Joint Hospital Grand Round Management of Chronic Gastric

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Joint Hospital Grand Round Management of Chronic Gastric Volvulus Kenny K Y Yuen Tseung

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

 • Clinical scenario • History • Predisposing factors • Classifications • Clinical presentations

• Clinical scenario • History • Predisposing factors • Classifications • Clinical presentations • Investigations • Treatment

Clinical Scenario • F/29 • Intermittent epigastric pain for years • Cramping after heavy

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

Clinical Scenario Erect AXR • Double air-fluid levels at LUQ Ba meal • Stomach

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

Definition • Gastric volvulus is rotation of all or part of the stomach more

Definition • 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

1579 Ambrose Pare GV after sword wound History of Gastric Volvulus 1866 Berti Described

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

Anatomy

Anatomy

Predisposing factors • Primary – Laxity of the supporting ligaments – Especially elongation of

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

Predisposing factors • Secondary Diaphragmatic defect – – – eventration paraesophageal hiatal hernia Bochdalek

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

Predisposing factors • Diaphragmatic defects - 43% • Gastric ligaments - 32% • Abnormal

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

Classifications • Onset - Acute Vs Chronic • Location – subdiaphragmatic / primary Vs

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

Classifications • Subdiaphragmatic, or primary – not associated with diaphragmatic defects – one third

Classifications • Subdiaphragmatic, or primary – not associated with diaphragmatic defects – one third of cases • Supradiaphragmatic, or secondary – – associated with diaphragmatic defects two thirds of cases

Classifications • Organoaxial volvulus Rotates about the cardiopyloric axis results in an upside down

Classifications • 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

Classifications • Mesenteroaxial volvulus Anterior rotation about an axis perpendicular to the cardiopyloric axis

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

Clinical Presentation • Borchardt’s classical triad (1904): – epigastric pain and distention – Non-productive

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

Presenting symptom Acute Chronic Total Abdominal pain 24 6 30 Vomiting 17 3 20

Presenting symptom Acute Chronic Total Abdominal pain 24 6 30 Vomiting 17 3 20 UGIB/anaemia 9 2 11 Abdominal distension 5 0 5 Gastro-esophageal reflux 5 2 7 Dysphagia 4 3 7 Respiratory symptoms/ chest pain 7 0 7 Postprandial discomfort 3 0 3 Altered bowel habit 2 0 2 Excess flatulence 2 0 2 Acute confusion 1 0 1 Dehydration 1 0 1 Teague et al, BMJ 2000

Investigations Barium study • high sensitivity and specificity • criterion standard for diagnosis •

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

Investigations X-Ray • findings suggestive of gastric volvulus should be • • confirmed with

Investigations X-Ray • findings suggestive of gastric volvulus should be • • confirmed with a barium study 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

Investigations Endoscopy • Both diagnostic and therapeutic • Mainly for therapeutic CT / MRI

Investigations Endoscopy • Both diagnostic and therapeutic • Mainly for therapeutic CT / MRI / USG • Not diagnostic • Consider in patient cannot tolerate endoscopy or fluoroscopy

Investigations Investigation Ordered Diagnostic Suggestive No yield Barium meal 25 14 7 4 CXR

Investigations Investigation Ordered Diagnostic Suggestive No yield Barium meal 25 14 7 4 CXR 19 0 5 14 Upper endoscopy 18 5 6 7 AXR 8 0 3 4 Manometry/p. H 4 0 0 4 Chest CT scan 2 0 1 1 Colonoscopy 1 0 0 1 USG 1 0 0 1 Teague et al, BMJ 2000

Treatment • Aims: – – – Reduction of volvulus Gastric fixation Repair of predisposing

Treatment • Aims: – – – Reduction of volvulus Gastric fixation Repair of predisposing factors • Open Vs Endoscopic Vs Laparoscopic Vs Combined endoscopic and laproscopic

Treatment – open surgery Open Surgery (traditional treatment >10 years ago) • Diaphragmatic hernia

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

Treatment- endoscopic Endoscopic reduction Alpha-loop maneuver Tat-Kin Tsang et al , 1995 J-type maneuver

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

Treatment – alpha loop A, B, C Survey of the stomach and gastric volvulus

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

Treatment - J-type maneuver A, B Formation of the ”J “by turn extremely up

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 anticlockwise direction and withdrawn Bhasin et al. 1990

Treatment - laparoscopic • 3 -ports / 4 -ports / 5 -ports • Reduction

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

Treatment - laparoscopic 2 vertical lines – fundus anchored to diaphragm X – anterior

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

Treatment - laparoscopic Esocardiopexy Phrenofundopexy Anterior gastropexy

Treatment - laparoscopic Esocardiopexy Phrenofundopexy Anterior gastropexy

Management - combined • Described by Arben Beqiri (1997): – Use endoscopic T-fasteners instead

Management - combined • 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

Treatment Follow-up • Clinical – – – reflux symptoms recurrent of symptoms - detection

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

Treatment • No RCT – rare disease (2. 6/million/year) • Largest series – Teague

Treatment • No RCT – rare disease (2. 6/million/year) • Largest series – Teague et al in 2000 – 36 patients were recruited • 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

Clinical Scenario • Laparoscopic approach • 3 -ports • Organoaxial type • No diaphragmatic

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

Clinical Scenario • Follow up: – Resume diet in D 3 – Contrast study

Clinical Scenario • Follow up: – Resume diet in D 3 – Contrast study in D 2 stomach in normal position no gross abnormal configuration of stomach

Clinical Scenario

Clinical Scenario

Conclusion • Chronic gastric volvulus is a rare disease • Require high index of

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

The End Thank you

The End Thank you