The Surgical Management of Acute Gastric Volvulus: Clinical Outcomes and Quality of Life Assessment

Introduction

Over the last 20 years, laparoscopic surgery has gained worldwide acceptance by decreasing procedural invasiveness and favoring fast recovery. Despite being the gold standard approach for many elective procedures, the adoption of laparoscopy in emergency settings has been limited by steep learning curve and little evidence on safety and effectiveness in current scientific literature. ¹ Of the many surgical emergencies, acute gastric volvulus is among the rarest and most challenging ones, carrying a mortality rate between 30% and 50%. ² It is therefore imperative not to delay diagnosis and treatment of these patients.^2–4 Even if laparotomy is still considered the standard of care, there is growing acceptance that selected patients with acute gastric volvulus can be safely approached laparoscopically.^4–6 Aim of this study is to provide additional evidence on safety and effectiveness of laparoscopy, and to compare outcomes between this approach and standard laparotomy. In addition, we report a quality of life (QoL) assessment of these patients after surgery. QoL is a valuable tool in the postoperative evaluation process, but it is often overlooked and scarcely reported. Indeed, to the best of our knowledge, this is the first study presenting postoperative QoL data of patients undergoing gastric volvulus repair.

Materials and Methods

After protocol approval by the Institutional Review Board of the University of Ferrara Medical Center, we conducted a retrospective chart review of a prospectively maintained database, looking for patients with gastric volvulus who underwent emergency surgery between 2016 and 2018. The preferred surgical approach was based on surgeon's experience and patient's hemodynamic stability. Patients' demographics, comorbidities, preoperative work-up, intraoperative data, and postoperative outcomes were collected and analyzed. Preoperative workup included CT scan and upper gastrointestinal (GI) endoscopy. Follow-up included clinical assessment, barium swallow X-ray, Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL), ⁷ and Gastrointestinal Symptom Rating Scale (GSRS) questionnaires. ⁸ The 30-day postoperative complication assessment was in accordance to the Clavien–Dindo Grade (CDG) classification. Radiological recurrence was defined by the presence of an abnormal anatomy of the upper GI, such as wrap disruption, sliding hernia, or any protrusion >2 cm above the diaphragm. Clinical recurrence was defined by radiological recurrence in the presence of symptoms. At 6-month follow-up, all patients were asked to grade their symptoms, if any, and to complete GERD-HRQL and GSRS questionnaires for QoL assessment. Results were analyzed by an independent statistician, and statistical analysis was performed with Stata v.14.1 (StataCorp LLC). Continuous data were reported as mean (standard deviation) or median (range). Postoperative success, complication, and mortality rates were calculated as the proportion of events among the number of patients available for follow-up, and 95% confidence intervals were then calculated for single proportions. Wilcoxon test for paired samples was used to compare continuous variables of which normal distribution was rejected and a logarithmic transformation was not attainable. “N-1” χ ² test was used to analyze data collected on non-continuous variables, as recommended by Campbell et al. ⁹ and Richardson et al. ¹⁰ P value <.05 was considered statistically significant.

Results

Over the 3-year study period, 9 patients underwent emergency surgery for symptomatic gastric volvulus. Individual patient characteristics are given in Table 1. Five (55%) out of 9 were male, and median age was 77 (47–95) years. Two-thirds of cases (67%) showed an American Society of Anesthesiologists (ASA) grade 3 or higher. Clinical presentation was acute in 6 (67%) and subacute in 3 (33%) patients. The most frequent symptoms were severe epigastric pain (100%) and vomiting (77%). All cases showed an organoaxial type of volvulus, secondary to long-standing hiatal hernia. On average, time between clinical onset and surgery was 5.5 (±4.5) days. Five out of 9 procedures (55%) were completed laparoscopically, with no conversions to open. Mean operative times were 108 (±40) and 165 (±36) minutes for open and laparoscopic approaches, respectively. To obtain a tension-free closure of the hiatus, crural repair in 1 (11%) patient was attained with a mesh (Gore BioA^® tissue reinforcement, Flagstaff, AZ), while in 7 (78%) cases interrupted sutures were deemed sufficient. Anterior gastropexy was completed in 3 patients (33%)—2 open and 1 laparoscopic. All surgical repairs were carried out without esophageal lengthening. In the absence of documented gastroesophageal reflux disease (GERD) for all patients undergoing laparotomy, surgeon's preference was to avoid a fundoplication. Conversely, all laparoscopic procedures were complemented by an antireflux procedure—4 floppy-Nissen and 1 Dor fundoplication. A soft diet was reintroduced on postoperative day (POD) 4,^4–6 with no difference between the two groups. Length of stay was longer for the open group (9 versus 7 days) but not statistically significant (P = .1). A difference in rate and severity of 30-day complications was found between open (75%) and laparoscopic (20%) groups, with the latter presenting just a transitory case of delayed gastric emptying (CDG-I). In order of severity, open group complications were pneumonia (CDG-II), mechanical bowel obstruction (CDG-IIIb), and sepsis with multiorgan dysfunction (CDG-IVb). The latter was the case of a critical patient presenting with diffuse gastric necrosis requiring damage-control surgery, hernia reduction and laparostomy. At a second look 24 hours later, the presence of a nonviable necrotic stomach required a total gastrectomy with Roux-en-Y esophagojejunostomy. Eventually, the clinical course was complicated by sepsis, and on POD-45, the patient died of multiorgan failure. At a median follow-up of 25 months (13–44), 1 patient in the laparoscopic group had symptomatic recurrence, successfully controlled with medical therapy. Peri- and postoperative outcomes are summarized in Table 2. Patients' satisfaction was higher in the laparoscopic group (80% versus 67%), although statistical significance was not reached. No difference between the two groups was found when comparing GERD-HRQL and GSRS scores. QoL questionnaire results are summarized in Table 3.

The present analysis has several limitations, such as its retrospective nature, possible selection bias, and small sample size. Yet, given the rarity of this condition, we believe that this study provides relevant information in support of the current available scientific literature.

Discussion

Acute gastric volvulus is a rare and severe emergency associated to a laxity of the gastric ligaments and/or diaphragmatic abnormalities. ¹¹ In the study here described, all cases of acute gastric volvulus were likely caused by the presence of hiatal hernia. The most common surgical approach to treat these patients is an emergency laparotomy, followed by a wide combination of procedures, such as simple gastropexy, gastropexy with division of gastrocolic omentum, partial gastrectomy, diaphragmatic hernia repair, and fundo-antral gastrogastrostomy (Opolzer's technique). ¹² However, regardless of surgeons' preferences, the optimal management of these patients relies on surgical principles of critical importance, such as volvulus reduction, hernial sac excision, diaphragmatic crura reapproximation, and reestablishment of an antireflux mechanism in selected patients. ¹³ With these key steps in mind and when patient's clinical health status allows, the laparoscopic approach stands for a valuable alternative for the treatment of acute gastric volvulus, ¹⁴ as described by some authors. ¹⁵ However, due to the rarity of this condition, data comparing laparoscopy to open is still scant. ¹⁶

The presence of just one minor complication not requiring surgery, in addition to faster recovery and absence of conversion to open support the notion that laparoscopy can be safe in selected patients with acute gastric volvulus. In addition, hiatal hernia recurrence was 11% (20% of laparoscopic cases), which is consistent with other published case series.^17,18 To our knowledge, there are very few cases of gastric volvulus requiring total gastrectomy in the literature.^19,20 Palanivelu et al. in a series of 14 cases, 4 of whom required emergency surgery for acute volvulus concluded that gastric necrosis is an uncommon finding and gastrectomy is rarely necessary. ²¹ We have reported one case of gastric necrosis (11%) successfully treated by means of second look laparostomy with total gastrectomy. Although our experience is limited to a sole case, we believe that hernia reduction with laparostomy is the right approach for damage-control surgery, as also reported by Okeny et al. ²² Eventually, sepsis leads to multiorgan failure and patient death. Our 11% mortality rate falls within the previously published mortality rate ranges (12%–50%) for acute cases. ²³

There is a growing body literature stressing the importance of QoL analysis when evaluating the efficacy of treatments.^24,25 Few series have shown quality-of-life analyses after paraesophageal hernia repair, ²⁶ but no data on gastric volvulus patients. We have attempted to address this lack of QoL assessments by using validated symptom-specific questionnaires—GERD-HRQL and GSRS. Although not specific for gastric volvulus, they provided an appropriate quantification of symptoms severity and a valuable satisfaction index tool.

In conclusion, our results support the available evidence that a laparoscopic approach represents an effective and safe alternative to laparotomy for the treatment of acute gastric volvulus in selected patients and provides good postoperative QoL and satisfaction level.