Acute tension gastrothorax post hiatal hernia repair and Nissen fundoplication: A case report

Abstract

BACKGROUND

Acute intrathoracic gastric volvulus with tension gastrothorax is a rare, life-threatening condition. Predisposing factors include hiatal or diaphragmatic defects, prior hiatal surgery, and disorders associated with repetitive retching. This case highlights key risk factors and the characteristic clinical and radiologic features required for rapid recognition of this surgical emergency, while demonstrating the role of a staged surgical approach with second-look laparoscopy in optimizing gastric preservation.

CASE SUMMARY

A 64-year-old woman with a history of hiatal hernia repair and bulimia presented with 5 days of infectious gastroenteritis, persistent retching, epigastric pain, and progressive abdominal distension. Imaging revealed a left paraesophageal hernia with intrathoracic migration of the stomach and proximal duodenum, consistent with acute mesenteroaxial gastric volvulus complicated by tension gastrothorax. Initial nasogastric decompression was unsuccessful, prompting emergent laparoscopic exploration. The stomach was reduced and noted to have diffuse ischemia and a large intramural hematoma. Given uncertain viability, a staged approach was pursued. After intensive care stabilization, second-look laparoscopy on postoperative day 3 demonstrated complete restoration of gastric perfusion. Definitive hiatal repair and gastropexy were then performed. The patient was discharged in good condition and remained asymptomatic at 1- and 3-month follow-ups.

CONCLUSION

A staged surgical approach with second-look laparoscopy may facilitate gastric salvage in complex cases of intrathoracic gastric volvulus.

Key Words: Hiatal hernia; Gastric volvulus; Tension gastrothorax; Second-look laparoscopy; Risk factors; Case Report

Core Tip: Acute intrathoracic gastric volvulus with tension gastrothorax is a rare, life-threatening complication that can occur after hiatal hernia repair, particularly in the setting of repetitive retching. High index of suspicion is essential, as this condition represents a true surgical emergency and may present with clinical features indistinguishable from acute tension pneumothorax. Prompt surgical intervention is the cornerstone of management. Following gastric reduction, assessment of gastric viability remains the most challenging step. When viability is uncertain, a staged laparoscopic strategy with intensive care stabilization and planned second-look exploration permits reassessment of perfusion, helps avoid unnecessary gastrectomy, and supports successful gastric preservation.

INTRODUCTION

Hiatal hernia (HH) is a common condition whose incidence is influenced by demographic and physiological factors, including age, sex, and body mass index[1-3]. It represents a heterogeneous clinical entity traditionally classified into four types: Type I, sliding hernia; type II, paraesophageal hernia; type III, mixed sliding and paraesophageal hernia; and type IV, herniation of additional abdominal organs into the thoracic cavity[4]. An HH is considered giant when at least 30% of the stomach herniates through the esophageal hiatus[5]. This classification is clinically relevant because each type carries distinct structural and physiological consequences that may increase the risk of gastroesophageal reflux disease (GERD) and other upper gastrointestinal symptoms or complications[6].

For symptomatic HH, laparoscopic repair with fundoplication is the preferred treatment, providing durable symptom relief with low morbidity and mortality[7]. However, rare but potentially fatal complications such as acute gastric volvulus (AGV) have been reported[8]. AGV is defined by abnormal rotation of the stomach around its axis and may occur in an intrathoracic form, particularly in patients with hiatal or diaphragmatic defects or after fundoplication[9]. Initial management typically involves gastric decompression with a nasogastric tube and urgent surgical evaluation. Definitive treatment generally requires surgical reduction with gastropexy, and some cases necessitate partial or total gastrectomy[10,11].

Here, we report the stepwise laparoscopic management of acute mesoaxial intrathoracic gastric volvulus complicated by tension gastrothorax, highlighting key predisposing factors and the use of a staged, organ-preserving second-look approach. This case was prepared in accordance with the surgical case report criteria[12].

CASE PRESENTATION

Chief complaints

A 64-year-old woman presented to the emergency department of our tertiary care hospital on September 29, 2025, with progressive epigastric pain, persistent retching, abdominal distension, and dyspnea.

History of present illness

Five days prior to presentation, the patient developed infectious gastroenteritis characterized by frequent diarrhea and repetitive retching. This was followed by 2 days of colicky, oppressive epigastric pain, persistent retching, and progressive abdominal distension. Her symptoms continued to worsen, prompting emergency evaluation.

History of past illness

The patient’s medical history was significant for bulimia, primary hypertension, and type 2 diabetes mellitus. She also had a history of a symptomatic giant type IV HH, previously treated with laparoscopic non-mesh HH repair and Nissen fundoplication in June 2024. The postoperative course was complicated by recurrent dysphagia and GERD due to supradiaphragmatic herniation of the wrap. Consequently, a redo Nissen fundoplication with HH repair was successfully performed in August 2025.

Personal and family history

The patient had no family history of the condition.

Physical examination

On presentation, the patient appeared acutely ill. Examination revealed decreased chest expansion and epigastric tenderness on deep palpation. Vital signs demonstrated tachycardia and hypoxemia, with an oxygen saturation of 88% on room air.

Laboratory examinations

Laboratory evaluation demonstrated metabolic and inflammatory abnormalities, including an elevated lactate level of 6.6 mmol/L (normal range: 0.5-2.0 mmol/L), leukocytosis of 17.4 × 10³/mL (normal range: 4-12 × 10³/mL) with neutrophilic predominance (91.1%), and an elevated erythrocyte sedimentation rate (11.05 mm/hour; normal range: 0.5-2.2 mm/hour).

Imaging examinations

Chest radiography demonstrated a complicated HH with rightward displacement of mediastinal structures and a concomitant left pleural effusion (Figure 1A). Contrast-enhanced computed tomography of the chest, abdomen, and pelvis revealed tension gastrothorax caused by a left paraesophageal hernia with intrathoracic migration of the stomach and proximal duodenum, consistent with acute mesenteroaxial gastric volvulus (Figure 1B).

Figure 1 Initial emergency department imaging examinations (September 29^th, 2025). A: Contrast-enhanced computed tomography of the chest, abdomen, and pelvis demonstrating tension gastrothorax caused by a left paraesophageal hernia with intrathoracic migration of the stomach and proximal duodenum; B: Chest radiograph showing a complicated hiatal hernia with rightward displacement of mediastinal structures and a concomitant left pleural effusion.

FINAL DIAGNOSIS

Acute mesenteroaxial intrathoracic gastric volvulus complicated by tension gastrothorax.

TREATMENT

Initial gastric decompression with a nasogastric tube was attempted but was unsuccessful. The patient was promptly prepared for and consented to emergent laparoscopic surgery. Intraoperatively, the strangulated herniation and volvulus were completely reduced, allowing full inspection of the stomach. This revealed diffuse ischemic changes involving most of the gastric surface, including the gastroesophageal junction, as well as a large intramural gastric hematoma (Figure 2).

Figure 2 Intraoperative findings during initial laparoscopy. A and B: Gastric body, fundus, and greater curvature demonstrating extensive ischemic changes and a large intramural hematoma; C: Ischemic involvement of the gastroesophageal junction; D: Ischemic changes affecting the gastric body.

Total gastrectomy with esophagojejunal anastomosis was considered; however, given the patient’s critical condition and the extent of ischemia, the risk of anastomotic leak was deemed prohibitively high. A staged approach was therefore adopted, with plans for second-look laparoscopy to reassess gastric and esophagogastric perfusion. The hiatal defect was temporarily sutured, a nasogastric tube was successfully placed, and two Blake drains were inserted. The patient was then transferred to the intensive care unit (ICU) for central venous access and close hemodynamic monitoring, with planned re-exploration within 24 hours.

Over the subsequent hours, the patient remained nil per os and demonstrated progressive clinical improvement, with stable vital signs and no vasopressor requirement. Inflammatory markers, serum lactate levels, and leukocyte counts showed a steady downward trend (Table 1). Given these favorable clinical and laboratory findings, the surgical team elected to continue intensive monitoring while maintaining readiness for urgent reoperation.

Table 1 Summary of intensive care unit clinical monitoring.

Postoperative day	Events	Vital signs	Labs
0 (September 30th, 2025)	ICU admission. Placement of central venous catheter. Nil per os 2 L/minute nasal cannula	Heart rate: 105 bpm, blood pressure: 103/68 mmHg, SpO2: 90%	Morning venous blood gas pH 7.32, PCO2: 35.9 mmHg (4.8 kPa), HCO3: 18.6 mmol/L, lactate: 6.7 mmol/L, blood count, leucocytes: 17.4 × 103/μL, neutrophils: 91.1%
	Chest X-ray: Evidence of reexpansion edema in the left hemithorax, associated with apical pneumothorax	Heart rate: 102 bpm, blood pressure: 98/70 mmHg, SpO2: 93%	Afternoon venous blood gas pH 7.36, PCO2: 41.8 mmHg (5.6 kPa), HCO3: 23.9 mmol/L, lactate: 2.5 mmol/L, blood count, leucocytes: 11.5 × 103/μL, neutrophils: 86.4%
1 (October 1st, 2025)	Oxygen requirements reduced to 1 L/minute	Morning heart rate: 88 bpm, blood pressure: 107/67 mmHg, SpO2: 93%	Venous blood gas pH 7.35, PCO2: 52.8 mmHg (7.0 kPa), HCO3: 29.6 mmol/L, lactate 14 mmol/L, blood count, leucocytes: 7.9 × 103/μL, neutrophils: 76.5%, C-reactive protein: 18.28 mg/dL
		Afternoon heart rate: 82 bpm, blood pressure: 106/71 mmHg, SpO2: 94%
2 (October 2nd, 2025)	Off oxygen supplementation	Morning heart rate: 87 bpm, blood pressure: 114/74 mmHg, SpO2: 98%	Venous blood gas pH 7.35, PCO2: 52.8 mmHg (7.0 kPa), HCO3: 29.6 mmol/L, lactate: 1.4 mmol/L, blood count, leucocytes: 7.9 × 103/μL, neutrophils: 76.5%
		Afternoon heart rate: 69 bpm, blood pressure: 112/71 mmHg, SpO2: 92%
3 (October 3rd, 2025)	Second-look scheduled	Heart rate: 78 bpm, blood pressure: 127/88 mmHg, SpO2: 96%	Blood count leucocytes: 5.5 × 103/μL, neutrophils: 64.7%

During intensive care unit admission, the patient maintained stable vital signs and demonstrated a progressive decline in leukocyte count and lactate levels, correlating with hemodynamic stabilization and clinical improvement. ICU: Intensive care unit; HCO₃: Bicarbonate; PCO₂: Partial pressure of carbon dioxide; SpO₂: Peripheral capillary oxygen saturation.

With sustained improvement, second-look laparoscopy was performed on postoperative day 3 (October 3, 2025). Intraoperatively, the stomach demonstrated marked recovery, with restoration of normal color and perfusion. Previously ischemic regions had resolved, indicating near-complete mucosal and seromuscular recovery (Figure 3). Definitive hiatal closure with interrupted non-absorbable sutures (polypropylene) was then performed, along with Nissen fundoplication and gastroesophageal and greatercurvature gastropexy.

Figure 3 Intraoperative findings during second-look laparoscopy. A: Gastric body demonstrating restoration of normal color and perfusion; B: Gastroesophageal junction and fundus showing resolving ischemic changes with minimal residual serosal erythema.

OUTCOME AND FOLLOW-UP

The patient was discharged in good condition on postoperative day 7 (October 10, 2025) (Table 2). Follow-up evaluations at 1 week (October 16, 2025), 1 month (October 30, 2025), and 3 months (January 2, 2026) demonstrated sustained clinical improvement and adequate oral intake. Informed written consent was obtained from the patient for publication of this report and any accompanying images.

Table 2 Summary of key postoperative events following the second-look laparoscopy.

Postoperative day	Events
1 (October 4th, 2025)	Clear liquid diet initiated
2 (October 5th, 2025)	Due to chest X-ray findings (left pleural effusion) and SpO2 of 85%, oxygen supplementation initiated at 15 L/minute. Nasogastric tube maintained, and clear liquid diet continued
3 (October 6th, 2025)	Nasogastric tube removed
4 (October 7th, 2025)	Pureed/soft diet initiated, and Foley catheter remove
5 (October 8th, 2025)	Parenteral nutrition suspended
6 (October 9th, 2025)	Oxygen supplementation reduced to 1 L/minute, followed by its removal
7 (October 10th, 2025)	Central venous catheter removed, and patient discharged from the hospital

Postoperative day-by-day clinical events and recovery milestones following second-look laparoscopy. SpO₂: Peripheral capillary oxygen saturation.

DISCUSSION

Acute intrathoracic gastric volvulus with tension gastrothorax is a rare complication that may occur in association with HHs, diaphragmatic anomalies, or following fundoplication[13]. Episodes of increased intra-abdominal pressure, such as vomiting or retching, have been linked to intrathoracic migration of the wrap and stomach through the esophageal hiatus, predisposing to the development of intrathoracic AGV[14]. This mechanism is thought to result from abrupt elevations in intra-abdominal pressure that compromise the crural repair[15]. The stomach may subsequently rotate along its longitudinal or transverse axis due to progressive distension, laxity of the gastric ligaments, and recurrent episodes of vomiting or retching, ultimately leading to volvulus formation. Several reports describe repeated vomiting and retching as important triggers in patients with pre-existing HHs or prior fundoplication, where normal gastric fixation is already compromised[6,16].

In the present case, the patient had a history of a giant type IV HH previously treated with redo Nissen fundoplication. A recent episode of gastroenteritis with repeated retching likely precipitated volvulus formation. It is plausible that repeated increases in intra-abdominal pressure, combined with compromised gastric fixation from prior surgery and the patient's history of bulimia, contributed both to initial fundoplication failure and to the subsequent acute presentation of intrathoracic AGV.

It is also important to consider the patient´s prior HH repairs performed in 2024 and again in 2025. When evaluating hernia repair type and its potential relationship to recurrence and complications, controversy persists over whether tension-free repair with mesh reinforcement is superior to primary suture repair. Current evidence suggests no significant difference in recurrence rates or overall success between mesh-reinforced and primary repairs. Furthermore, intraoperative complications and reoperation rates are comparable between groups.

The classical triad of AGV symptoms, first described by Borchardt, includes retching, epigastric pain, and difficulty or inability to pass a nasogastric tube, all of which were present in this patient[17]. Patients with the intrathoracic form complicated by tension gastrothorax may also develop symptoms related to compression of intrathoracic structures, often indistinguishable from those of tension pneumothorax, including chest pain, dyspnea, and tachycardia. Progressive distension of the intrathoracic stomach can cause mediastinal shift, leading to respiratory failure and obstructive shock[18]. This condition therefore represents a true surgical emergency.

Initial attempts at nasogastric decompression should be made, but prompt surgical intervention remains the cornerstone of management. Surgical treatment includes reduction of herniated contents, detorsion of the stomach, and repair of the hiatal defect. Although the stomach is relatively resilient due to its rich collateral blood supply, intraoperative assessment of gastric viability remains critical, as the decision to perform partial or total gastrectomy depends on the extent and severity of ischemic injury[19]. When the gastroesophageal junction is involved, meticulous evaluation is essential to determine whether organ-preserving resection is feasible or whether total gastrectomy with esophagojejunal anastomosis is required. Adjunctive tools such as indocyanine green (ICG) fluorescence imaging may aid in assessing tissue perfusion and guiding resection. Although this technique was not utilized in the present case, its potential utility is acknowledged. Notably, in the setting of significant edema or large intramural hematomas, as was observed in our patient, the reliability of ICG may be limited, which may reduce its clinical applicability in such contexts[20].

When gastric viability is uncertain, a damage-control, second-look strategy offers an effective organ-preserving approach[21]. Initially developed in trauma surgery, this staged concept has been successfully adapted to non-trauma patients with visceral hypoperfusion[22]. A key component of this strategy is ICU stabilization with vigilant monitoring[23,24]. After initial laparoscopic reduction and temporary repair, our patient was transferred to the ICU for ongoing resuscitation and close observation. Serial laboratory evaluations, including lactate levels, leukocyte counts, and inflammatory markers, were used to monitor metabolic recovery, while repeated clinical assessments focused on hemodynamic status, abdominal findings, and respiratory function. This period of controlled resuscitation and continuous reassessment was critical in guiding the timing of re-exploration and ultimately enabled successful gastric preservation.

Given the limited number of reported cases and lack of robust clinical data, no standardized criteria currently exist to guide surgical decision-making among available management strategies. Our case illustrates how an individualized, organ-preserving approach may be successfully employed when gastric viability is uncertain. However, the short follow-up period in our case precludes drawing conclusions about long-term outcomes, particularly regarding the risk of recurrence. Future studies examining intraoperative findings, patient-centered clinical parameters, and long-term patient outcomes are needed to establish evidence-based guidelines to support treatment selection in these complex presentations.

CONCLUSION

Acute intrathoracic gastric volvulus complicated by tension gastrothorax is a rare but life-threatening complication that requires a high index of suspicion, particularly in the presence of predisposing factors such as large HHs, prior fundoplication, and episodes of increased intra-abdominal pressure. This case highlights the importance of individualized, staged management when gastric viability is uncertain. A second-look strategy, supported by intensive critical care monitoring, allows physiological optimization and reassessment of organ perfusion, ultimately facilitating gastric preservation.