What is the treatment for gastric volvulus?

Treatment of Gastric Volvulus

The definitive treatment for gastric volvulus is surgical intervention, with laparoscopic gastropexy being the preferred approach due to its safety, efficacy, and favorable outcomes in both acute and chronic cases. 1, 2

Diagnosis

• Gastric volvulus should be suspected in patients presenting with the classic triad of retching, severe epigastric pain, and difficulty passing a nasogastric tube 3
• Diagnosis is typically confirmed through:
  • Plain abdominal radiographs as first-line imaging, which may show a high air-fluid level in the chest 4
  • Barium swallow studies to confirm the diagnosis 4
  • CT scan, which provides comprehensive assessment of the thoracic lesion and stomach viability 4

Treatment Algorithm

Acute Gastric Volvulus

• Acute gastric volvulus is a surgical emergency requiring immediate intervention 4, 3
• The primary surgical goals include:
  1. Reduction of the volvulus
  2. Reintegration of the stomach into the abdominal cavity (if intrathoracic)
  3. Correction of underlying causes (such as hiatal hernia)
  4. Prevention of recurrence 4
• Laparoscopic approach is recommended with the following benefits:
  • Lower postoperative complication rates (20% vs 75% with open surgery)
  • Shorter hospital stays (typically 48-72 hours)
  • Better quality of life outcomes 5, 2

Chronic Gastric Volvulus

• Elective surgery is indicated for chronic gastric volvulus 1
• Laparoscopic gastropexy is the procedure of choice, with excellent outcomes reported in multiple studies 1, 5
• In cases with associated diaphragmatic defects:
  • Repair of the defect is necessary, preferably with mesh reinforcement 1
  • For patients with hiatal hernias, a Nissen fundoplication with crural closure may be performed 5

Surgical Techniques

• Laparoscopic anterior gastropexy:
  • Effective as a standalone procedure in high-risk patients 5
  • Associated with early diet resumption and short hospital stays 5
• Combined approaches:
  • For secondary volvulus, treatment of the underlying cause (e.g., hiatal hernia repair) is essential 1, 4
  • Gastropexy should be performed in all cases to prevent recurrence 1

Outcomes and Prognosis

• Laparoscopic management shows:
  • Low recurrence rates (reported as low as 20% in long-term follow-up) 2
  • High patient satisfaction (80% fully satisfied with laparoscopic approach) 2
  • Better quality of life scores compared to open surgery 2
• Complications to monitor for include:
  • Delayed gastric emptying (reported in 20% of laparoscopic cases) 2
  • Respiratory complications, particularly in open surgical approaches 2

Special Considerations

• Pregnant patients with gastric volvulus can be safely managed with laparoscopic surgery 1
• For elderly patients or those with significant comorbidities, laparoscopic anterior gastropexy alone may be sufficient to reduce surgical risk while effectively treating the condition 5
• Alternative approaches such as combined endoscopic and laparoscopic techniques or percutaneous endoscopic gastrostomy have been reported with good results in selected cases 1