ScenarioClinical ScenarioClinical Scenario
• Laparoscopic approachLaparoscopic approach• 3-ports 3-ports • OrganoaxialOrganoaxial type type• NoNo diaphragmatic hernia and eventratio diaphragmatic hernia and eventratio
n of diaphragmn of diaphragm• Gastropexy Gastropexy
– 0-0-EthibonEthibon– 2 anchoring fundus to the diaphragm2 anchoring fundus to the diaphragm– 2 anchoring greater curve to the anterior ab2 anchoring greater curve to the anterior ab
dominal walldominal wall
• Laparoscopic approachLaparoscopic approach• 3-ports 3-ports • OrganoaxialOrganoaxial type type• NoNo diaphragmatic hernia and eventratio diaphragmatic hernia and eventratio
n of diaphragmn of diaphragm• Gastropexy Gastropexy
– 0-0-EthibonEthibon– 2 anchoring fundus to the diaphragm2 anchoring fundus to the diaphragm– 2 anchoring greater curve to the anterior ab2 anchoring greater curve to the anterior ab
dominal walldominal wall
Clinical ScenarioClinical ScenarioClinical ScenarioClinical Scenario
• Follow up:Follow up:– Resume diet in D3Resume diet in D3– Contrast study in D2 Contrast study in D2
stomach in normal positionstomach in normal position
no gross abnormal configuration of stomachno gross abnormal configuration of stomach
• Follow up:Follow up:– Resume diet in D3Resume diet in D3– Contrast study in D2 Contrast study in D2
stomach in normal positionstomach in normal position
no gross abnormal configuration of stomachno gross abnormal configuration of stomach
Clinical ScenarioClinical ScenarioClinical ScenarioClinical Scenario
ConclusionConclusionConclusionConclusion
• Chronic gastric volvulus is a Chronic gastric volvulus is a rarerare disease disease • Require high Require high index of suspicionindex of suspicion in diagno in diagno
sissis• PainPain and and vomitingvomiting are the main symptom are the main symptom
ss• Barium mealBarium meal is the most diagnostic tool is the most diagnostic tool• Can be safely treated by Can be safely treated by laparoscopic aplaparoscopic ap
proachproach
• Chronic gastric volvulus is a Chronic gastric volvulus is a rarerare disease disease • Require high Require high index of suspicionindex of suspicion in diagno in diagno
sissis• PainPain and and vomitingvomiting are the main symptom are the main symptom
ss• Barium mealBarium meal is the most diagnostic tool is the most diagnostic tool• Can be safely treated by Can be safely treated by laparoscopic aplaparoscopic ap
proachproach
The EndThe End Thank you Thank you
The EndThe End Thank you Thank you