Dr. Sudarshan
Under Guidance of
Dr. B. L. Yadav
Assistant Professor,
Upgraded Department of Surgery
History
Name: Bhori singh
Age & sex: 45 yrs ,male
Resident :Baroli ,Bharatpur

DOA:05/01/2013

Clinical presentation
Pain ...
Cont..
Past history:
 No h/o similar complaint
 No h/o previous surgery
 No h/o DM, TB, COPD, Hypertension , Bronchial
...
Examination











Conscious
Oriented
Afebrile
Pulse-92/min
B.P-100/70 mmHg
No pallor
No L.N Pathy
No icteru...
P/A
Inspection:
 Abdomen distended with fullness present in upper abdomen
 No visible pulsation , peristalsis
Palpation:...
Investigations











HB- 11.6 gm/dl
TLC- 1400 /mm3
PLT- 1.35 lakh/ml
Serum urea/creatinine- 87/2.0 mg/dl
S.T...
Provisional diagnosis:
 Acute intestinal obstruction
 Perforation peritonitis

Plan:
 Exploratory Laparotomy
Procedure performed
 Exploratory laparotomy with Gastropexy
Per operative photos
cranial

R
L

caudal
Cont…
CRANIAL

R

L
Cont..
cranial

R

L
Cont..

Cranial

Caudal
Contd..

Stomach Fixed to
Diaphragm &
AnteroLateral
Abdominal Wall
With Silk
Post operative follow up
 Vitals monitoring
 Input /output monitoring
 Chest physiotherapy
 Skin stitches removal-7th ...
Discussion
 Definition

Gastric volvulus or volvulus of stomach a twisting of
all or part of the Stomach by more than 180...
Cont..
 Very uncommon clinical entity
 First described by Berti in 1866
 Seen in both children and elderly people
 Rar...
Classification of gastric volvulus
On the basis of:
1)OnsetAcute
Chronic
2)Axis of rotation Organoaxial
Mesentroaxial
Comb...
Gastric volvulus
1. Organoaxial(along longitudinal axis-MC)
a)Acute presentation
b)associated with diaphragmatic defects
c...
Diagrammatic representation

Organoaxial

Mesentroaxial
Aetiology
 Type 1 or Idiopathic gastric volvulus

comprises two thirds of cases and is presumably due to
abnormal laxity ...
Cont..
 Type 2 or secondary

Type 2 gastric volvulus is found in one third of patients and is
usually associated with con...
AETIOLOGY
Clinical features
 Pain abdomen (acute in onset)
 Recurrent retching with little vomitus
 Inability to pass a Ryles tub...
Investigations
 X Ray FPA- Gas filled viscus in chest and or upper





abdomen, multiple air fluid levels,
Barium co...
X-ray findings in gastric volvulus
Contd …
Barium meal:
Organoaxial volvulus

Before surgery

After surgery
Mesentricoaxial Gastric volvulus
Endoscopy view:
USG:
 Peanut sign in a case of chronic gastric volvulus.
 The ultrasonographic features consist of a constricted

segmen...
CT image:
Advantage of CT Scan
 detection of gastric pneumatosis and

pneumoperitoneum, suggestive of necrosis and
perforation, res...
Limitation of Techniques
 Plain radiography may demonstrate findings that are

indistinguishable from those that are prod...
Treatment
 Aims:

1) Reduction of volvulus
2) Gastric fixation
3) Repair of predisposing factor
 Apporach:

Open
Endosco...
Cont..
Open surgery:
 Diaphragmatic hernia repair
 Division of bands
 Gastropexy
 Partial gastrectomy(In case of necro...
Surgical procedures
Anterior suture gastropexyThe stomach along the
gastro colic omentum is
suspended to the anterior
abdo...
Cont..
Endoscopic :
Reduction
 Alpha loop maneuver
 J type maneuver
With or without gastrostomy(for fixation of stomach)...
PEG Tube
Cont..
Laproscopic
 Reduction of volvulus
 Anchoring fundus of stomach to diaphragm and

greater curvature of stomach to...
Cont..
Combined approach
 Described by Arben Beqiri in 1997
 Less time consuming
 Endoscopic T-fasteners are used inste...
T-fastener system
Method for providing apposition of two
bodily walls
a) forming a puncture site through the two walls;
b) inserting an acce...
Follow up





Clinical:
Reflux symptoms
Recurrence
Removal of PEG Tube
Imaging:
Contrast study
Complications of volvulus
 Strangulation
 Necrosis
 Perforation of stomach
 Gastrointestinal haemorrhage

 Cardiopulm...
Complications related to PEG Tube
 Wound infection
 Peritonitis
 Peristomal leakage
 Dislodgement

 Bowel perforation...
Association
 Wandering spleen
 Congenital diaphragmatic hernia
 Diaphragmatic eventration
Chronic gastric volvulus
 Patient presents with recurrent episodes of vague

abdominal pain and discomfort
 Bloating
 S...
Gastric volvulus and other types of volvulus
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Gastric volvulus and other types of volvulus

  1. 1. Dr. Sudarshan Under Guidance of Dr. B. L. Yadav Assistant Professor, Upgraded Department of Surgery
  2. 2. History Name: Bhori singh Age & sex: 45 yrs ,male Resident :Baroli ,Bharatpur DOA:05/01/2013 Clinical presentation Pain abdomen: last 3 days Abdominal distention: last 3 days Not passing flatus motion: last 2 days No h/o fever No h/o vomiting
  3. 3. Cont.. Past history:  No h/o similar complaint  No h/o previous surgery  No h/o DM, TB, COPD, Hypertension , Bronchial Asthma Personal history  Smoker  Tobacco chewer  Non alcoholic  Normal bowel bladder habits
  4. 4. Examination           Conscious Oriented Afebrile Pulse-92/min B.P-100/70 mmHg No pallor No L.N Pathy No icterus No clubbing No pedal oedema
  5. 5. P/A Inspection:  Abdomen distended with fullness present in upper abdomen  No visible pulsation , peristalsis Palpation:  Abdomen is tense, tender  Guarding present  No Rigidity Percussion:  Tympanic note present  Normal liver dullness and span  No shifting dullness Auscultation:  Bowel sounds absent
  6. 6. Investigations          HB- 11.6 gm/dl TLC- 1400 /mm3 PLT- 1.35 lakh/ml Serum urea/creatinine- 87/2.0 mg/dl S.Total bilirubin-1.2 mg/dl Direct- 0.5 mg/dl Indirect- 0.7 mg/dl SGOT/SGPT- 70/18 Serum amylase-175.0 u/lt Serum electrolytes- wnl X-Ray FPA- Multiple air fluid level with large single stomach gas shadow
  7. 7. Provisional diagnosis:  Acute intestinal obstruction  Perforation peritonitis Plan:  Exploratory Laparotomy
  8. 8. Procedure performed  Exploratory laparotomy with Gastropexy
  9. 9. Per operative photos cranial R L caudal
  10. 10. Cont… CRANIAL R L
  11. 11. Cont.. cranial R L
  12. 12. Cont.. Cranial Caudal
  13. 13. Contd.. Stomach Fixed to Diaphragm & AnteroLateral Abdominal Wall With Silk
  14. 14. Post operative follow up  Vitals monitoring  Input /output monitoring  Chest physiotherapy  Skin stitches removal-7th post op. day  Discharge-8th post op. day
  15. 15. Discussion  Definition Gastric volvulus or volvulus of stomach a twisting of all or part of the Stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death.
  16. 16. Cont..  Very uncommon clinical entity  First described by Berti in 1866  Seen in both children and elderly people  Rare below fifth decades of life
  17. 17. Classification of gastric volvulus On the basis of: 1)OnsetAcute Chronic 2)Axis of rotation Organoaxial Mesentroaxial Combined
  18. 18. Gastric volvulus 1. Organoaxial(along longitudinal axis-MC) a)Acute presentation b)associated with diaphragmatic defects c)more common in adults d)vascular compromise more common 2. Mesentroaxial (along vertical axis) a) recurrent episodes of pain abdomen b) Diaphragmatic defects are not seen c) more common in children 3. Combined
  19. 19. Diagrammatic representation Organoaxial Mesentroaxial
  20. 20. Aetiology  Type 1 or Idiopathic gastric volvulus comprises two thirds of cases and is presumably due to abnormal laxity of the gastrosplenic*, gastrocolic*, gastrophrenic and gastrohepatic* ligaments.
  21. 21. Cont..  Type 2 or secondary Type 2 gastric volvulus is found in one third of patients and is usually associated with congenital or acquired abnormalities that result in abnormal mobility of the stomach  Diaphragmatic defect Eventration Paraoesophagial hiatal defect Trauma Paralysis  Congenital bands and adhesions  Intestinal malrotation  Pyloric stenosis and gastric distension  Colon distention
  22. 22. AETIOLOGY
  23. 23. Clinical features  Pain abdomen (acute in onset)  Recurrent retching with little vomitus  Inability to pass a Ryles tube OTHERS  Abdominal pain       Vomiting Upper GI bleed Dysphagia Gastro oesophageal reflux Respiratory symptoms Altered bowel habit Borchardts Triad
  24. 24. Investigations  X Ray FPA- Gas filled viscus in chest and or upper     abdomen, multiple air fluid levels, Barium contrast studies :sensitive and specific Upper GI Endoscopy: both diagnostic and therapeutic USG CT scan abdomen and MRI
  25. 25. X-ray findings in gastric volvulus
  26. 26. Contd …
  27. 27. Barium meal: Organoaxial volvulus Before surgery After surgery
  28. 28. Mesentricoaxial Gastric volvulus
  29. 29. Endoscopy view:
  30. 30. USG:  Peanut sign in a case of chronic gastric volvulus.  The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.  In several case reports, however, the ultrasonographic evaluation of gastric volvulus showed normal findings.
  31. 31. CT image:
  32. 32. Advantage of CT Scan  detection of gastric pneumatosis and pneumoperitoneum, suggestive of necrosis and perforation, respectively  detection of predisposing factors, e.g. diaphragmatic defects or hernias, dense adhesions  detection of other abnormalities associated with gastric volvulus, viz. wandering spleen, intrathoracic kidney, malrotation with asplenia  excluding other extra-gastric or vascular causes of gastric ischaemia
  33. 33. Limitation of Techniques  Plain radiography may demonstrate findings that are indistinguishable from those that are produced by other causes of gastric atony or obstruction. However, the modality is useful for excluding other causes of the patient's symptoms, such as pneumoperitoneum or pneumothorax.  Barium study is highly sensitive and specific. However, the diagnosis may be missed in cases of intermittent torsion.
  34. 34. Treatment  Aims: 1) Reduction of volvulus 2) Gastric fixation 3) Repair of predisposing factor  Apporach: Open Endoscopic Laproscopic Combined (endoscopic + laproscopic)
  35. 35. Cont.. Open surgery:  Diaphragmatic hernia repair  Division of bands  Gastropexy  Partial gastrectomy(In case of necrosis)  Gastrojejunostomy  Repair of eventration of diaphragm
  36. 36. Surgical procedures Anterior suture gastropexyThe stomach along the gastro colic omentum is suspended to the anterior abdominal wall Partial gastrectomy – Indicated if a portion of the stomach is gangrenous
  37. 37. Cont.. Endoscopic : Reduction  Alpha loop maneuver  J type maneuver With or without gastrostomy(for fixation of stomach) (PEG)
  38. 38. PEG Tube
  39. 39. Cont.. Laproscopic  Reduction of volvulus  Anchoring fundus of stomach to diaphragm and greater curvature of stomach to anterior abdominal wall  Repair of diaphragmatic defects  fundoplication
  40. 40. Cont.. Combined approach  Described by Arben Beqiri in 1997  Less time consuming  Endoscopic T-fasteners are used instead of PEG for anchoring stomach
  41. 41. T-fastener system
  42. 42. Method for providing apposition of two bodily walls a) forming a puncture site through the two walls; b) inserting an access cannula into the puncture site; c) passing a guide tube through the access cannula, the guide tube retroflexing after passing beyond a distal end of the access cannula; d) positioning a distal end of the guide tube proximate one of the bodily walls; e) passing a flexible puncturing device through the guide tube and puncturing the two bodily walls at a second location; f) connecting a fastener to the puncturing device; g) retracting the puncturing device to draw the fastener through the two bodily walls at the second location; and h) securing the fastener to maintain apposition of the two walls at the second location.
  43. 43. Follow up     Clinical: Reflux symptoms Recurrence Removal of PEG Tube Imaging: Contrast study
  44. 44. Complications of volvulus  Strangulation  Necrosis  Perforation of stomach  Gastrointestinal haemorrhage  Cardiopulmonary failure
  45. 45. Complications related to PEG Tube  Wound infection  Peritonitis  Peristomal leakage  Dislodgement  Bowel perforation  Gastrocolic fistula
  46. 46. Association  Wandering spleen  Congenital diaphragmatic hernia  Diaphragmatic eventration
  47. 47. Chronic gastric volvulus  Patient presents with recurrent episodes of vague abdominal pain and discomfort  Bloating  Surgery is only indicated if the episodes of pain are severe and disabling  T/t of choice- conservative  Operation of choice-anterior gastropexy

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