Acute gastric volvulus complicated by gastric perforation following laparoscopic Nissen fundoplication; A case report

Abstract

Introduction

Laparoscopic Nissen Fundoplication is an effective standard surgical procedure for treatment of severe GERD. While it is generally safe and effective, a rare but potentially fatal complication known as acute gastric volvulus can occur following this procedure.

Case presentation

A 28-year-old male, ten months post Laparoscopic Nissen Fundoplication presented with a one-day history of severe epigastric pain, abdominal distention, unproductive retching, and difficulty in breathing. Examination revealed tachypnea, subcutaneous emphysema and a tender distended abdomen. Imaging studies showed a left pneumothorax, pneumoperitoneum, and a grossly distended stomach.

Emergency exploratory laparotomy confirmed organoaxial gastric volvulus, necrosis of the greater curvature and gastric perforation. Partial gastrectomy and anterior gastropexy were performed. A left thoracostomy tube was placed to drain the left pneumothorax. He recovered fully post-operatively with complete resolution of all symptoms.

Discussion

Acute Gastric volvulus post Laparoscopic Nissen Fundoplication is attributed to adhesions, gastrostomy tubes, and foreign bodies like sutures. Life-threatening complications, such as gastric perforation, can ensue, underscoring the need for swift diagnosis and treatment.

Conclusion

Acute gastric volvulus following Laparoscopic Nissen Fundoplication is a rare condition, and is difficult to diagnose. Given the steadily increasing rates of laparoscopic Nissen fundoplications performed in Uganda, maintaining a high index of suspicion is crucial for favorable patient outcomes among patients with this potentially fatal complication.

Highlights

• •Laparoscopic Nissen Fundoplication is a safe and effective procedure.
• •Acute gastric volvulus can rarely complicate laparoscopic Nissen fundoplication.
• •Acute gastric volvulus is a surgical emergency.
• •A high index of suspicion is required to diagnose acute gastric volvulus.
• •Gastric perforation can rarely present with pneumothorax.

1. Introduction

Gastroesophageal reflux disease (GERD) ranks among the most prevalent health issues worldwide with a 10–20 % prevalence in the adult population [1,2]. Laparoscopic Nissen fundoplication (LNF) is a safe, cost-efficient, and effective anti-reflux procedure for treatment of severe GERD [[3], [4], [5]]. However, acute gastric volvulus (GV) is an extremely rare potentially fatal complication that can occur following LNF.

GV, an abnormal rotation of the stomach, often presents a diagnostic challenge and constitutes a surgical emergency [6]. Delayed diagnosis and management can result in potentially fatal complications, including gastric perforation, ischemia, and necrosis. Therefore, clinicians ought to have a high level of suspicion to diagnose this life-threatening condition among patients presenting with obstructive symptoms following LNF.

We describe a case of a 28-year-old male who presented with left pneumothorax due to gastric perforation following an organoaxial acute GV, ten months after undergoing LNF for treatment of GERD.

This case report has been written in line with the Surgical Case Report (SCARE) criteria [7].

2. Case presentation

2.1. Case history

28-year-old male, ten months post LNF for treatment of severe GERD, presented to our emergency unit at St. Francis Hospital Nsambya, Kampala-Uganda, with sudden-onset severe epigastric pain, abdominal distension, and profound nausea, but with inability to vomit for one day. He also reported worsening difficulty in breathing, chest pain and sudden-onset swelling of the left side of the neck and upper chest area. He had last passed stool three days prior to presentation; he had no dysphagia or fever.

2.2. Clinical examination

He was sick-looking, afebrile, dehydrated, and in respiratory distress. He had tachycardia of 112 beats per minute, normotensive at 110/78 mmHg, saturating at 88 % on room air and 98 % when supplemented with 2 L of oxygen via nasal prongs.

He was tachypneic at 26 breaths per minute with crepitus (subcutaneous emphysema) over the left side of the neck, left upper anterior chest extending to the left nipple area, and in both axillae. Reduced breath sounds were noted on the left hemithorax.

The abdomen was asymmetrically distended, more marked in the epigastrium. Generalized abdominal tenderness, guarding, and rebound tenderness were noted. The bowel sounds were increased in pitch and frequency. There was normal anal sphincter tone and the rectum contained pellet-like stool.

2.3. Investigations

Laboratory investigations revealed leukocytosis of 16,200 cells per microliter, elevated C-Reactive protein level of 22 mg/L, normal renal function tests, and electrolytes.

Chest X-ray (Fig. 1) showed air under both the right and left diaphragm indicating pneumoperitoneum, a sign of gut perforation, and air under the soft tissues showing subcutaneous emphysema.

Fig. 1.

Chest X-ray showing air under both right and left diaphragm indicating pneumoperitoneum (blue arrows), a sign of gut perforation and air under the soft tissues (red arrows) showing subcutaneous emphysema. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Erect abdominal X-ray (Fig. 2) also showed pneumoperitoneum, a large stomach bubble with an air-fluid level.

Fig. 2.

Erect abdominal showing pneumoperitoneum (blue arrows), a large stomach bubble and an air-fluid level (pink arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Chest Computed Tomography (CT) scan (Fig. 3) showed left pneumothorax and bilateral subcutaneous emphysema.

Fig. 3.

CT scan of the chest showing left pneumothorax (white arrows) and subcutaneous emphysema (red arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

An abdominal CT scan (Fig. 4) showed pneumoperitoneum and a grossly dilated stomach; suggestive of a gastric volvulus and gastrointestinal tract perforation.

Fig. 4.

CT scan of the abdomen showing pneumoperitoneum (blue arrows) and grossly dilated stomach (orange asterixis). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

2.4. Diagnosis

He was diagnosed with acute GV complicated by gastric perforation, based on the typical presentation of epigastric pain, abdominal distension, and inability to vomit, supported by characteristic Xray and CT scan findings.

2.5. Treatment

Emergency resuscitation included intravenous fluids, analgesia, and restriction of oral feeding. Gastric decompression using a nasogastric tube (NGT) was unsuccessfully attempted.

During emergency exploratory laparotomy, we found an organoaxial gastric volvulus ∼180° with one axis of rotation at the fundal wrap site and the other at the pylorus. The fundal wrap was intact with an Ethibond suture, no anatomical abnormalities or adhesions were seen. The stomach was grossly distended with full-thickness necrosis along the greater curvature measuring 10 × 10 cm. (Fig. 5). There was a 2 × 2 cm perforation on the posterior aspect of the necrotic area of the stomach. Following gentle untwisting of the stomach, partial (Sleeve) gastrectomy was performed to remove necrotic tissue and simple anterior gastropexy done using a non-absorbable suture. We left a drain in the left paracolic gutter, inserted NGT and placed a chest tube in the left hemidiaphragm. Postoperative management included intravenous antibiotics, analgesia, proton pump inhibitors, and rehydration.

Fig. 5.

Intra-operative image showing an organoaxial gastric volvulus with grossly distended stomach, full thickness necrosis of the body of the stomach, 10 × 10 cm along the greater curvature (Fig. 5).

2.6. Follow-up and outcome

The post-operative period was uneventful; we removed the chest tube on the 2nd post-operative day, after repeat chest x-ray showed resolution of left pneumothorax and subcutaneous emphysema. On the 6th post-operative day, the abdominal drain was removed, NGT spigoted and the patient allowed to take oral sips. NGT was removed on the 9th post-operative day and the patient was started on a soft diet.

He was discharged home on the 12th postoperative day. During subsequent reviews at one, two, and three months post-discharge, he had no complaints.

3. Case discussion

Laparoscopic fundoplication is a minimally invasive (keyhole) standard operative anti-reflux procedure for patients with severe GERD [8,9]. It involves creating a flap valve by wrapping the gastric fundus around the gastroesophageal junction. The Nissen fundoplication, consisting of a total or complete (360°) wrap, is the most commonly performed form of fundoplication. Partial fundoplications, such as the Toupet fundoplication (270° posterior wrap) or the Dor fundoplication (180° anterior wrap) around the gastro-esophageal junction are also options [9,10]. Our patient underwent LNF.

GV is the abnormal rotation of the stomach over itself. It is a rare complication that has been described among only a few cases following LNF [4]. GV can be classified according to onset and clinical presentation as acute or chronic, according to the axis of rotation as organoaxial, mesenteroaxial, or a combination of both, and according to etiology as primary or secondary [6].

In the most common type, organoaxial volvulus, the stomach rotates along its long (cardiopyloric) axis causing closed-loop obstruction. It's often associated with gastric ischemia and perforation (5–28 % of cases). Mesenteroaxial volvulus, which constitutes one-third of cases, involves rotation around a transverse axis that bisects the lesser and greater curvatures. Vascular compromise is rare due to incomplete and intermittent rotation. Combination volvulus is rare [4,6,11]. Our patient developed acute organoaxial GV causing gastric tissue necrosis and gastric perforation.

Primary GV results from the laxity of gastrophrenic, gastrosplenic, gastrohepatic and gastrocolic ligaments [12] while most cases are secondary to diaphragmatic defects or other intra-abdominal factors such as left diaphragmatic eventration, adhesions, gastric ulceration, and gastric or duodenal carcinoma [13,14].

GV post Laparoscopic Nissen Fundoplication is attributed to adhesions, gastrostomy tubes, or foreign bodies like sutures [4]. Our patient developed secondary GV following LNF, likely due to an Ethibond suture acting as a foreign body since one of the axes of gastric rotation was at the fundal wrap site and he had an intact wrap site and absence of adhesions.

Acute GV can present with the Borchardt triad, characterized by severe epigastric pain and distension, inability to vomit or retching, and difficult or impossible NGT bypass; observed in 70 % of patients with GV [11]. Epigastric tenderness and distention can suggest acute GV and in cases of stomach necrosis or severe obstruction, peritonitis can be present. Rarely, gastric perforation can cause left pneumothorax [12,15,16]. Due to connections between retroperitoneum, mediastinum and cervical subcutaneous tissues, air from perforated abdominal viscera can track into these regions leading to pneumothorax and subcutaneous emphysema [17]. Patients with chronic GV present with unspecific intermittent epigastric pain, abdominal discomfort after meals or even dysphagia [11,12]. Our patient presented with typical features of Borchardt's triad, peritonitis, and left pneumothorax.

Computed Tomography (CT) scan of the abdomen is the recommended imaging modality to confirm the diagnosis of GV [16,18,19]. In this case, the diagnosis of acute GV with gastric perforation was confirmed by abdominal and chest CT scans which showed typical features.

Acute GV is a surgical emergency; requiring decompression, volvulus reduction, and prevention of recurrence with gastropexy. Initial patient resuscitation and insertion of a nasogastric tube for decompression are recommended, but tube placement may fail if the gastroesophageal junction is completely obstructed. In such cases, reduction of the volvulus can be performed by endoscopy or by gentle traction on the stomach during open laparotomy. After untwisting the stomach during laparotomy, perfusion, and viability of gastric tissue should be observed for a period of 10–15 min. If the ischemia persists, a total or partial gastrectomy can be performed depending on the extent of tissue necrosis [6,15,16,20].

Simple anterior gastropexy involves suturing the stomach's anterior wall, towards the abdominal wall with a non-absorbable suture. Other variations of gastropexy include gastrostomy tube placement, suturing the lesser curvature to the ligamentum teres or the free edge of the liver, posterior fixation of the greater curvature to the parietal peritoneum and colonic mesentery or fundus fixation to the diaphragm [6,20].

Our patient underwent an emergency open exploratory laparotomy, revealing a 180-degree stomach rotation. Partial gastrectomy and simple anterior gastropexy were performed.

4. Conclusion

Acute GV, though rare, is a potentially fatal complication of LNF, occurring even months later. With the steadily increasing number of LNFs performed in Uganda, comprehensive understanding of this uncommon complication among healthcare professionals can enhance their ability to promptly diagnose and treat it effectively, thereby optimizing favorable patient outcomes. A high index of suspicion is required to diagnose acute GV post LNF.

Consent

We obtained written informed consent from the patient and his family for the publication of this case report and accompanying images. A copy of the written informed consent document is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The Research and Ethics Committee (REC) of St. Francis Hospital Nsambya waived off the need for ethics approval for the publication of this case report. Reference number; SFHN-2024-027. However, the REC strongly emphasised obtaining written informed consent from the patient before publishing this case report.

Funding

We received no financial support from any organization for this work.

Author contribution

Tracy Tushabe Namata: study concept or design; writing of the original draft and editing the manuscript.

Annanda Nyisomeh Ndamenyi: gathered the relevant case information, and edited the manuscript.

Ali Henry Bukenya: managed the case, gathered the relevant case information, and edited final draft.

Lukuman Mukungu; gathered relevant case information and edited the manuscript.

Brian Bbosa: study concept or design; supervision; validated the findings and case management, and edited final draft.

All of the authors have reviewed the final manuscript and approved it for publication.

Guarantor

Tracy Tushabe Namata, Annanda Nyisomeh Ndamenyi, Ali Henry Bukenya, Lukuman Mukungu, Brian Bbosa

Conflict of interest statement

We declare no conflicts of interest.