What is the management of organoaxial volvulus?

Management of Organoaxial Volvulus

The optimal management of organoaxial gastric volvulus requires prompt diagnosis followed by endoscopic decompression if uncomplicated, or immediate surgical intervention if complications such as ischemia or perforation are present. 1

Diagnostic Approach

• Imaging studies are crucial for diagnosis:
  • Plain abdominal radiographs as first-line test
  • Abdominal CT is the gold standard showing:
    • Dilated stomach with air/fluid level
    • "Whirl sign" representing twisted stomach and mesentery 1
  • Upper gastrointestinal contrast studies can also confirm the diagnosis 2

Treatment Algorithm

Initial Assessment

1. Evaluate for signs of critical illness:
   • Presence of septic shock
   • Evidence of gastric ischemia
   • Perforation
   • Peritonitis

For Uncomplicated Volvulus

1. Endoscopic decompression as first-line treatment 1

   • Success rates of 70-91% reported for decompression of volvulus
   • Low complication rates (2-4.7%) 1

2. Post-decompression management:

   • Immediate fluid resuscitation
   • Broad-spectrum antibiotics to control bacterial translocation 1
   • Early definitive intervention to prevent recurrence

3. Definitive treatment options:

   • Laparoscopic repair with:

     • Reduction of volvulus
     • Excision of hernia sac (if present)
     • Reapproximation of diaphragmatic crura
     • Nissen fundoplication to prevent reflux
     • Gastropexy to anterior abdominal wall 2

   • Percutaneous endoscopic gastrostomy (PEG) placement:

     • Useful alternative for high-risk patients
     • Alpha-loop maneuver to reduce volvulus followed by PEG tube placement
     • Effective in preventing recurrence in elderly or poor surgical candidates 3, 4

For Complicated Volvulus (ischemia, perforation, shock)

1. Immediate surgical intervention without delay 1

   • Resection of infarcted tissue without detorsion
   • Minimal manipulation to prevent release of endotoxins and bacteria 1

2. Surgical approach:

   • Laparoscopic approach preferred when expertise available 2, 4
   • Open surgery for unstable patients or complex cases
   • Repair of associated diaphragmatic hernia if present 5

Special Considerations

Risk Factors for Mortality

• Age over 60 years
• Presence of shock on admission
• History of previous episodes of volvulus 1

Complications to Monitor

• Strangulation (reported in up to 28% of cases) 5
• Ischemia-reperfusion injury
• Peritoneal exudate
• Electrolyte disturbances
• Hypoproteinemia 1

Pitfalls to Avoid

1. Delayed diagnosis - The high incidence of strangulation necessitates urgent intervention 5
2. Inadequate fixation - Recurrence is common without proper fixation
3. Missing associated conditions - Paraesophageal hernias often coexist and should be repaired 5
4. Underestimating severity - Minimal abdominal findings may be present when the stomach is in the thorax 5

Follow-up

• Close monitoring for recurrence
• Patients should be educated about symptoms of recurrence
• Consider elective repair of any associated paraesophageal hernias to prevent future episodes 5