Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report

A 43-year-old female presented to our emergency room complaining of abdominal pain,
fullness, and vomiting. The pain was acute in onset, colicky, and continuous, and
these symptoms gradually worsened. Just prior to the onset of these symptoms, she
had been completely well and eaten dinner as usual. Her medical history was unremarkable.
Because she had periodically experienced similar symptoms since childhood, she had
undergone detailed examinations several times, but the origin of the symptoms was
not identified. The patient was conscious and oriented and had a pulse of 77 beats
per minute, a blood pressure of 154/92 mmHg, a body temperature of 36.5 °C, and an
oxygen saturation of 98 % on room air. Physical examination revealed abdominal distension
with mild epigastric tenderness. Laboratory results were as follows: white blood cell
count 12,820/mL (normal, 4000–9000) and serum C-reactive protein concentration 0.48 mg/dL
(0.3) and liver functions, renal functions, creatine kinase, and lactate dehydrogenase
within normal ranges.

Abdominal radiography showed a massively distended viscus in the upper abdomen. A
plain computed tomography (CT) scan demonstrated the stomach to be markedly distended
and filled with gas and fluid. A nasogastric (NG) tube was inserted with difficulty.
A large volume of gastric contents was suctioned out via the NG tube, promptly relieving
the abdominal pain. Further, plain abdominal radiography showed the stomach to be
markedly dilated with a double air fluid level when the patient was standing. The
patient underwent a contrast-enhanced CT, which revealed a grossly enlarged stomach
with resultant displacement of the gastric antrum above the gastroesophageal junction
and a normal-size spleen positioned inferiorly toward the left kidney as compared
to its normal anatomical location, and there was no evidence of ischemia, infarction,
or perforation of the abdominal organs (Fig. 1). Upper gastrointestinal (GI) series through the NG tube showed an elevated greater
curvature, with the greater curvature crossing the esophagus, the pylorus pointing
downward, and the gastric fundus in a lower position than normal (Fig. 2). These findings pointed to a diagnosis of acute mesenteroaxial gastric volvulus.
Upper GI endoscopy revealed distortion of the gastric anatomy with difficulty intubating
the pylorus (Fig. 3). Employing various endoscopic maneuvers such as clockwise rotation and pulling the
endoscope back, we succeeded in repositioning the stomach and GI endoscopy then passed
through the pylorus into the duodenum. Abdominal radiography confirmed gastric volvulus
reduction. The patient’s symptoms showed immediate and complete solution after this
reduction, and her subsequent course was uneventful. After a 3-day recovery period,
the patient was performed a further GI fluoroscopy with contrast medium. Initially,
most of the contrast medium accumulated in the fundus, which was drawn prominently
downward, and then began flowing into the duodenum with anteflexion. The patient was
discharged from the hospital, and elective surgery was planned for 1 month later.

Fig. 1. Contrast-enhanced abdominal CT findings. The arrow shows the NG tube inserted into the stomach. Axial CT scan at the abdominal esophagus
level (a) demonstrates the grossly enlarged stomach with resultant displacement of the gastric
antrum (A and arrowheads) above the abdominal esophagus. More caudal axial CT scan (b) and coronal CT images (c, d) reveal the stomach to be twisted mesenteroaxially, with the antrum (A) positioned higher than the fundus (F). CT findings (b, d) show the normal-sized spleen positioned inferiorly toward the left kidney as compared
to its normal position. CT computed tomography, NG tube nasogastric tube, A antrum, B body, C cardia, Duo duodenum, Eso esophagus, F fundus, Sp spleen

Fig. 2. Upper GI contrast radiogram. Upper GI series in the supine position (a) and a lateral view obtained with the patient standing upright (b) demonstrate a high greater curvature (short arrows), with the greater curvature crossing the esophagus (long arrow), the pylorus pointing downward (arrowheads), and that the gastric fundus is lower than normal (thick arrow). GI gastrointestinal

Fig. 3. Endoscopic reduction of gastric volvulus using radiographic imaging. a Upper GI endoscopy shows the dilated stomach containing residual food and fluid (GI
image of a is b). c The endoscope cannot be passed through the pylorus (GI image of c is d). e With various endoscopic maneuvers, such as clockwise rotation and pulling the GI
endoscope back, the gastric volvulus is reduced and the endoscope passes through the
pylorus into the duodenum (GI image of e is f). GI gastrointestinal

Laparoscopic surgery was performed under general anesthesia. A 12-mm port was inserted
at the umbilicus and two 5-mm ports were placed in the epigastrium and the lower left
abdomen (Fig. 4a). There was no evidence of hiatal hernia or diaphragmatic defect. The stomach was
in its normal anatomical position, but the fundus was folded posteroinferiorly. The
spleen attached to the fundus was normal in size but hyper-mobile (Fig. 4b). The surrounding splenic ligaments other than the gastrosplenic ligament were absent.
Therefore, we diagnosed a wandering spleen based on the operative findings. The lower
than the normal position of the fundus was attributed to the abnormal gastrophrenic
ligament which was probably associated with wandering spleen. We performed phrenofundopexy
and anterior gastropexy, laparoscopically. The fundus at the greater curvature of
the stomach was fixed to the diaphragm with five interrupted nonabsorbable sutures
in order to prevent the fundus from being folded and to keep the spleen fixed in the
left upper abdomen (Fig. 4c). The upper body was anchored to the anterior abdominal wall with two interrupted
absorbable sutures in order to prevent the stomach from twisting (Fig. 4d).

Fig. 4. Laparoscopic surgery for gastric volvulus. a The placement of three trocars and two small incisions made for gastropexy. b The fundus is folded posteroinferiorly, and the spleen is attached to the fundus
which is freely mobile. The operative findings confirm the diagnosis of wandering
spleen. c Phrenofundopexy is performed to prevent lowering of the fundus and to keep the spleen
fixed in the left upper abdomen. d Anterior gastropexy is performed to prevent the stomach from twisting

The postoperative period was uneventful. The contrast medium used for GI radiography
on the fourth day after surgery showed good passage without pooling in the fundus,
and the patient was discharged 5 days postoperatively. She remained asymptomatic,
and there has been no evidence of gastric volvulus or wandering spleen on the radiological
images obtained to date, 24 months after the operation.

Discussion

It is critical to make a prompt and precise diagnosis in order to avoid the potentially
fatal conditions associated with prolonged volvulus such as ischemia, necrosis, and
perforation of the stomach. Since the diagnosis is difficult to make based on clinical
features alone, several imaging studies may be employed to facilitate the diagnosis
of gastric volvulus and coexisting disorders. Radiography, GI fluoroscopy, and CT
are the effective modalities most frequently employed 3]. Radiography shows a massive distended stomach with air in supine position and a
double air-fluid level in upright position. Upper GI fluoroscopy can be performed
to evaluate rotation of the stomach and the passage of ingested contrast material
into the duodenum. CT is especially reliable for diagnosing acute gastric volvulus,
consequent critical complications, and factors triggering the onset. GI endoscopy
is, however, unreliable for the diagnosis of latent gastric volvulus 23]. With the advanced diagnosis and management now available, the mortality rate of
acute gastric volvulus has decreased to 15–20 % 24].

The radiological findings in our case demonstrated a mesenteroaxial gastric volvulus.
Mesenteroaxial gastric volvulus results from rotation of the stomach around the lesser
and greater curvatures, with resultant displacement of the antrum above the gastroesophageal
junction. Mesenteroaxial volvulus usually occurs partially and intermittently, and
obstruction and strangulation are less common 1], 3]. The patient had complained of intermittent dyspeptic pain and abdominal fullness
after meals, which was the chronic symptoms with a high recurrence rate (64 %) 23], and acute-on-chronic gastric volvulus with Borchardt’s triad was occurred. The radiological
and surgical findings of our present patient included the fundus being located posteroinferiorly
as compared to its normal position and a wandering spleen attached to the fundus.
Since some patients of wandering spleen are completely asymptomatic, the diagnosis
may be made incidentally by routine physical examination or imaging 17]. A preoperative diagnosis of wandering spleen reportedly accounts for only approximately
50 % of cases 12]. We were not able to diagnose a wandering spleen preoperatively in this case. Presumably,
in our case, the etiology of gastric volvulus would have been acquired laxity of the
gastric ligaments, possibly associated with a wandering spleen, allowing the resultant
rotation of the stomach due to the weight of gastric contents accumulated in the fundus
along the short axis when the stomach was full, leading to volvulus 10].

The treatment of gastric volvulus involves decompression of the stomach, reduction
of the volvulus, gastropexy, and correction of the underlying cause 1], 25]. NG tube placement is a brief and effective procedure for decompression of the stomach.
Upper GI endoscopy is the most effective method of achieving decompression and reduction
of the stomach in the emergency setting, rapidly leading to a marked improvement of
the patient’s condition 26]–28]. Definitive treatment of gastric volvulus includes gastropexy and correction of the
associated predisposing factors. It merits emphasis that correction of predisposing
factors and gastric fixation procedures is required to prevent volvulus recurrence.
Recent reports have documented the prevention of gastric volvulus by percutaneous
endoscopic gastropexy with wide fixation of the stomach as a means of avoiding recurrence
28], 29]. This may be a feasible technique for high-risk patients because of its minimal invasiveness,
but long-term studies are needed. Definitive treatments such as gastropexy, splenopexy,
hernia reduction, and diaphragmatic hernia and esophageal hiatus repairs have been
performed laparoscopically, for both acute and chronic conditions 24]–26], 30]. Laparoscopic surgery is reportedly a safe and effective procedure, with lower morbidity
rate and a significantly shorter hospital stay than laparotomy 30]. Moreover, laparoscopy yields an accurate etiologic diagnosis, and like laparotomy,
several therapeutic options are available intraoperatively 12], 16], 24], 25]. In our patient, after endoscopic maneuvering to reduce acute symptoms, elective
laparoscopic gastropexy was performed. Phrenofundopexy was performed to prevent lowering
of the fundus and keep the spleen fixed in the left upper abdomen, and anterior gastropexy
was performed to prevent the stomach from rotating. The pitch between the sutures
was about 2.5 cm to prevent an internal herniation. In general, gastropexy in addition
to splenopexy is recommended in the case of gastric volvulus with wandering spleen.
The gastrosplenic ligament of the patient worked to localize wandering spleen around
the left upper quadrant and to prevent torsion of splenic vessels. Because the spleen
was closely fixed between the stomach and abdominal wall by the gastrosplenic ligament
and gastropexy procedure, splenopexy was not performed for the purpose of the correction
of associated predisposing factors. Moreover, splenopexy is the recommended procedure
of choice to prevent future splenic torsion when wandering spleen is present at surgery
4], 16]. Approximately 65 % of patients with an acute presentation are asymptomatic prior
to the occurrence of splenic torsion and infarction 4], 8]. However, splenopexy was not performed in this case, because it was unlikely to be
torsion of the vascular pedicle owing to the presence of gastrosplenic ligament and
the fixation of the spleen to the abdominal wall 6], 7], 9], 12]. The patient remained asymptomatic, and there has been no evidence of gastric volvulus
recurrence or wandering spleen.