Ghady Moafa, MD1, Divyesh Nemakayala, MD2, Matthew Reif, BA2, Monik Lammi, MD1; 1Ochsner Medical Center, New Orleans, LA; 2Ochsner Clinic Foundation, Jefferson, LA
Introduction: We discuss a rare case of partial gastric volvulus with complete herniation of the stomach into the lower thorax as a complication of laparoscopic Heller myotomy(LHM) with Dor fundoplication.
Methods: A 37-year-old female with refractory GERD and progressive dysphagia to solids and liquids was diagnosed with type II achalasia by manometry and esophagogram. She subsequently underwent LHM with Dor fundoplication and her symptoms of dysphagia and regurgitation resolved after surgery. She presented to our motility clinic 2 years later with esophageal dysphagia, weight loss, nausea, vomiting, and chest pain. Her symptoms started 6 months after surgery and progressed over time. Upper GI series showed gastric volvulus, likely organo-axial, with the majority of the stomach in the thoracic cavity due to a large hiatal hernia, along with partial or transient obstruction. EGD showed previous fundoplication with narrowing and twisting in the gastric body. CT abdomen showed complete herniation of the stomach into the lower thorax with organo-axial malrotation and partial gastric volvulus. The patient underwent LHM with mesh placement resulting in resolution of her symptoms. Discussion: Gastric volvulus is a rare clinical entity defined as an abnormal rotation of the stomach of more than 180 degrees, which creates a closed-loop obstruction that can result in incarceration and strangulation. Our case manifested as a chronic intermittent problem. Patients can present with dysphagia, early satiety, and chest discomfort. Strangulation and necrosis are the most feared complications and can be life-threatening. Diagnosis is usually based on barium studies and CT imaging showing an antropyloric transition point without any abnormality at the transition zone and antrum at the same level as or higher than the fundus. Strangulated volvulus warrants emergent surgical intervention while a chronic gastric volvulus can be managed surgically on a non-emergent basis. There are few case reports of gastric volvulus after LHM with fundoplication. Our patient had no evidence of a hernia prior to her LHM. Our case describes a complication of LHM with Dor fundoplication resulting in a large hiatal hernia, both of which increase the risk of acquired gastric volvulus. This patient had no signs or symptoms of strangulation. She was managed appropriately by LHM repair with mesh placement. Gastroenterologists and surgeons should be aware of this life-threating albeit rare postoperative complication.
CT abdomen showing complete herniation of the stomach into the lower thorax with organo-axial malrotation and partial gastric volvulus.
Upper GI series showed gastric volvulus, likely organo-axial, with the majority of the stomach in the thoracic cavity due to a large hiatal hernia, along with partial or transient obstruction.
EGD showing fundoplication with narrowing and twisting of the gastric body.
Disclosures: Ghady Moafa indicated no relevant financial relationships. Divyesh Nemakayala indicated no relevant financial relationships. Matthew Reif indicated no relevant financial relationships. Monik Lammi indicated no relevant financial relationships.