|Year : 2019 | Volume
| Issue : 5 | Page : 161-168
Acute gastric volvulus in children: A systematic review
Wan-Yu Hung1, Tai-Wai Chin2, Yao-Jen Hsu2, Yu-Wei Fu2
1 Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
2 Division of Pediatric Surgery, Changhua Christian Children's Hospital, Changhua, Taiwan
|Date of Submission||03-Jan-2019|
|Date of Decision||23-Apr-2019|
|Date of Acceptance||27-May-2019|
|Date of Web Publication||25-Oct-2019|
Dr. Yu-Wei Fu
Division of Pediatric Surgery, Changhua Christian Children's Hospital, No. 320, Xuguang Rd., Changhua 500
Source of Support: None, Conflict of Interest: None
This study aimed to review pediatric cases of acute gastric volvulus, explore the distinguishing features, and outline the diagnosis and management of this life-threatening condition. We searched PubMed, ScienceDirect, and Ovid Medline in March 2018 for cases of gastric volvulus in the pediatric age range (<18 years). Citations that were not published in English, or did not discuss gastric volvulus mainly in its topics, or that it included reports only on cases of adults, or abstract only were excluded from the search. All relevant articles were accessed in full text. The manual search included references of retrieved articles. We extracted data on patients' age, gender, and presentation of acute or chronic, volvulus-type, clinical presentations, associated pathologies, diagnostic tools, and treatment. We analyzed the data and reported the results in tables and text. There have been 63 cases of gastric volvulus in the pediatric group published in English between 1979 and 2017, with a total of 65 cases by adding our two cases. We divided the 37 acute cases for investigation. Cases' ages ranged from newborn to 18-year-old adolescents, with 14 cases (37.8%) in mesenteroaxial axis, 15 cases (40.5%) in organoaxial type, and one in combine type. The most common symptom is emesis, which was counted in 25 cases, with a ratio of 67.6%, abdominal pain or distention in 17 cases (45.9%), and pulmonary symptoms were observed in 10 cases. In the associated pathologies, congenital diaphragmatic hernia (CDH) is the most commonly associated pathology, which was counted in 15 cases (40.5%). Within the 37 cases, 7 cases (18.9%) underwent laparoscopic surgery and 30 cases (81.1%) underwent laparotomy. Gastropexy was performed in 19 cases, and 17 cases underwent a repair of CDH. One case underwent gastric reduction, repair of congenital heart disease, and perforation, but this patient ultimately died of gastric perforation-induced sepsis. Surgical intervention is always applied to an emergency treatment of acute gastric volvulus, and laparoscopic, even single port surgery, is also a choice for these patients.
Keywords: Acute gastric volvulus, children, gastropexy, laparoscopy, pediatric
|How to cite this article:|
Hung WY, Chin TW, Hsu YJ, Fu YW. Acute gastric volvulus in children: A systematic review. Formos J Surg 2019;52:161-8
| Introduction|| |
Gastric volvulus is a rare disease which is widely recognized as a life-threatening condition. The term “volvulus” is a Latin verb known as volvere, which means to turn or roll. “Gastric volvulus” is defined as an abnormal rotation of the stomach of more than 180°, which creates a closed-loop obstruction of the foregut that can result in incarceration and strangulation. A twisting of the stomach of 180° that results in only partial foregut obstruction is best defined as “gastric torsion.”, Berti reported the first gastric volvulus case in adults in 1866, based on the autopsy of a 61-year-old woman. In 1899, the first gastric volvulus in children was described by Baert et al. The levels of a gastric volvulus may be divided into acute and chronic, primary, and secondary. There are three types of gastric volvulus namely mesenteroaxial, organoaxial, and combine type, in which the organoaxial type was most commonly observed in primary and chronic gastric volvulus. Most of the mesenteroaxial volvulus in children are secondary to a diaphragmatic hernia or wandering spleen. Gastric volvulus in children is a difficult issue in diagnosis because children always present nonspecific clinical symptoms. The incidence and prevalence of gastric volvulus have not been calculated in studies, but the peak age group of incidence has been determined to be in the fifth decade; this disease in a particular group of infants and children continues to be considered rare., In children, neonatal period accounts for 26% of all cases.
Gastric volvulus in children has been published in many case reports, but review articles are rare. In 2008, Randolph has published about gastric volvulus in infants and children, but no literature has done a systemic review of acute gastric volvulus in children. In this article, we share two typical childhood cases in acute gastric volvulus whose clinical symptoms were resolved after laparoscopic surgery. We will also try to explore the distinguishing features and outline the diagnosis and management of this life-threatening condition based on all acute gastric volvulus cases in pediatric literature published to date that had been reviewed in the English literature.
| Materials and Methods|| |
We describe two cases of acute gastric volvulus that were diagnosed during April 2016–March 2018. An electronic literature search was performed on the PubMed, ScienceDirect, and Ovid Medline in March 2018 by using the search terms “gastric volvulus” with “pediatric.” On March 20, 2018, 157 citations were searched. Citations that were not published in English, or did not discuss gastric volvulus mainly in its topics, or that it included reports only on cases of adults, or abstract only were excluded from the search. An additional 54 citations were adopted, including 42 case reports, 8 retrospective studies, 2 review articles, and 2 articles about images. We reviewed all the 54 citations and coordinated the data of 42 case reports, to investigate the age, gender, and presentation of acute or chronic, volvulus type, clinical presentations, associated pathologies, diagnostic tools, and treatment, and excluded cases with incomplete data. Definition of acute gastric volvulus is an episode of acute onset. We aimed to outline the features, diagnosis, and treatment of acute gastric volvulus.
This study is approved by Institute Review Board Committee C of Changhua Christian Hospital (CCH IRB No. 18068 obtained on July 4th, 2018) and the documentation of informed consent is waived.
A 2.8-year-old girl was referred from the branch hospital for acute abdominal pain, nausea, and nonbilious vomiting 12 h ago. She was generally healthy previously. On physical examination, her vital signs were stable and severe abdominal distention was found, with a tender abdomen. Abdominal computed tomography (CT) presented an infarcted spleen situated medially to the markedly distended stomach in favor of gastric outlet obstruction due to mesenteroaxial volvulus, secondary to a wandering spleen with torsion [Figure 1]a. A nasogastric tube was placed with aspiration for stomach contents, and a laparoscopic surgery was performed. Under laparoscopic evaluation, her stomach was returned to normal axis spontaneously, and the spleen was located to its normal position. She presented a stable disease after the first 2 days of the operation. However, on the 3rd day, she had a recurrence of abdominal pain and emesis. The upper gastrointestinal series showed a vertical stomach with a pylorus projecting above the gastroesophageal junction and anterior–superior rotation of the antrum with the posterior surface of the stomach lying anteriorly [Figure 1]b. The second laparoscopic surgery was performed in emergency, and during this operation, the spleen was found toward the posterior of the stomach, and ligamental laxity of the stomach was recognized, resulting in gastric malrotation. Laparoscopic reduction of the stomach with a gastropexy was performed. Her clinical symptoms were improved after the operation, and she was discharged on the 9th postoperative day uneventfully.
|Figure 1: (a) An infarcted spleen is situated medial to the markedly distended stomach in favor of gastric outlet obstruction due to mesenteroaxial volvulus secondary to a wandering spleen with torsion. (b) The antrum displaced above the gastroesophageal junction and the pylorus were superior to the fundus and proximal body|
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A 1.5-year-old girl was admitted to the pediatric intensive care unit for postprandial vomiting, nonbilious emesis for twenty times in 2 days, and fever was developed then. According to her electronic medical record, she had a history of acute gastroenteritis; there was no obvious abnormality in the imaging records. Physical examination found that her abdomen was distended with tenderness. The plain abdomen and abdominal CT revealed a markedly distended stomach with gastric outlet obstruction. Aspiration of gastric contents was applied; the gastric distention was improved on the next day, but her emesis remained. A barium swallow was arranged which showed contrast medium accumulated in the stomach. The stomach laid in a vertical plane, and the antrum and pylorus rotated anterior and superior to the gastroesophageal junction [Figure 2]. A single-port laparoscopic surgery was performed. According to the intraoperative finding, the greater curvature was located above the lesser curvature and stomach was rotated more than 180°. Single-port laparoscopic reduction was performed with three-point gastropexy [Figure 3]. After reduction of the stomach, the spleen was placed at its normal position. The child had an uneventful postoperative recovery and was discharged on the 8th postoperative day.
|Figure 2: Contrast medium accumulated at the stomach, the stomach lay in a vertical plane, and gastric antrum is located above the esophagogastric junction from mesenteroaxial volvulus with gastric outlet obstruction. The arrow indicates the point of rotation in the dilated stomach|
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|Figure 3: Single-port laparoscopic surgery: make a trans-umbilical vertical incision and input three trocars-5 mm Trocar for the camera and 3 mm Trocars for laparoscopic instruments. Three-point gastropexy: fix the fundus, antrum, and anterior of the stomach for preventing malrotation (star marks)|
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| Results|| |
There have been 63 cases of gastric volvulus in the pediatric group published in English literature between 1979 and 2017, with a total of 65 cases by adding our two cases. Among the cases, 37 cases were acute and 28 cases were chronic. We divided the 37 acute cases for investigation; the details of the 37 cases are presented in [Table 1]. Cases' ages ranged from newborn to 18-year-old adolescents. The most prominent group was preschoolchildren, which accounted for 12 cases (32.4%), the second group is adolescent in 11 cases (29.7%), the third with 9 neonatal cases accounting for 24.3%, and infant group with only 5 cases (13.5%). 19 female cases and 17 male cases were calculated, with one case of unidentified gender. 14 cases (37.8%) in mesenteroaxial axis, 15 cases (40.5%) in organoaxial type, one in combine type, and 7 cases have not mentioned the rotated axis of the stomach. Primary volvulus accounted for 10.8% (4 cases) and secondary volvulus accounted for 83.8% (31 cases), where 2 cases cannot be classified.
|Table 1: Characteristics of acute gastric volvulus in the pediatric population|
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The most common symptom is emesis, which was counted in 25 cases, with a ratio of 67.6% (including 8 nonbilious vomiting, 2 hematemesis, 1 bilious vomiting, and 1 coffee ground emesis), abdominal pain or distention in 17 cases (45.9%), pulmonary symptoms were observed in 10 cases (including 7 respiratory distress, 2 shortness of breath, and 1 apnea). Other symptoms such as nonproductive retching (3 cases), hypersalivation (3 cases), and anorexia (2 cases) were also being recorded, where the less common symptoms were failure to thrive, diarrhea, chest pain, back pain, and inability to pass a nasogastric tube [Figure 4]. In the associated pathologies, congenital diaphragmatic hernia (CDH) is the most commonly associated pathology, which was counted in 15 cases (40.5%), whereas gastric ligamental laxity was counted in 4 cases (10.8%), 3 cases had a wandering spleen, 3 cases had postoperative adhesion, 3 cases had asplenia, and 3 cases had traumatic diaphragmatic rupture. Other uncommon etiologies are iatrogenic artifact, situs inversus, left pneumonectomy, and Ladd's band. Two cases had reported an unclear etiology [Figure 5].
Upper gastrointestinal series was performed in 24 (64.9%) cases as a diagnostic tool, 10 (27%) cases were diagnosed by CT, 7 cases were diagnosed by plain abdomen, and ultrasound and chest film were performed in 2 cases and 3 cases, respectively. One case was diagnosed through nuclear isotope scanning, and one case did not mention the examination process. Within the 37 cases, 7 cases (18.9%) underwent laparoscopic surgery, and 30 cases (81.1%) underwent laparotomy. Gastropexy was performed in 19 cases, and 17 cases underwent a repair of CDH. Gastrectomy was performed in three cases due to the perforation with necrosis of gastric tissue. Fundoplication was indicated in one case for reflex esophagitis treatment. One case underwent gastric reduction, repair of congenital heart disease, and perforation, but this patient ultimately died of gastric perforation-induced sepsis [Table 1].,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
| Discussion|| |
In our review, acute gastric volvulus is prominent in preschoolchildren. Most cases belong to the secondary subtype. The most common clinical presentations are emesis, abdominal pain or distention, and pulmonary symptoms such as respiratory distress or dyspnea. The most common associated factor is CDH, where the second is gastric ligamental laxity, and wandering spleen was the third common associated pathology. Upper gastrointestinal series was most popularly used in the diagnosis of acute gastric volvulus. In 37 cases, 7 cases underwent laparoscopic surgery, 30 cases underwent laparotomy, and gastropexy was performed in 51.4% of all cases. Only one case led to death due to gastric perforation-related sepsis. The two cases we described above presented similar symptoms such as nonbilious vomiting. The images revealed a vertical stomach, and its antrum and pylorus are larger than esophagogastric junction. Laparoscopic reduction with gastropexy was indicated in both cases, and they had good recoveries after the operations.
The complications of gastric volvulus include ulceration, perforation, hemorrhage, pancreatic necrosis, and omental avulsion; rotation of the stomach may even disrupt the splenic vessels, resulting in hemorrhage and splenic rupture. Acute gastric volvulus is an emergency condition that was reported with high mortality in the pediatric population. Nevertheless, the diagnosis is difficult and is conventionally depending on radiology in children with suspicious clinical findings. Plain abdomen, chest X-ray, upper gastrointestinal series, and abdominal CT are commonly used in the diagnosis of gastric volvulus. Barium meal examination is the gold standard for the diagnosis of gastric volvulus.
There are three types of gastric volvulus described according to the rotational axis namely mesenteroaxial, organoaxial, and combined type. The oganoaxial type is the most common, accounting for 59% of all cases (chronic and secondary volvulus is usually of this type), with the second being mesenteroaxial type (29%) and the last common being the combine type (12%)., Organoaxial is defined as the rotation around an axis adjoining the gastroesophageal junction and the pylorus, resulting in the greater curvature rest superior to the lesser curvature, that lies in the horizontal plane when viewed on plain radiography. Mesenteroaxial is defined as the rotation of the stomach along with an axis perpendicular to its longitudinal axis, resulting in the stomach lying in the vertical plane with the antrum and pylorus rotated anterior and superior to the gastroesophageal junction, forming a single bubble, long air-free level sign. The combined type is the rotation of the stomach in both organoaxial and mesenteroaxial axes.
Acute gastric volvulus always presents complete obstruction in the stomach and results in serious consequences. The mortality rate of acute gastric volvulus is more than two times of chronic gastric volvulus;, instant diagnosis is therefore necessary even though the clinical presentations are usually not significant. Acute gastric volvulus commonly causes complete obstruction; it is more often seen in infants. In contrast, chronic gastric volvulus occurs more in older children and adults. Borchardt's triad, which was described by Borchardt in 1904 for clinical evaluation of gastric volvulus, consists of unproductive vomiting, epigastric distention, and difficult to set a nasogastric tube. Borchardt's triad was reported with a 70% sensitivity in adults, but only 50% of all children cases presented the Borchardt's triad, and various reports recorded that children with an acute gastric volvulus often result in defection., Acute gastric volvulus usually presents obvious clinical symptoms in the pediatric population; the most common presentations include nonbilious emesis, acute abdominal pain, and distention. But, in our review, pulmonary symptoms such as respiratory distress and dyspnea are also noted. Primary and secondary gastric volvulus were divided by associated pathologies with the deficient ligamentous attachment of the stomach. Primary gastric volvulus occurs as a result of neoplasia, adhesions, or an abnormality in the attachment of the stomach. There are four ligaments responsible for fixing stomach in its normal position: gastrocolic, gastrohepatic, gastrophrenic, and gastrosplenic. Absent of gastric ligaments, elongation, disruption, or laxity of ligaments could result in gastric malrotation. Most of the pediatric gastric volvulus are secondary to congenital diaphragmatic malformations, asplenia/polysplenia syndrome, wandering spleen, pyloric stenosis, traumatic injury to the diaphragm, phrenic nerve palsy, after repairing of esophageal, atresia with tracheoesophageal fistula, and malrotation of the gut., The less commonly associated pathologies such as ectopic kidney, agenesis of left lobe of the liver, and iatrogenic artifact have also been reported.
Treatment of gastric volvulus depends on the clinical presentations, associated pathologies, and the degree of obstruction. In the case of an acute volvulus, it may have the risk of vascular compromise, and the mortality rate is high. Acute gastric volvulus, therefore, always requires an emergency surgery; if possible, nasogastric tube aspiration of stomach contents may also be necessary. Surgical intervention aims to restore normal orientation, decompression of distended stomach, treatment of predisposing factors, and fixes the stomach at its normal position. Despite several operations being available, such as Tanner's operation, which perform diaphragmatic hernia repair, simple gastropexy, gastropexy with the division of the gastrocolic omentum; Opolzer's operation, performs the partial gastrectomy, fundoantral gastrogastrostomy. Repair of eventuation of the diaphragm is the most frequently performed procedure for gastric volvulus. In the past decade, laparoscopic surgery for gastric volvulus was developed with a shorter operation time compared to laparotomy. Laparoscopic gastropexy and even single port surgery are options in correcting the acute gastric volvulus.
The limitations of this study include its retrospective nature, having only 37 registered cases worldwide, the unpredictable human population rates, the poor control over the exposure factors, the covariates, and other potential factors.
| Conclusion|| |
Acute gastric volvulus is a life-threatening condition that may result in serious consequence of the stomach in the pediatric population; instant diagnosis and treatments are therefore necessary. Based on our observation, in the pediatric population, acute gastric volvulus happens more often in preschoolchildren and commonly presents an emesis, abdominal pain/distention, and pulmonary symptoms such as respiratory distress or dyspnea. CDH is the most commonly associated pathology. Upper gastrointestinal series has been popularly used for the diagnosis of gastric volvulus. Surgical intervention is always applied to an emergency treatment of acute gastric volvulus, and laparoscopic, even single-port surgery, is also a choice for these patients.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]