Gastric volvulus

The stomach or part of the stomach is rotated at least 180 degrees along its longitudinal or transverse axis

Classification

Anatomical (not clinically as important)
- Organoaxial (35%)
  - Stomach rotates around its longitudinal axis (a transverse line between the pylorus and GOJ)
  - In most cases the antrum rotates anteriorly and superiorly and the fundus posteriorly and inferiorly, and the greater curvature comes to lie superior to the lesser curvature
- Mesenteroaxial (65%)
  - Stomach rotates around its short axis - a longitudinal line parallel to the gastrohepatic omentum, connecting the middle of the greater and lesser curvatures
  - Pylorus rotates anteriorly and superiorly (most common), but can sometimes move posteriorly from right to left
  - The posterior of the stomach lies anteriorly
- Combined (2%)
Aetiological
- Primary (30%):
  - Rotation due to laxity/disruption of the gastric ligaments. Due to agenesis, elongation, or disruption (neoplasia, adhesions, skeletal deformity). More common with chronic symptoms.
  - Usually mesenteroaxial
- Secondary (70%):
  - Volvulus due to other anatomical abnormalities (paraoesophageal hernia (most common), congenital diaphragmatic hernia, diaphragmatic eventration, phrenic nerve paralysis)
  - Mostly organoaxial
Onset
- Acute
- Chronic

Stomach rotation >180 degrees causes complete gastric outlet obstruction, and partial is less likely with smaller rotations
Strangulation is much more common with organoaxial than mestenteroaxial, and can occur with torsion >180 degrees

Borchardt's Triad - sudden onset of constant and severe epigastric pain, retching with minimal vomitus, and inability to pass NGT (70% have it)
Haematemesis can occur
Gastric outlet obstruction
Suspect strangulation with fever, tachycardia and leukocystosis
Chronic/subacute symptoms are often vague and non-specific

CXR - single large, spherical gas bubble in upper abdomen or chest with air-fluid level. Note that other aetiologies of GOO are less likely to have a spherical contour
CT - dilated stomach, often abnormal position, swirl sign (oesophagus and stomach rotating around one another), look for gastric necrosis
Gastroscopy: tortuous stomach, paraoesophageal hernia, inability to locate and pass through the pylorus, possibly evidence of gastric ischaemia

NGT (if bedside NGT is not possible, can do gastroscopy-assisted and decompress the stomach at the same time)
- Can sometimes detort the stomach spontaneously
Resuscitate
Antibiotics
Many would argue for routine gastroscopy, even if NGT is in

Goals - return stomach to anatomic position, repair associated abnormalities, and prevent recurrence (otherwise occurs in 64% of patients treated conservatively)
In unstable patients, open approach is recommended
OT can be done electively in patients that improve well or achieve detorsion with low risk of strangulation
Technique
- Abdominal approach with upper midline laparotomy (can sometimes be done laparoscopically)
- Decompression, detorsion, and observation for ischaemia
  - Any strangulated segments need to be resected
    - Close the stomach if you can
    - If patient is unstable and large gastric resection is required, drain the distal oesophagus, close the duodenal stump and place a feeding jejunostomy. Roux-en-Y jejuno-oesophagostomy will subsequently be needed.
  - If unable to reduce:
    - Guide NGT into place
    - Consider aspirating contents of stomach via needle or gastrotomy
    - Thoracotomy
- If the patient is stable, fix any diaphragmatic defect and do a proper 'elective' repair
  - Excise hernia sac
  - Suture the crura
  - If a paraoesophageal hernia was present, consider a fundoplication
- If the patient is unstable, just do a suture gastropexy to anterior abdominal wall and complete the operation
Stable patients with high surgical risk could have PEG gastropexy (two tube gastrostomies will fix the stomach better than one) but this is uncommonly done
- This could also be done for a spontaneous volvulus