Intrathoracic Mesenteroaxial Gastric Volvulus with Massive Gastric Necrosis Requiring Total Gastrectomy and Roux-En-Y Esophagojejunostomy Reconstruction
Introduction: Acute gastric volvulus is a surgical emergency with high morbidity and mortality due to associated ischemic gastric necrosis, perforation, and severe cardiorespiratory compromise. It is characterized by abnormal rotation of the stomach of more than 180°. It is classified based on the axis of rotation into organoaxial and mesenteroaxial volvulus. Intrathoracic gastric volvulus occurs uncommonly in association with organoaxial rotation which draws the stomach through a defect at the hiatus, mesenteroaxial rotation has rarely been reported intrathoracically. We report a case of Intrathoracic Mesenteroaxial volvulus associated with a para-esophageal hernia presenting with gastric necrosis. Case Report: A 70-year-old female, with a complex medical history including a known type III hiatal diagnosed via CT scan two years prior, presented to the emergency room with acute onset abdominal pain, nausea, and inability to vomit. She describes the abdominal pain initially as intermittent that started in the lower left quadrant and had progressively worsened with radiation to the back and left shoulder. Initial laboratory tests showed leukocytosis, anemia and elevated lipase. A nasogastric tube was inserted, and 1 L of dark red fluid was retrieved. Concerns for acute abdominal vascular catastrophe called for A CT angiogram of the abdomen and pelvis, which showed pneumoperitoneum and subphrenic fluid collection with a large para-esophageal hiatal hernia and intrathoracic stomach with pneumatosis and disruption of the anterior gastric wall. An emergency celiotomy was performed. The entire stomach was noted to be frankly ischemic and gangrenous. A Damage Control Surgery (DCS) was utilized. A total gastrectomy without reconstruction was performed (phase I) to control contamination. The patient was taken to the surgical intensive care unit for resuscitation (phase II). After 24 hours, the patient underwent a definitive surgery (phase III) that included a Roux-en-Y esophagojejunostomy with jejunal pouch reconstruction and feeding jejunostomy tube. The patient was discharged 15 days after the inciting operation. Conclusion: Gastric volvulus is a serious condition with a mortality rate ranging from 30 to 50%. Rarely a volvulus can present intrathoracically in the presence of a large hiatal hernia and should be considered a surgical emergency due to increased risk of ischemia. Giant hiatal hernia, in which >50% of stomach resides in the chest, should undergo surgical repair to prevent this potentially devastating complication. We present this case report to raise clinical awareness of intrathoracic gastric volvulus complicated with gastric necrosis.