Management of Acute Upside-down Stomach

Tobias S Schiergens; Michael N Thomas; Thomas P Hüttl; Wolfgang E Thasler


BMC Surg. 2013;13(55) 

In This Article

Management of Acute Incarceration – Case Presentation

A 32-year-old male presented to the emergency department (ED) after acute thoraco-epigastric pain had set in after dinner several hours before. On arrival in the ED, his intolerant epigastralgia and anterior chest pain had been associated with acute onset of nausea and vomiting. The patient reported on having had recurrent substernal pain and dysphagia as well as mild symptoms of reflux which had persisted for more than a year. He reported on a previous surgical intervention due to a hiatal hernia, whereupon a anterior hemifundoplication had been performed two years ago. Furthermore the patient had a history of Ebstein's anomaly which had been addressed by a reconstruction of the tricuspid valve a year ago.

A naso-gastric tube was tried to be placed but pushing it forward proved to be challenging and required repeated attempts, which all turned out to be unsuccessful. On admission the patient's lactate level was mildly elevated (2.4 mmol/L) and besides a slightly increased WBC (12/nL) unremarkable. Notably, no elevation of cardiac enzymes was detected. Electrocardiogram on admission showed sinus tachycardia, an incomplete right bundle branch block and a distinct S1Q3-pattern. Echocardiography revealed a normal left-ventricular ejection fraction, however the right ventricle was dilated. Upright chest radiography showed no subdiaphragmatic free air but visceral gas was seen in projection on the posterior mediastinum. Adjacent contrast-enhanced computer tomography disclosed a giant hiatal hernia (Figure 1). Most portions of the stomach and some of the greater omentum had migrated into the posterior mediastinum, whereas parts of the greater curvature appeared to be incarcerated in the diaphragmatic hiatus. Immediate esophago-gastroscopy showed a kinking-stenosis of the cardia and a stenosis caused by the strangling diaphragm which could hardly be passed. A naso-gastric tube was then positioned endoscopically and food residue and gas were sucked off for therapeutic decompression of the incarcerated stomach. Altogether mucosa appeared unremarkable and there were no signs of ischemia or restrained perfusion (Figure 2). After endoscopy the patient's complains were attenuated but not resolved.

Figure 1.

Contrast-enhanced computer tomography. (A–C) Giant mixed-type hernia (upside-down stomach (S)) with an incarcerated portion of the stomach (red arrows). (D) Visceral gas distribution seen from the 3D-reconstruction showing the proximal gastric portion (S) in the posterior mediastinum (incarceration: red arrows).

Figure 2.

Esophago-gastroscopy. (A) Distended stomach migrated intrathoracically exhibiting the stenosis caused by the strangling diaphragm which could hardly be passed endoscopically. (B) Gastric mucosa appearing unremarkable aside from minor petechial bleedings.

Emergent surgery for reduction of the incarcerated stomach and repair of the hiatal defect was performed through five trocars evenly dispersed to the upper abdomen (Figure 3). First, retracting the left liver lobe laparoscopic reduction of the stomach and attached portions of the greater omentum was conducted (Figure 3A–C) opening the view to a giant hiatal defect (Figure 3D). After preparation of the diaphragmatic crura and the distal esophagus preserving the rami of N. vagus a hiatoplasty was performed by anterior and posterior approximation of the diaphragmatic crura (Figure 3E–G). Given the fact of a recurrent hernia and a very wide defect of approimately 8 cm, a gradually absorbable GORE® BIO-A®-mesh (W.L. Gore & Associates Inc., Flagstaff, AZ) of biocompatible synthetic polymers was inserted enlacing the gastro-esophageal transition (Figure 3H–I). In a final step, a 360° floppy Nissen fundoplication was accomplished (Figure 3J–L). Postoperatively the patient recovered very well and was discharged five days later without any complication. He is to be followed up by the surgical outpatient department and is presently free of any complaints.

Figure 3.

Laparoscopic reduction (A–D) and repair (E–G) of the incarcerated upside-down-stomach with insertion of a gradually absorbable mesh (H–I) and accomplishment of a 360° floppy Nissen fundoplication (J–L).