Katkhouda N, Mavor E, Achanta K, Friedlander M H, Grant S W, Essani R, Mason R J, Foster M, Mouiel J
Division of Emergency Non Trauma and Minimally Invasive Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, Calif, USA.
Surgery. 2000 Nov;128(5):784-90. doi: 10.1067/msy.2000.108658.
Totally intrathoracic gastric volvulus is an uncommon presentation of hiatal hernia, in which the stomach undergoes organoaxial torsion predisposing the herniated stomach to strangulation and necrosis. This may occur as a surgical emergency, but some patients present with only chronic, non-specific symptoms and can be treated electively. The aim of this study is to describe a comprehensive approach to laparoscopic repair of chronic intrathoracic gastric volvulus and to critically assess the pre-operative work-up.
Eight patients (median age, 71 years) underwent complete laparoscopic repair of chronic intrathoracic gastric volvulus. Symptoms of epigastric pain and early satiety were universally present. Five patients had reflux symptoms. The diagnostic evaluation included a video esophagogram, upper endoscopy, 24-hour pH measurement, and esophageal manometry in all patients. Operative results and postoperative outcome were recorded and follow-up at 1 year included a barium swallow in all patients.
All patients had documented intrathoracic stomach. Five of 8 patients had a structurally normal lower esophageal sphincter. All 4 patients with reflux esophagitis on upper endoscopy had a positive 24-hour pH study, and 2 of these patients had a structurally defective lower esophageal sphincter on manometry. None of the patients had preoperative evidence of esophageal shortening. All procedures were completed laparoscopically. The procedure included reduction of the stomach into the abdomen, primary closure of the diaphragmatic defect, and the construction of a short, floppy Nissen fundoplication. There were no major complications. One patient required repair of a trocar site hernia 6 months postoperatively. At 1-year follow-up, there were no radiologic recurrences of the volvulus. One patient complained of temporary swallowing discomfort and another had recurrent gastroesophageal reflux disease (GERD) symptoms caused by a breakdown of the wrap. All other patients remained asymptomatic during follow-up.
The repair of chronic gastric volvulus can be accomplished successfully with a laparoscopic approach. A preoperative endoscopy and esophagogram are crucial to detect esophageal stricture or shortening, and manometry is needed to access esophageal motility; pH measurements do not affect operative strategy. The procedure should include a Nissen fundoplication to treat preoperative GERD, to prevent possible postoperative GERD, and to secure the stomach in the abdomen. The procedure is safe but technically challenging, requiring previous laparoscopic foregut surgical expertise.
完全胸腔内胃扭转是食管裂孔疝的一种罕见表现，其中胃发生器官轴扭转，使疝入胸腔的胃易于发生绞窄和坏死。这可能作为外科急症出现，但一些患者仅表现为慢性非特异性症状，可选择进行治疗。本研究的目的是描述一种慢性胸腔内胃扭转的腹腔镜修复综合方法，并严格评估术前检查。
8例患者（中位年龄71岁）接受了慢性胸腔内胃扭转的完全腹腔镜修复。上腹部疼痛和早饱症状普遍存在。5例患者有反流症状。所有患者的诊断评估包括视频食管造影、上消化道内镜检查、24小时pH值测量和食管测压。记录手术结果和术后结局，1年随访时所有患者均进行了吞钡检查。
所有患者均有胸腔内胃的记录。8例患者中有5例食管下括约肌结构正常。上消化道内镜检查发现的4例反流性食管炎患者24小时pH值研究均为阳性，其中2例患者测压显示食管下括约肌结构缺陷。所有患者术前均无食管缩短的证据。所有手术均通过腹腔镜完成。手术包括将胃复位至腹腔、一期关闭膈肌缺损以及构建一个短而松弛的Nissen胃底折叠术。无重大并发症。1例患者术后6个月需要修复套管针部位疝。1年随访时，扭转无放射学复发。1例患者主诉暂时吞咽不适，另1例患者因胃底折叠术失败出现复发性胃食管反流病（GERD）症状。所有其他患者在随访期间无症状。
慢性胃扭转的修复可通过腹腔镜方法成功完成。术前内镜检查和食管造影对于检测食管狭窄或缩短至关重要，需要进行测压以了解食管动力；pH值测量不影响手术策略。手术应包括Nissen胃底折叠术，以治疗术前GERD、预防可能的术后GERD并将胃固定在腹腔内。该手术安全但技术上具有挑战性，需要有腹腔镜前肠手术经验。
