Keywords
gastric volvulus - laparoscopic gastric greater curvature plication - bariatric surgery
This article presents a rare case of gastric volvulus in a patient with a surgical
history that includes laparoscopic gastric greater curvature plication (LGGCP). The
article tackles how the case was managed and conducts a literature review of similar
cases, but post laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass.
Case Presentation
We present to you the case of a 24-year-old healthy female lady with a body mass index
(BMI) of 27. Her medical history includes morbid obesity (history of BMI of 41) treated
by LGGCP at another institution, 5 years prior to presentation (PTP). She also suffered
from upper gastrointestinal (GI) bleed that was treated by endoscopic clipping 2 years
PTP. Two months PTP, she had idiopathic acute pancreatitis.
She presented to Lebanese Hospital Geitaoui—University Medical Center, for severe
epigastric pain and postprandial vomiting for 3 days. Her vitals showed mild tachycardia
at 110 bpm. Her physical exam was significant for severe epigastric tenderness. Labs
performed 3 days PTP showed an amylase level six times higher than the normal (790
U/L) and a lipase level 1.5 times higher than the normal (230 U/L). Labs upon admission
showed hemoglobin of 10.6 g/dL, white blood cell count of 13,300/mm3, but normal levels of pancreatic enzymes.
She was admitted under the assumption of chronic pancreatitis/pseudocyst. She was
started on supportive treatment.
Nevertheless, the patient kept deteriorating within the next 24 hours. CT scan of
the abdomen and pelvis was done ([Fig. 1]). It showed an abnormal displacement of the entire stomach to the posterior of the
superior mesenteric artery (SMA) and superior mesenteric vein (SMV) with the antrum
on the left side, consistent with mesenteroaxial gastric volvulus. The gastroesophageal
junction (GEJ) was seen inferior to the antrum. Also noted was the pancreas having
an inverted V-shape.
Fig. 1 CT scanner of the abdomen and pelvis with intravenous contrast showing abnormal displacement
of the entire stomach to posterior of the SMA and SMV. The antrum is shown on the
left side consistent with mesenteroaxial gastric volvulus. The GEJ is shown inferior
to the antrum and the pancreas has an inverted V-shape. (A–C) Axial reformat. (D,E) Sagittal reformat. CT, computed tomography; GEJ, gastroesophageal junction.
The diagnosis of gastric volvulus was established. Urgent gastroscopy was attempted
but failed due to the impossibility to pass the GEJ because of an obstruction at that
level.
The patient was informed of her situation and signed consent was obtained for an urgent
operation for reduction of the volvulus. The anesthesiologist cleared her for an urgent
surgery and classified her as American Society of Anesthesiologists class II.
The patient was transferred to the operating room and put in a modified French position-tilted
reverse Trendelenburg. A 11-mm trocar was inserted via an open laparoscopic technique
through a 1-cm incision 5 fingerbreadths below the xiphoid process. Insufflation of
the abdomen was achieved with CO2 at a pressure of 12 mm Hg. Then, a 10-mm 30-degree lens was inserted and we identified
a spastic and distended stomach with 90-degrees (mixture of volvulus) rotation around
itself toward the liver. Three other trocars were inserted as follows: 5-mm subxiphoid
used for liver retraction, two 5-mm right and left paraumbilical trocars used to insert
working instruments, monopolar cautery, and vessel sealing device, as needed. Several
adhesive bands were seen and liberated using a 5-mm LigaSure. Dissection was performed
through the fibrotic line and into the gastro-gastric space using monopolar cautery
fixed on an L-hook and scissors. As the dissection was continued, we identified two
layers of suture lines. Removal of all suture remnants was done, starting at the antrum
and reaching the fundus ([Fig. 2]). Finally, the plication was fully reversed and the stomach was brought back to
its original shape. Hemostasis was secured and the abdomen was desufflated.
Fig. 2 Intraoperative laparoscopic view. (A,B) Spastic and distended stomach with 90 degrees (mixture of volvulus) rotation around
itself toward the liver. (C) Dissection of adhesions to the stomach. (D) Removal of all suture remnants from the antrum and up to the fundus.
The operation took around 2 hours and went smoothly with minimal blood loss. The patient
was transferred postoperatively (post-op) to the surgery ward. She was kept fasted
for the following 24 hours. Day 2 post-op, an upper GI series was done and showed
a normal stomach with no leaks ([Fig. 3]). Day 3 post-op, the patient had a full recovery and she was discharged home.
Fig. 3 Upper gastrointestinal series. Image shows a normal-shaped stomach (arrowheads) and a good passage of water-soluble oral contrast into the duodenum (short arrow). Absence of any leakage or stenosis.
Follow-up visits were unremarkable and the patient reported no symptoms of any kind.
Gastroscopy was repeated 5 months later and was normal.
Discussion
LGGCP is a strictly restrictive bariatric surgery procedure.[1] It is done by first liberation of gastrocolic, gastrosplenic, and gastrophrenic
ligaments. Then division of the posterior gastric attachments is achieved. After that,
invagination and plication of the gastric greater curvature are done using a 2–0 nonabsorbable
sutures, over a Faucher tube ranging in size from 32 to 38 F.[1]
[2]
[3]
[4] So this is a reversible technique that results in the reduction of the volume of
the stomach without tissue resection.[1] Nevertheless, this technique remains experimental and the American society for metabolic
and bariatric surgery published that plication procedures should be considered investigational
and performed under a study protocol.[5]
Several articles were published detailing the post-op complications of this type of
surgery. Andraos et al[2] reported obstruction due to intraesophageal fold invagination. They also reported
gastric fold complications like gastric fold edema, rupture, and herniation. Skrekas
et al[1] and Khidir et al[3] reported several cases of severe nausea and vomiting requiring readmission but which
resolved with only supportive treatment. Nevertheless, there have been no reported
cases of gastric volvulus post-LGGCP as far as we know. We found several case reports
of gastric volvulus post-LSG and even volvulus of the stomach remnant post-gastric
bypass. One case was even reported post-removal of a gastric band.[6] To note most of the reported cases were associated with diaphragmatic eventration.
As with most bariatric surgeries, the newly formed stomach pouch is left free from
most of its attachment, which puts it at a higher risk of volvulus. Gastric volvulus
or torsion is defined as an abnormal rotation and overstretching of the stomach. It
can occur along the mesenteroaxial plane of the stomach (short vertical axis perpendicular
to the cardiopyloric line), along the organoaxial plane (long vertical axis between
the pylorus and the cardia, most common) or both.[7] It is a rare pathology and only a few hundred cases have been reported in the literature.[8]
Gastric volvulus has been divided into two categories, primary subdiaphragmatic and
secondary supradiaphragmatic. The primary subtype occurs due to adhesions, tumors,
or laxity/absence of gastric ligaments. The secondary type is related to diaphragmatic
pathology and patients in this group develop paraesophageal hernia which leads to
volvulus.[9]
The extensive liberation of gastric ligaments puts it at risk of volvulus. This risk
increases especially after liberation of the posterior gastric attachments. Additional
risk factors include incorrect positioning of the stomach postsurgical manipulation
and asymmetrical plication or sleeve changing the long axis of the stomach.[10] In summary, any surgery changing the anatomy, positioning, or attachments of the
stomach, puts the patient at risk of developing gastric volvulus in the future. This
risk rises if the patient suffers from any diaphragmatic abnormalities.
Volvulus presents acutely as a GI obstruction. Symptoms include abdominal distention
and severe abdominal pain.[7] Classic triad is the Borchardt's triad which consists of retching without any vomiting,
severe epigastric pain, and inability to pass nasogastric tube into the stomach.[11] Volvulus can be complicated by ischemia and can lead to gastric necrosis, shock,
and even death if left untreated.
Diagnosis of gastric volvulus is usually tricky as most physicians do not suspect
it early. Murcia et al[12] found endoscopy very valuable for the diagnosis of gastric volvulus post-LSG. Nevertheless,
CT remains the most useful tool for diagnosis. Sinwar[8] used CT and upper GI series. Light et al[13] described the advantages of CT as consisting of 24-hour access, speed, and assessment
of gastric viability. They reported a 100% sensitivity. A study conducted by Verde
et al[14] also reported that multidetector CT allows for rapid characterization of volvulus
and its complications. Oral contrast, if needed to properly distend the stomach and
evaluate the gastric wall, should restrain to water. Verde et al[14] also found CT helpful for diagnosing the conditions predisposing the volvulus.
Treatment of gastric volvulus is most often surgical. Various techniques have been
tried, from nasogastric tube decompression to endoscopy ± stent placement. Light et
al[13] have even described conservative management. Nevertheless, surgery remains the gold
standard in most cases. Moreover, conservative and endoscopic treatments have a high
risk of recurrence.
Various procedures have been suggested and described: gastric detorsion + lysis of
adhesions,[12] gastric detorsion + lysis of adhesions + gastropexy,[12] antrectomy with gastroenteric anastomosis,[10] shortening of the lesser omentum,[7] and conversion to Roux-En-Y gastric bypass in the presence of gastric obstruction
and/or gastric necrosis.[6]
[15] In the setting of LGGCP, deplication and removal of the sutures ± gastropexy seems
to be an effective and safe means of treatment. This could be followed in a few months
by LSG for weight loss if the patient wished or needed so.
Conclusion
Bariatric surgeries impose a risk of gastric volvulus due to the extensive liberation
of the attachments of the stomach. This diagnosis should be kept in mind when dealing
with an acute abdomen with vomiting in a patient operated by a weight loss surgery.
Moreover, despite being introduced as an alternative to LSG, LGGCP is still an experimental
bariatric surgery. It should only be done on a trial basis and by expert laparoscopic
surgeons. If the sutures and invagination are not aligned properly, this would lead
to a change in the long axis of the stomach and further increase the risk of volvulus.
