Gastric volvulus: modern aspects of diagnosis and treatment

Abstract

Aim. To determine the optimal surgical treatment strategy for gastric volvulus in patients with paraesophageal hernias and to evaluate the effectiveness of different surgical techniques, specifically fundoplication versus gastropexy.

Materials and methods. Between 2020 and 2024, 145 patients with paraesophageal hernias underwent surgery at the Department of Thoracoabdominal Surgery, State Institution “O. O. Shalimov National Scientific Center for Surgery and Transplantation” of the National Academy of Medical Sciences of Ukraine. Gastric volvulus was diagnosed in 20 patients (13.7 %), including 18 cases of chronic volvulus and 2 cases of acute volvulus. According to the C. Singleton classification, 18 cases were organoaxial gastric volvulus, 1 case was mesenteroaxial, and 1 case was the combined type. Gastric volvulus was associated with type III paraesophageal hernias in 16 patients and with type IV hernias in 4 patients. Two clinical cases of surgical treatment for gastric volvulus are presented.

Results. Among the 20 patients with gastric volvulus, the mean length of hospital stay was 3 ± 1 days. Intraoperative complications included pneumothorax in 1 (5 %) patient who underwent fundoplication. One patient (5 %) in the fundoplication group experienced early postoperative gastroparesis. No cases of postoperative gastroparesis were observed in patients who underwent gastropexy. No recurrence of gastric volvulus was reported during a long-term follow-up of up to 2 years after either fundoplication or gastropexy. One patient (5 %) experienced an anatomical hiatal hernia recurrence after fundoplication without progression of gastroesophageal reflux disease. A comparison of long-term outcomes (esophagogastroduodenoscopy and upper GI radiography) between the fundoplication and gastropexy groups revealed no significant differences in the incidence of erosive lesions or gastroparesis.

Conclusions. Gastric volvulus associated with a paraesophageal hiatal hernia is a rare but potentially life-threatening complication that requires prompt diagnosis and often a multi-stage treatment approach. Multislice computed tomography with contrast enhancement is the most informative imaging modality for diagnosing gastric volvulus. Laparoscopic access is the preferred surgical approach for treating all types of hiatal hernias, including those complicated by gastric volvulus. The optimal treatment includes laparoscopic mediastinal dissection with esophageal mobilization and transposition into the abdominal cavity, cruroplasty, and fundoplication. However, in elderly patients with significant comorbidities, less invasive procedures, such as gastropexy, may be more appropriate.