INTRODUCTION
Gastric volvulus is a rare condition in which the stomach rotates about the central axis, causing displacement of the stomach and adjacent organs, leading to impaired gastric emptying and a series of physiological changes. It was first described by Berti in 1866, following the autopsy of a 61-year-old woman[1]. This condition predominantly affects adults, accounting for approximately 80% of cases, with a peak incidence around the age of 50[2]; 20% of gastric volvulus cases occur in infants under one year of age[3]. To date, no studies have demonstrated an association with sex or ethnicity. The clinical presentation of gastric volvulus depends on the degree of torsion and the rate at which it occurs. When the stomach twists > 180°, complete obstruction of the gastric outlet occurs. This condition can be classified as acute or chronic, with clinical manifestations varying according to the degree of obstruction and speed of onset; however, it typically causes symptoms such as upper abdominal pain, nausea, and vomiting[4]. In severe cases, this may lead to ischemic strangulation, necrosis, perforation, and abdominal sepsis of the gastric wall[5]. Gastric volvulus can be classified as primary or secondary according to different causes[6]. Primary gastric volvulus is caused by the absence or laxity of perigastric ligaments, gastric adhesions, or gastric tumors. Secondary gastric volvulus is more common clinically, accounting for approximately two-thirds of all cases. These causes are attributed to anatomical defects, such as diaphragmatic hernia, free spleen, hiatal hernia, diaphragmatic injury, and phrenic nerve palsy[7]. In this case, the patient presented with both secondary causes (diaphragmatic hernia) and primary causes (laxity of the hepatogastric ligament); a combination of these factors led to the development of gastric volvulus. Therefore, early diagnosis and prompt treatment are crucial.
At present, there is no consensus on the diagnosis and treatment of gastric volvulus, and there are obvious controversies regarding the diagnostic criteria, imaging selection, and treatment strategy[8]. The concept and classification systems for this disease are not uniform. The diagnostic criteria for chronic gastric volvulus, gastric inversion, and large paraesophageal hernia are often confusing in clinical practice, and there is no unified standard for the onset time or symptom definition of chronic gastric volvulus[9]. The consistency of the traditional anatomical classification between imaging and intraoperative evaluation is poor, which is not conducive to the standardized selection of treatment plans.
Gastroscopy can directly visualize gastric mucosal ischemia, necrosis, and complete reduction, but it is difficult to perform endoscope insertion in complete gastric volvulus due to many contraindications and limited diagnostic efficiency[10]. In terms of imaging diagnosis, upper gastrointestinal barium meal has a high diagnostic value for chronic and partial volvulus, but is not suitable for acute severe patients. Computed tomography (CT) is highly sensitive and can evaluate gastric wall perfusion as well as associated hernias, and perforations. It is the most important examination method for gastric volvulus; however, whether there is excessive examination in patients with mild volvulus remains controversial[11]. Therapeutic controversy is equally prominent. For acute gastric volvulus, there is a consensus that patients with gastric necrosis and perforation need emergency surgery, but there is still a disagreement on whether the hemodynamically stable partial volvulus should be treated with emergency surgery. Some researchers have advocated for endoscopic reduction and conservative treatment to avoid unnecessary surgical trauma. However, several studies have shown that the recurrence rate of conservative treatment can reach 50%-70%[12,13], and patients are at risk of strangulation necrosis at any time; therefore, early surgical intervention is advocated.
Currently, laparoscopic gastric repositioning and fixation are the primary surgical approaches used to treat this condition. Laparoscopic reduction and anterior gastropexy were first performed in 2003[14]. A patient with acute gastric volvulus underwent laparoscopic surgery and recovered well postoperatively. After that, more and more patients with gastric volvulus underwent laparoscopic surgery. The laparoscopic approach can minimize surgical invasiveness in these patients and results have been published of its use not only in the management of chronic gastric volvulus associated with hiatal hernia, but also in acute situations compared with traditional open laparotomy[15,16].
CASE PRESENTATION
Chief complaints
A 44-year-old female patient presented to our Department of Gastrointestinal Surgery with severe upper abdominal pain and nausea as the main symptoms.
History of present illness
The patient began experiencing severe upper abdominal pain following meals a fortnight ago, with intermittent cramping, which worsened with walking or postprandially and alleviated by fasting or resting in a semi-recumbent position, accompanied by nausea. There was no significant vomiting, abdominal distension, diarrhea, fever, or chills, and to relieve the abdominal pain, the patient frequently reduced food intake or abstained from eating altogether.
History of past illness
The patient had a three-year history of hypertension, with a maximum blood pressure of 160/90 mmHg, had not received any antihypertensive medication, and had a history of a caesarean section. She denied any history of diabetes, heart disease, infectious diseases such as hepatitis B or tuberculosis, or drug or food allergies.
Personal and family history
The patient denied any relevant family history.
Physical examination
Temperature: 36.3 °C, pulse: 79 beats per minute, respiratory rate: 18 breaths per minute, blood pressure: 156/94 mmHg. The patient was alert, walked to the ward unaided, and cooperated during the physical examination. No jaundice of the skin or mucous membranes; no palpable enlargement of the superficial lymph nodes. No cranial deformities; pupils are equal and reactive to light. The neck was soft, the trachea was midline, and no thyroid enlargement was observed. Chest examination revealed no deformities; breath sounds were clear in both lungs, with no rales heard; rhythm was regular, heart sounds were normal, and no murmurs were heard; the abdomen was flat and soft, with distension in the upper abdomen; an old surgical scar was visible in the lower abdomen; there was no tenderness or rebound tenderness throughout the abdomen; the liver and spleen were not palpable below the costal margin; Murphy’s sign was negative; shifting dullness was negative; and bowel sounds were normal at approximately 4 per minute.
Laboratory examinations
Blood cell count: White blood cell: 3.05 × 109/L (low), neutrophil: 1.67 × 109/L (low), lymphocyte: 1.06 × 109/L (low), red blood cell: 3.60 × 1012/L (low); interleukin-6: Normal; liver function: Total protein 60.2 g/L ↓, albumin 38.4 g/L ↓, phosphate 191 mg/L ↓; renal function: Normal; electrolytes: Chloride 112 mmol/L ↑; disseminated intravascular coagulation: Normal.
Imaging examinations
Gastroscopy revealed narrowing and torsion of the gastric lumen. Contrast-enhanced abdominal CT (Figure 1) demonstrated an elevation of the left diaphragm, upward displacement and torsion of the gastric fundus, significant colonic contents, colonic appearance of the small bowel contents, and localized small bowel dilation with air in the upper abdomen. Upper gastrointestinal barium contrast study (Figure 2) revealed elevation of the left diaphragm; the stomach appeared arched, the fundus was displaced downwards, the pylorus was elevated, and gastric volvulus was suspected.
Figure 1 Contrast-enhanced abdominal computed tomography.
A: The coronal view, it shows elevation of the left side of the diaphragm, upward displacement and torsion of the gastric fundus, and displacement of the spleen towards the midline; B: The sagittal view, it shows gastric volvulus, with the body of the stomach rotating at the points where the lesser and greater curvatures meet.
Figure 2 Upper gastrointestinal barium meal before and after surgery.
A: Preoperative: Widening of the upper mediastinal shadow; elevation of the left diaphragm; the stomach is predominantly arched; the fundus is displaced downwards; the body and antrum of the stomach are first displaced upwards and then rotate anti-clockwise to the right; B: Postoperative: Elevation of the left diaphragm; the fundus is displaced more upwards than before; the antrum of the stomach has returned to its normal anatomical position.
FINAL DIAGNOSIS
The patient’s blood pressure was measured at 156/94 mmHg upon admission, and abdominal pain was considered to induce a stress response. The pain was relieved after analgesic and antispasmodic treatment, and blood pressure remained stable during preoperative monitoring. Three days after admission, the patient underwent laparoscopic reduction and fixation of gastric volvulus. Following successful induction of general anesthesia, laparoscopy was performed. A longitudinal incision was made along the lower margin of the umbilicus and the abdominal cavity was entered layer-by-layer. No significant adhesions were observed in the surrounding areas. A 10 mm trocar (observation port) was inserted, and an artificial pneumoperitoneum was established at a pressure of 13 mmHg, with the patient positioned in the head-up, feet-down ‘starfish’ position. Laparoscopic trocars (12 mm and 10 mm) were inserted at the outer edges of the left and right rectus abdominis muscles at the level of the umbilicus as working ports. Intraoperative exploration (Figure 3) revealed that the gastric body had shifted towards the left upper abdomen at the site of diaphragmatic bulging; the pylorus and antrum were displaced superiorly and ran downwards to the right, continuing into the duodenal bulb, while the transverse colon was pulled upward. The gastric wall was pulled downwards to reduce gastric volvulus. Marked dilatation of the gastric fundus was observed, with the left diaphragm elevated and thinned, the gastric body situated at the level of the left diaphragm, and the spleen markedly displaced towards the midline. No abnormalities were noted in the hiatal region or other organs. During the operation, the gastric wall was pulled downwards and to the left, and the greater curvature of the gastric body was continuously sutured with 3/0 barbed sutures to the mesentery near the transverse colon using three stitches. The anterior wall of the gastric antrum near the pylorus was sutured to the falciform ligament of the liver with 3/0 barbed sutures using three stitches, and the knots were tied under endoscopic visualization to ensure secure fixation. Following a reduction in the intra-abdominal pressure, the gastric wall was flat without marked wrinkling, indicating that the stomach had returned to its normal anatomical position. Based on the patient’s medical history, imaging, and intraoperative examination findings, the diagnosis of gastric volvulus was confirmed.
Figure 3 Intraoperative exploration.
A: During the operation, elevation of the left diaphragm was observed; the body of the stomach first twisted from bottom to top, then rotated anti-clockwise towards the lower right. The green arrow indicates the elevation of the left diaphragm; B: During the operation, the greater curvature of the stomach was sutured to the transverse colon, and the anterior wall of the pyloric antrum, near the pylorus, was sutured to the falciform ligament of the liver.
DISCUSSION
Gastric volvulus refers to the condition in which the stomach rotates about a specific axis, causing displacement of the stomach and adjacent organs, resulting in associated symptoms. Based on the axis of rotation, it can be classified into three types: (1) Organ-axis type, where torsion occurs about the longitudinal axis of the stomach (the axis connecting the cardia and the pylorus). This type of volvulus is associated with diaphragmatic defects, such as para-esophageal hernias and diaphragmatic eventration. This causes obstruction of the gastroesophageal junction, of the pylorus, or both and consequently may produce strangulation and necrosis[13]; (2) The mesenteric-axis type, in which the body of the stomach rotates about an axis (transverse axis) defined by a line connecting the midpoint of the lesser curvature to the greater curvature, which refers to rotation about the short axis of the stomach leading to the folding of the anterior gastric wall upon itself such that there is a close approximation of the pylorus and antrum to the gastroesophageal junction[17]. The reason for this is the laxity of the gastrosplenic ligament. This type of volvulus is not typically associated with diaphragmatic defects[18]; and (3) Mixed types combine the above two types[19]. Currently, the organ-axis type is the most common, accounting for approximately 59% of the cases, whereas the mesenteric-axis type accounts for approximately 29%[20]. Anatomically, the stomach is primarily fixed to the upper left abdomen by four main ligaments: The gastrocolic, gastrohepatic, gastrodiaphragmatic, and gastrosplenic ligaments. Together with the cardia and pylorus, these ligaments support the stomach and prevent abnormal rotation[19]. The etiology of gastric volvulus can be classified as primary or secondary[21]. Primary gastric volvulus is caused by the absence or laxity of ligaments, gastric adhesions, or gastric tumors. Under normal circumstances, the stomach is anchored to the abdominal wall by surrounding ligaments to prevent gastric rotation. In pathological states, weakness, elongation, or injury of these ligaments impairs their ability to fix the stomach, resulting in gastric volvulus, which is more common clinically and accounts for approximately two-thirds of the cases. These causes are attributed to anatomical defects, such as diaphragmatic hernia, free spleen, hiatal hernia, diaphragmatic injury, and phrenic nerve palsy[22]. In this case, the patient presented with both secondary (diaphragmatic hernia) and primary causes (laxity of the hepatogastric ligament), and a combination of these factors led to the development of gastric volvulus.
Gastric volvulus can be classified as acute or chronic depending on the rate of onset and the degree of obstruction[23]. Acute gastric volvulus presents as sudden, severe upper abdominal pain and can be distinguished from chronic gastric volvulus by Borchardt’s triad, which includes: (1) Severe upper abdominal pain; (2) Retching without productive vomiting; and (3) Difficulty or inability to insert a nasogastric tube. Approximately 70% of patients with acute gastric volvulus present with these symptoms, and in severe cases, the condition may lead to ulcers, perforation, hemorrhage, and necrosis[24,25]. Patients with chronic gastric volvulus typically present with nonspecific clinical symptoms, including intermittent abdominal pain, postprandial bloating, dysphagia, and a burning sensation in the stomach, and require differentiation from other upper gastrointestinal disorders such as gastritis, gastric ulcers, and enteritis[26]. The patient in this case presented with severe upper abdominal pain that had persisted for a fortnight, accompanied by nausea. Given the prolonged duration of symptoms and the absence of significant abnormalities on gastroscopy, blood tests, and liver and kidney function tests, the diagnosis of chronic gastric volvulus was consistent with the clinical presentation.
Gastric volvulus typically presents with vague and nonspecific clinical symptoms, and a definitive diagnosis is difficult to establish based on medical history and physical examination alone. A definitive diagnosis usually requires chest and abdominal radiography, abdominal CT, upper gastrointestinal radiography, and gastroscopy. An upright abdominal radiograph may reveal a double gas level beneath the left diaphragm or at the fundus of the stomach, which may indicate gastric volvulus or rotation[19]; Upper gastrointestinal barium contrast studies may reveal a horizontally oriented or inverted stomach[22]. Abdominal CT offers significant advantages over plain radiography: It can not only confirm the diagnosis of gastric volvulus but also identify the precise location of the torsion and any associated obstruction, which is of great assistance in planning surgical intervention. Therefore, this is the imaging modality of choice[27,28]. However, a limitation of this study is that we could not definitively determine the presence or severity of gastric mucosal ischemia[29]. Clinically, it is essential to perform a gastroscopy as early as possible to determine the presence of gastric ischemia. Furthermore, a nasogastric tube can be inserted under endoscopic guidance to relieve pressure; however, gastroscopy cannot reposition the twisted stomach to its normal anatomical position, and the risk of recurrence is high[30].
Surgical treatment of gastric volvulus was first described and successfully performed by Berg in 1896[31]. The aim of surgical intervention is to preserve gastric function; if there is any evidence of ischemia or necrosis, the affected tissue should be resected. Surgical management includes gastric decompression and reduction, gastric fixation, and correction of intra-abdominal factors that precipitate torsion. Tanner[32] described various methods for the surgical repair of gastric volvuli. These include simple gastric fixation, gastric fixation combined with omentopexy division, gastrojejunal anastomosis, partial gastrectomy, hiatal hernia repair, and repair of the diaphragmatic bulge (Tanner’s operation). Current research demonstrates that laparoscopic surgery is a safer and more efficient surgical approach owing to its advantages of being minimally invasive and causing less trauma, resulting in milder pain, fewer complications, faster recovery, and shorter hospital stay[17]. Laparoscopic treatment can be applied in many situations, including both acute and chronic conditions, and gastric volvulus complicated by large paraesophageal hernias or diaphragmatic hernias can also be treated laparoscopically.
In the present case, laparoscopic gastric fixation was performed. First, the greater curvature of the gastric body was sutured to the mesentery near the transverse colon. Subsequently, the anterior wall of the pyloric antrum near the pylorus was sutured to the falciform ligament of the liver. This created a triangular configuration between the pylorus and the liver, thereby ensuring a more secure fixation of the stomach. This case further supports the safety and feasibility of laparoscopic treatment for gastric volvulus, although standardization of this technique is lacking. The patient’s postoperative recovery was uneventful, confirming the accuracy of our treatment decisions. Furthermore, although the patient presented with a left diaphragmatic hernia, as there were no significant clinical symptoms, we decided not to proceed with corrective surgery for the left diaphragmatic hernia at this stage.
