Monday, March 31, 2008
Interesting case the other day. A reasonably healthy 51 year old lady presented to the ER with acute, severe epigastric pain, accompanied by unrelenting vomiting. Her history included an operation 7 years ago for "twisting of the stomach". Not clear what was done at that time, however. When I saw her she looked beaten and worn out. Electrolytes out of whack, severely dehydrated. A nasogastric tube had fortunately been placed and she was feeling a little better. The CT scan showed most of the stomach up in the chest and it appeared that none of the oral contrast was making it into the decompressed duodenum. Classic gastric volvulus. Her lactate was elevated and I was worried about ongoing ischemia.
I took her to OR in the middle of the night and the volvulus was easily reduced and the stomach returned to the peritoneal cavity. No ischemic changes; it actually pinked up and looked pretty healthy. There was a large posterior hiatal hernia with the sac extending high up into the mediastinum. I'm still not sure what was done at the initial operation, but the adhesions and scarring made things difficult. The key thing is to get that sac down, otherwise the hernia will recur and you'll end up in the same position in a few months/years. I didn't wrap the fundus around the esophagus (Nissen/Toupet) because I didn't know anything about her esophageal motility and I didn't want to potentiate dysphagia at the GE junction. Instead, I did a primary crural repair and then fixed the greater curve of the stomach to the anterior abdominal wall with sutures (gastropexy) and placed a Stamm gastrostomy tube to further fix the stomach intra-abdominally. Ideally, I'll remove the tube in 6weeks or so. She had a barium study today that confirmed easy passage of contrast through the GE junction and into a completely intra-abdominal stomach.