Abstracts: CLINICAL VIGNETTES/CASE REPORTS - STOMACH
Sequential Endoscopic Gastropexy and Esophageal Stent Placement for Treatment of Gastric Volvulus With Early Signs of Ischemia
Introduction: Gastric volvulus could either be acute or chronic. The former is an emergency while the latter can be treated electively. Laparoscopic repair of the diaphragmatic hernia with gastropexy is the treatment of choice. We report a case of gastric volvulus managed with a combination of laparoscopic and endoscopic gastropexy along with esophageal stent placement in a patient with gastric volvulus and suspected gastroesophageal junction ischemia. The patient is an 86-year-old Caucasian female, who presented with complaints of intermittent epigastric pain, inability to tolerate oral intake and post-prandial emesis of one week duration. A CT scan of the chest and abdomen showed an organo-axial gastric volvulus with no transition of oral contrast past the diaphragmatic hiatus and gastric outlet obstruction. A nasogastric tube was placed for gastric decompression. Due to the concern for strangulation, she was taken to the operating room for endoscopic evaluation and laparoscopic reduction of the volvulus with hernia repair. During the intra-operative esophagogastroduodenoscopy, a small area of patchy discoloration of the esophageal mucosa near the hiatus was identified. In consideration of the mucosal findings and to avoid the risk of devitalizing the esophago-gastric junction by division of the short gastric arteries, it was decided to abandon definitive repair and instead to perform a gastropexy. The stomach was reduced back into the abdomen using laparoscopic approach. An endoscopic gastropexy was accomplished by the placement of a PEG tube. On post-operative day 1, the patient developed chest discomfort and imaging study showed significant dilatation of intrathoracic part of the stomach and severe narrowing of the diaphragmatic hiatus. A 23 x 155 mm, fully covered, self-expandable metallic stent was placed across the hiatus under endoscopic and fluoroscopic guidance. The patient did well after the procedure and was subsequently discharged home. This combined procedure of endoscopic gastropexy and esophageal stent placement can be used as a temporizing measure for surgery, such as in this patient, when there are signs of ischemia. The procedure is less invasive, safe and effective in maintaining the position of the stomach after laparoscopic reduction and gastropexy and decompressing the intra-thoracic part of the stomach.© The American College of Gastroenterology 2014. All Rights Reserved.