Monday, March 31, 2008
Interesting case the other day. A reasonably healthy 51 year old lady presented to the ER with acute, severe epigastric pain, accompanied by unrelenting vomiting. Her history included an operation 7 years ago for "twisting of the stomach". Not clear what was done at that time, however. When I saw her she looked beaten and worn out. Electrolytes out of whack, severely dehydrated. A nasogastric tube had fortunately been placed and she was feeling a little better. The CT scan showed most of the stomach up in the chest and it appeared that none of the oral contrast was making it into the decompressed duodenum. Classic gastric volvulus. Her lactate was elevated and I was worried about ongoing ischemia.
I took her to OR in the middle of the night and the volvulus was easily reduced and the stomach returned to the peritoneal cavity. No ischemic changes; it actually pinked up and looked pretty healthy. There was a large posterior hiatal hernia with the sac extending high up into the mediastinum. I'm still not sure what was done at the initial operation, but the adhesions and scarring made things difficult. The key thing is to get that sac down, otherwise the hernia will recur and you'll end up in the same position in a few months/years. I didn't wrap the fundus around the esophagus (Nissen/Toupet) because I didn't know anything about her esophageal motility and I didn't want to potentiate dysphagia at the GE junction. Instead, I did a primary crural repair and then fixed the greater curve of the stomach to the anterior abdominal wall with sutures (gastropexy) and placed a Stamm gastrostomy tube to further fix the stomach intra-abdominally. Ideally, I'll remove the tube in 6weeks or so. She had a barium study today that confirmed easy passage of contrast through the GE junction and into a completely intra-abdominal stomach.
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So since the gastrostomy tube is to "fix the stomach intra-abdominally", when will you allow her to eat (mouth to stomach)?
The patient is on clear liquids now. You simply clamp the g-tube and let them eat normally. Sometimes a pureed or soft diet for a week or so and regular food when tolerated. Good question though.
Thoughts on mesh, alloderm in this setting to buttress primary repair?
The hiatus was easily repaired with two simple vicryl sutures. I don't like the cost/benefit analysis in this scenario for mesh/alloderm. I do, however, like to reinforce the hiatal repair for giant paraesophageal repairs done laparoscopically. Concerns about mesh erosion into the esophagus are real, but the literature doesn't condemn it at this point.
I am a 4th year med student starting surg residency next year. I enjoy reading your blog because of the way in which you illustrate your clinical and technical approach to surgical problems.
I can tell from your posts that you are pretty skilled with a laparoscope. Last year I helped author a case-series on laparoscopic treatment of gastric volvulus. We have suggested using anterior three-point gastropexy without fundoplication as a good alternative in older and high-risk patients, backed up by very strong mid-term results (5-10 yrs). Poster at the national SAGES meeting this month. Just thought I would share.
I didn't entertain the option of taking care of this lady laparoscopically because of the elebvated lactate and white count. I thought she needed something done expeditiously. Whe I repair large paraesophageal hernias laparoscopically, I usually book it for 2-4 hours; tough cases generally. Moreover, at 3 in the morning, I don't like to screw around.
Good luck on your career; I'll look for the case series in the journals.
I can definitely understand how in a situation such as this an open approach would be preferable. Great learning case for me, thanks.
similar case in an 80 yo. i did a reduction of the hernia, fundopexy to the left hemidiaphram, g-tube, and a nissen over a 56F maloney. my question: is there data as to when to remove the g-tube? i know you said 6 weeks, but what is this based on? thanks.
I wouldn't worry so much about what the "literature" shows for this issue. I'd let clinical judgment and specific patient chracteristics guide my decision making. A 88 year old lady who's demented and aspirates would probably keep her G-tube in until she checked out for good. Younger, functional patients (like the one I describe) can have theirs removed a lot sooner. I use 6 weeks as a semi-arbitrary end point because 6 weeks is the point of maximal collagen cross linking and you can assume the fundus has scarred itself to the abdominal wall at this point.
My mum had Gastric Volvulus 6weeks ago as an emergency, and the tubes are to remain in situ until further surgery to repair the hiatus. She is eating well, but during the last few days around the tubes and through the wound fluid has been leaking out. She has had erythromycin for staphyloccus aureus, but the Gp seems unconcerned regarding this leakage.
I am not a medical student, but a very concerned daughter, and would be grateful if you could advise, thankyou
Leakage from gastric and small intestine tubes is par for the course. As long as there isn't too much skin breakdown, it shouldnt be a problem. Stoma nurses are a good resource for skin care solutions.
I had a Nissan 10 years ago for newly diagnosed gastric volvulus. I have been very stable, until just recently.
The pressure and upper abdominal pain are frightening. I get some pressure from semi fowler's, and forcing pressure on my upper abdomen. I can't stand to have all of this start again.
I will get in to see gastroenterology. My previous doc retired.
But any speculation about what I can expect? Or what has started happening after a stable GI system for 10 years.
I am a 52 yr. old female. I have been having digestive problems for approx. 6 months now. A recent Endoscopy indicated a deformity of my stomach. Upper GI indicated Gastric volvulus left diaphragm. Ct Chest Abdomen and Pelvis was just done today. Findings:
1. Significant asymmetric elevation of the left hemidiaphragm
2. Organoaxial rotation of the stomach without evidence for volvulus
3. Mild left basilar pulmonary atelectasis.
4. A hemangioma is identified within the T9 vertebral body.
Surgeon states that I need surgery sooner than later. Should wait no longer than 2 months. Next step is to schedule Esophageal motility test. From this it is hoped to determine best fix; unfolding stomach and tacking it down or unfolding stomach and wrapping around esophagus?? Surgeon admits he has not perfomred this surgery before but seems confident he can repair. He states he has lots of experience with all the elements of the surgery, just hasn't done this particular surgery. I know this is not a common diagnosis. So how likely am I going to find an experienced surgeon? In Indiana or close by? What are your thoughts?
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