Gastric Volvulus in the Pediatric Daniel L.
Miller, MD; Michael D. Pasquale, MD; Russell P. Seneca, MD; Earl Hodin,
gastric volvulus in children is uncommon. Since 1899, only 77 cases have been documented in the world
\s=b\ Acute
literature. In children, mesenteroaxial volvulus is the most common type and associated anatomic defects are the rule. Diagnostic delays result in gastric ischemia, perforation, and death. Nonoperative mortality is 80%. Early recognition, surgical reduction with gastric fixation, and repair of associated defects are the mainstays of therapy for acute gastric volvulus in the pediatric population.
(Arch Surg. 1991;126:1146-1149) is a rare condition in the pédiatrie Awareness of this entity is important because it represents a true surgical emergency; delays in diagnosis may be fatal. We describe two cases of acute gastric volvulus in children and present an updated review of the world literature.
volvulus Gastric population.1
REPORT OF CASES Case 1.—A 3-year-old girl with Down syndrome presented with an 8-hour history of abdominal pain and nonproductive vomiting. Plain abdominal roentgenograms showed an "upsidedown" stomach. Passage of a nasogastric tube was not at¬ tempted. Exploratory laparotomy disclosed an enormously di¬ lated and cyanotic stomach. A combined organomesenteroaxial gastric volvulus was identified and reduced. After reduction, a 4 x 5-cm ischémie area in the greater curvature of the stomach was evident, as well as absence of ligmental attachments to the stomach. The nonperforated ischémie area was resected, supe¬ rior and inferolateral gastropexies were performed, and a gastrostomy tube was inserted. The patient had an uneventful recovery. Case 2.—A 14-year-old girl with chronic abdominal pain pre¬ sented with a 12-hour history of abdominal discomfort, and complained of abdominal distension and nonproductive retch¬ ing for the first time. Plain abdominal roentgenograms showed a dilated stomach. After successful passage of a nasogastric tube, an upper gastrointestinal series showed a gastric volvulus (Fig 1). At exploratory laparotomy, a mesenteroaxial volvulus of the stomach was identified and reduced. No signs of gastric is-
Accepted for publication May 19, 1991. From the Department of General Surgery, Georgetown University Hospital, Washington, DC (Drs Miller and Pasquale), and the
Departments of General Surgery (Dr Seneca) and Pediatric Surgery (Dr Hodin), Fairfax Hospital, Falls Church, Va. Reprint requests to the Department of Surgery, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (Dr Miller).
Population MD
chemia were evident, but elongation of gastric ligaments was noted. Thickening of the second portion of the duodenum was also present, apparently secondary to chronic intermittent vol¬ vulus of the stomach. Anterior gastropexy was performed and a gastrostomy tube was inserted. The patient had an uncompli¬ cated postoperative course.
REVIEW OF REPORTED CASES Gastric volvulus has been reported in children, pre¬ dominantly boys, from age 1 day to 15 years, with a mean age of 2.4 years. Twenty percent of the children were younger than 1 month old, 44% younger than 1 year, and 82% were younger than 5 years. Sufficient data to determine the type of volvulus were available in 74 (96%) of 77 cases reported. The majority of cases were mesenteroaxial. A combined organomesen¬ teroaxial volvulus was present in three patients. There¬ fore, our first patient represents only the fourth combined case, to
our
knowledge.
Information on associated defects was available for 72 (94% ) of 77 patients described. Most commonly associated defects involved the diaphragm and gastric ligaments. Multiple defects were found in 25 (35% ) of the 72 children. Associated defects are summarized in the Table. Surgical treatment was the primary mode of therapy in 87% of the children. Seventy surgical procedures were performed in 67 patients; they included reduction alone (20%), reduction after trocar decompression (10%), re¬ duction with fixation (24%), reduction with repair of as¬ sociated defects (20%), and combination reduction, fixa¬ tion, and repair of associated defects (26%). Sixty-nine of the 70 procedures were performed transabdominally. The one thoracic approach was used for an associated recur¬ rent diaphragmatic hernia. Gastric fixation consisted of single or multiple gastropexies, gastrostomy tube inser¬ tion, or transverse colon fixation. Primary repair of asso¬ ciated defects included lysis of adhesions, division of congenital bands, closure of perforations, repair of dia¬ phragmatic hernias, and plication of diaphragmatic eventrations. Three children (4%) experienced recurrence of their gastric volvulus after surgical correction; two of these three patients had undergone reduction alone while the third underwent combined reduction and anterior
gastropexy only.
Delays in diagnosis and definitive treatment lead to fa¬ complications such as gastric ischemia, perforation, obstruction, gastric pouch hemorrhage, splenic rupture, and aspiration pneumonia. Gastric ischemia and/or per¬ foration were found in 10 (13%) of patients; two thirds of tal
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 2. —Diagram of a gastric mesenteroaxial volvulus.
A')
Fig t. Roentgenogram (supine position) of an upper gastrointes¬ tinal series showing a nasogastric tube in a dilated volvulized stom¬ —
ach (Case 2).
Associated Anatomic Defects (n
Type of Defect
=
72)
No. (%) of Patients
Diaphragm
Eventration Hernia
Paralysis
Total
21 21 1 43 (60)
Gastric
ligaments Elongated
Absent Torn Total
22 7 3 32 (44)
Attachments
Congenital bands Adhesions Total
Asplenism
Malrotations Small intestine
Large
intestine
Total
Pyloric stenosis
Colon distension Rectal atresia
6 3 9 (12) 5 (7) 3 1 4 (6) 2 (3) 1 (1) 1 (1)
these children died. The majority of 77 ischémie areas located in the greater curvature of the stomach. Eight (12%) of the 67 patients who underwent surgical intervention for acute gastric volvulus died. Four (50%) of these eight patients underwent reduction only; two patients (25%) underwent reduction after trocar decom¬ pression; one patient (12.5%) underwent reduction, gas¬ trostomy fixation, and Nissen's fundiplication for an as-
were
occurs
Rotation (A to
about the short axis of the stomach.
sociated diaphragmatic hernia; and one patient (12.5%) underwent reduction, gastrostomy fixation, and partial gastric resection for perforation. Ten (13%) of the 77 pa¬ tients did not undergo surgical intervention; eight of these died. The nonoperative mortality was 80%; overall mor¬ tality was 21%. COMMENT Acute gastric volvulus was first documented in 1866 by Berti2 in a 60-year-old woman. In 1897, Berg3 reported the first successful treatment with trocar decompression and reduction. In 1899, Oltmann4 described the first pédiatrie case of a 15-year-old boy who died of perforated gastric volvulus. Since then, only 76 additional cases of gastric volvulus in children have been documented in the world literature, to our knowledge.5"21 The most recent pédiatrie review (51 cases) was in 1980.15 Three types of gastric volvulus have been described: mesenteroaxial, organoaxial, and combined. Mesentero¬ axial volvulus (Fig 2) occurs abort a sagittal plane with rotation around the long axis of the gastrohepatic omentum, while organoaxial volvulus (Fig 3) occurs about a coronal plane with rotation around the long axis of the stomach. Associated defects or disease processes tend to be the rule rather than the exception in the pédiatrie population. Predisposing factors include laxity of gastric ligaments, presence of bands or adhesions, and displacement of the stomach into abnormal spaces.6 Absence or attenuation of gastric ligaments is considered the result of abnormal fu¬ sion of fetal mesenteries. Anatomical attachments of the stomach are shown in Fig 4. Symptoms of acute gastric volvulus depend on the de¬ gree of rotation and obstruction of the stomach. Acute onset of epigastric pain is almost always the first symp¬ tom, followed rapidly thereafter by gastric distension and then retching, which may or may not be productive. In 1904, Borchardt22 described his classic triad for acute gas-
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 3. —Diagram of an organoaxial volvulus. long axis of the stomach.
Rotation (B to B') occurs
about the
trie volvulus: acute distension of the stomach, difficult passage of a nasogastric tube, and nonproductive retch¬ ing. This triad was present in 70% of the children. Other symptoms include chest pain, dysphagia, dyspnea, dys¬ pepsia, and borborygmi. Radiologie findings of acute gastric volvulus are as characteristic as the clinical presentation. The presence of concomitant pyloric obstruction results in a massively di¬ lated viscus and usually paucity of gas within the remain¬ der of the intestinal tract. In the mesenteroaxial volvulus, the distended stomach appears spherical in supine roent¬ genograms, while in upright roentgenograms a double air-fluid is seen. "Beaking" may be seen next to the gastroesophageal junction secondary to pyloric obstruction.22 In organoaxial volvulus, the body of the stomach is inverted, with the greater curvature above the lesser cur¬ vature. The radiologie differential diagnosis includes gas¬ tric atony secondary to diabetic gastroparesis, pyloric ob¬ struction due to hypertrophie pyloric stenosis, and acute gastric distension caused by bezoars, of which only the latter two are frequently encountered in children. Effective treatment for acute gastric volvulus in children requires immediate surgical intervention after appropri¬ ate resuscitative
measures.
Initially, gastric decompres¬
sion may be required to facilitate reduction of the stom¬ ach and to prevent impending gastric ischemia. In adults, preoperative nasogastric tube decompression is used routinely. However, this maneuver is potentially fatal in children because of perforation risks. Therefore, intraop¬ erative decompression may be required. Gastrostomy tubes serve this purpose well. Repositioning may be nec¬ essary for long-term decompression and fixation after re¬ turn of the stomach to its normal configuration. Earlier reports advocated trocar decompression, but mortality
Fig 4. —Ligamental attachments of the stomach include the gastrophrenic, gastrohepatic, gastrocolic, and gastrosplenic. Interiorly, the stomach is anchored by the second portion of the duodenum. Axes of the stomach include the mesenteroaxial (short) and the or¬ ganoaxial (long).
(33%) curtailed its use.8 Also, endoscopie decom¬ pression has been used in adults, but should be avoided risks
in children because of perforation risks.23 Surgical correction should include reduction, primary repair of associated anatomical defects, and fixation of the stomach. An abdominal approach is recommended, even in the presence of an intrathoracic stomach, to ensure identification of all associated anatomical defects and to facilitate reduction of the dilated stomach. Gastric fixation is required to prevent recurrence; two of the three patients with operative recurrences underwent reduction alone. In children, a gastrostomy tube serves the purpose of fixa¬ tion well and also provides a means of postoperative de¬ compression and feeding.15 Of the patients described in the literature, there were no recurrences in those under¬ going gastrostomy fixation, and it was performed in our
patients without complications. Gastroenterostomies or major gastric resections are usually not necessary in chil¬ dren.24 However, ischémie
area can
as
in
our
first case, resection of
an
usually be accomplished without com¬
promising the dilated stomach. Since 1950, only four deaths (7%) have occurred in 56 reported cases of acute gastric volvulus in the pédiatrie population. Before 1950, the mortality rate was 57%. This significant decrease in mortality is attributed to earlier recognition of this uncommon entity, improved periop¬ erative care, and the introduction of antibiotics.
Prompt operative treatment after appropriate resusci¬ tation is recommended for acute gastric volvulus in chil¬ dren. Diagnostic delays lead to gastric ischemia, perfora¬ tion, and death. The use of preoperative nasogastric tubes is not advocated. Exploration should be performed transabdominally to facilitate reduction of the stomach and lo¬ cation of associated defects. Gastric fixation is required to
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
11. Mitchell EA, Wojciechowski AH, Younghusband JD. Acute volvulus in childhood. Br JClin Pract. 1977;31:61-62. 12. Asch MJ, Sherman NJ. Gastric volvulus in children:
prevent recurrence. In children, especially infants, gas¬ trostomy tubes serve this purpose well and also provide a means
of
postoperative decompression.
report of two
appreciate the secretarial assistance of Pamela F. Miller and Cynthia M. Pasquale in preparing the manuscript and the artwork We
13.
J Pediatr Surg. 1977;12:1059-1062. Neonatal gastric volvulus. AJR Am JRoent-
cases.
Campbell JB.
genol. 1979;132:723-725. 14. Ziprkowski MN, Teele RL. Gastric volvulus in childhood. AJR Am JRoentgenol. 1979;132:921-925. 15. Idowu J, Aitken DR, Georgeson KE. Gastric volvulus in the newborn. Arch Surg. 1980;115:1046-1049. 16. Aoyama K, Tateishi K. Gastric volvulus in three children with a splenic syndrome. J Pediatr Surg. 1986;21:307-310. 17. Schindler AM, Widzer SJ. Persistent jaundice and failure to thrive. Hosp Pract. 1986;21:22-24.
of Peter Stone.
References 1. Wastell C, Ellis H. Volvulus of the stomach: a review with a report of 8 cases. Br JSurg. 1971;58:557-562. 2. Berti A. Singolare attortigliamento dell'esofago col duodeno sequito da rapida morte. Gazz Med Ital Prov Ver. 1866;9:139. 3. Berg J. Zwei Falle von Axendrehung des Magens: Opera-
tion; Heilung. Nord Med Arkiv. 1897;30:1.
18. Iko BO. Volvulus of the stomach: an African series and review. J Natl Med Assoc. 1987;79:171-176. 19. Cameron AE, Howard ER. Gastric volvulus in childhood. J Pediatr Surg. 1987;22:944-947. 20. Mizrahi S, Vinograd I, Schiller M. Neonatal gastric volvulus secondary to rectal atresia. Clin Pediatr. 1988;27:302-304. 21. Bonadio WA, Wood BP. Intrathoracic stomach with volvulus. AJDC. 1989;143:503-504. 22. Borchardt M. Zur Pathologie und Therapie des Magne\x=req-\ volvulus. Arch Klin Chir. 1904;74:243-260. 23. Patel NM. Chronic gastric volvulus: report of a case and review of the literature. Am J Gastroenterol. 1985;80:170-173. 24. Gean AD, Deluca SA. Acute gastric volvulus. AFP Radio-
4. Oltmann H. Kiel. 1899. Inaugural discussion. 5. Dalgaard JB. Volvulus of the stomach: case
a
report and Scand.1952;103:131-153. survey. Acta Chir 6. Tanner NC. Chronic and recurrent volvulus of the stomach with late results of 'colonic displacement.' Am J Surg.
1968;115:505-515. 7. Gwinn JL, Lee FA. Volvulus of the stomach. AJDC. 1970;120:551-552. 8. Cole BC, Dickison SJ. Acute volvulus of the stomach in infants and children. Surgery. 1971;70:707-717. 9. Kilcoyne RF, Babbitt DP, Sakaguchi S. Volvulus of the stomach. Radiology. 1972;103:157-158. 10. Campbell JB, Rappaport LN, Skerker LB. Acute mesenteroaxial volvulus of the stomach. Radiology. 1972;103:153-156.
graphic Highlights. 1986;34:99-100.
In Other AMA
Journals
ARCHIVES OF NEUROLOGY
Vegetative State After Closed-Head Injury:
A Traumatic Coma Data Bank Report Harvey S. Levin, PhD; Christy Saydjari; Howard M. Eisenberg, MD; Mary Foulkes, PhD; Lawrence F. Marshall, MD; Ronald M. Ruff, PhD; John A. Jane, MD; Anthony Marmarou, PhD To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury avail¬ able for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious sur¬ vivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury compli¬ cated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state. (Arch Neurol. 1991;48:580-585).
Reprint requests to the Division of Neurosurgery D-73,
(Dr Levin)
the
University
of Texas Medical Branch, Galveston, TX 77550
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Miller, MD; Michael D. Pasquale, MD; Russell P. Seneca, MD; Earl Hodin,
gastric volvulus in children is uncommon. Since 1899, only 77 cases have been documented in the world
\s=b\ Acute
literature. In children, mesenteroaxial volvulus is the most common type and associated anatomic defects are the rule. Diagnostic delays result in gastric ischemia, perforation, and death. Nonoperative mortality is 80%. Early recognition, surgical reduction with gastric fixation, and repair of associated defects are the mainstays of therapy for acute gastric volvulus in the pediatric population.
(Arch Surg. 1991;126:1146-1149) is a rare condition in the pédiatrie Awareness of this entity is important because it represents a true surgical emergency; delays in diagnosis may be fatal. We describe two cases of acute gastric volvulus in children and present an updated review of the world literature.
volvulus Gastric population.1
REPORT OF CASES Case 1.—A 3-year-old girl with Down syndrome presented with an 8-hour history of abdominal pain and nonproductive vomiting. Plain abdominal roentgenograms showed an "upsidedown" stomach. Passage of a nasogastric tube was not at¬ tempted. Exploratory laparotomy disclosed an enormously di¬ lated and cyanotic stomach. A combined organomesenteroaxial gastric volvulus was identified and reduced. After reduction, a 4 x 5-cm ischémie area in the greater curvature of the stomach was evident, as well as absence of ligmental attachments to the stomach. The nonperforated ischémie area was resected, supe¬ rior and inferolateral gastropexies were performed, and a gastrostomy tube was inserted. The patient had an uneventful recovery. Case 2.—A 14-year-old girl with chronic abdominal pain pre¬ sented with a 12-hour history of abdominal discomfort, and complained of abdominal distension and nonproductive retch¬ ing for the first time. Plain abdominal roentgenograms showed a dilated stomach. After successful passage of a nasogastric tube, an upper gastrointestinal series showed a gastric volvulus (Fig 1). At exploratory laparotomy, a mesenteroaxial volvulus of the stomach was identified and reduced. No signs of gastric is-
Accepted for publication May 19, 1991. From the Department of General Surgery, Georgetown University Hospital, Washington, DC (Drs Miller and Pasquale), and the
Departments of General Surgery (Dr Seneca) and Pediatric Surgery (Dr Hodin), Fairfax Hospital, Falls Church, Va. Reprint requests to the Department of Surgery, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (Dr Miller).
Population MD
chemia were evident, but elongation of gastric ligaments was noted. Thickening of the second portion of the duodenum was also present, apparently secondary to chronic intermittent vol¬ vulus of the stomach. Anterior gastropexy was performed and a gastrostomy tube was inserted. The patient had an uncompli¬ cated postoperative course.
REVIEW OF REPORTED CASES Gastric volvulus has been reported in children, pre¬ dominantly boys, from age 1 day to 15 years, with a mean age of 2.4 years. Twenty percent of the children were younger than 1 month old, 44% younger than 1 year, and 82% were younger than 5 years. Sufficient data to determine the type of volvulus were available in 74 (96%) of 77 cases reported. The majority of cases were mesenteroaxial. A combined organomesen¬ teroaxial volvulus was present in three patients. There¬ fore, our first patient represents only the fourth combined case, to
our
knowledge.
Information on associated defects was available for 72 (94% ) of 77 patients described. Most commonly associated defects involved the diaphragm and gastric ligaments. Multiple defects were found in 25 (35% ) of the 72 children. Associated defects are summarized in the Table. Surgical treatment was the primary mode of therapy in 87% of the children. Seventy surgical procedures were performed in 67 patients; they included reduction alone (20%), reduction after trocar decompression (10%), re¬ duction with fixation (24%), reduction with repair of as¬ sociated defects (20%), and combination reduction, fixa¬ tion, and repair of associated defects (26%). Sixty-nine of the 70 procedures were performed transabdominally. The one thoracic approach was used for an associated recur¬ rent diaphragmatic hernia. Gastric fixation consisted of single or multiple gastropexies, gastrostomy tube inser¬ tion, or transverse colon fixation. Primary repair of asso¬ ciated defects included lysis of adhesions, division of congenital bands, closure of perforations, repair of dia¬ phragmatic hernias, and plication of diaphragmatic eventrations. Three children (4%) experienced recurrence of their gastric volvulus after surgical correction; two of these three patients had undergone reduction alone while the third underwent combined reduction and anterior
gastropexy only.
Delays in diagnosis and definitive treatment lead to fa¬ complications such as gastric ischemia, perforation, obstruction, gastric pouch hemorrhage, splenic rupture, and aspiration pneumonia. Gastric ischemia and/or per¬ foration were found in 10 (13%) of patients; two thirds of tal
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 2. —Diagram of a gastric mesenteroaxial volvulus.
A')
Fig t. Roentgenogram (supine position) of an upper gastrointes¬ tinal series showing a nasogastric tube in a dilated volvulized stom¬ —
ach (Case 2).
Associated Anatomic Defects (n
Type of Defect
=
72)
No. (%) of Patients
Diaphragm
Eventration Hernia
Paralysis
Total
21 21 1 43 (60)
Gastric
ligaments Elongated
Absent Torn Total
22 7 3 32 (44)
Attachments
Congenital bands Adhesions Total
Asplenism
Malrotations Small intestine
Large
intestine
Total
Pyloric stenosis
Colon distension Rectal atresia
6 3 9 (12) 5 (7) 3 1 4 (6) 2 (3) 1 (1) 1 (1)
these children died. The majority of 77 ischémie areas located in the greater curvature of the stomach. Eight (12%) of the 67 patients who underwent surgical intervention for acute gastric volvulus died. Four (50%) of these eight patients underwent reduction only; two patients (25%) underwent reduction after trocar decom¬ pression; one patient (12.5%) underwent reduction, gas¬ trostomy fixation, and Nissen's fundiplication for an as-
were
occurs
Rotation (A to
about the short axis of the stomach.
sociated diaphragmatic hernia; and one patient (12.5%) underwent reduction, gastrostomy fixation, and partial gastric resection for perforation. Ten (13%) of the 77 pa¬ tients did not undergo surgical intervention; eight of these died. The nonoperative mortality was 80%; overall mor¬ tality was 21%. COMMENT Acute gastric volvulus was first documented in 1866 by Berti2 in a 60-year-old woman. In 1897, Berg3 reported the first successful treatment with trocar decompression and reduction. In 1899, Oltmann4 described the first pédiatrie case of a 15-year-old boy who died of perforated gastric volvulus. Since then, only 76 additional cases of gastric volvulus in children have been documented in the world literature, to our knowledge.5"21 The most recent pédiatrie review (51 cases) was in 1980.15 Three types of gastric volvulus have been described: mesenteroaxial, organoaxial, and combined. Mesentero¬ axial volvulus (Fig 2) occurs abort a sagittal plane with rotation around the long axis of the gastrohepatic omentum, while organoaxial volvulus (Fig 3) occurs about a coronal plane with rotation around the long axis of the stomach. Associated defects or disease processes tend to be the rule rather than the exception in the pédiatrie population. Predisposing factors include laxity of gastric ligaments, presence of bands or adhesions, and displacement of the stomach into abnormal spaces.6 Absence or attenuation of gastric ligaments is considered the result of abnormal fu¬ sion of fetal mesenteries. Anatomical attachments of the stomach are shown in Fig 4. Symptoms of acute gastric volvulus depend on the de¬ gree of rotation and obstruction of the stomach. Acute onset of epigastric pain is almost always the first symp¬ tom, followed rapidly thereafter by gastric distension and then retching, which may or may not be productive. In 1904, Borchardt22 described his classic triad for acute gas-
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 3. —Diagram of an organoaxial volvulus. long axis of the stomach.
Rotation (B to B') occurs
about the
trie volvulus: acute distension of the stomach, difficult passage of a nasogastric tube, and nonproductive retch¬ ing. This triad was present in 70% of the children. Other symptoms include chest pain, dysphagia, dyspnea, dys¬ pepsia, and borborygmi. Radiologie findings of acute gastric volvulus are as characteristic as the clinical presentation. The presence of concomitant pyloric obstruction results in a massively di¬ lated viscus and usually paucity of gas within the remain¬ der of the intestinal tract. In the mesenteroaxial volvulus, the distended stomach appears spherical in supine roent¬ genograms, while in upright roentgenograms a double air-fluid is seen. "Beaking" may be seen next to the gastroesophageal junction secondary to pyloric obstruction.22 In organoaxial volvulus, the body of the stomach is inverted, with the greater curvature above the lesser cur¬ vature. The radiologie differential diagnosis includes gas¬ tric atony secondary to diabetic gastroparesis, pyloric ob¬ struction due to hypertrophie pyloric stenosis, and acute gastric distension caused by bezoars, of which only the latter two are frequently encountered in children. Effective treatment for acute gastric volvulus in children requires immediate surgical intervention after appropri¬ ate resuscitative
measures.
Initially, gastric decompres¬
sion may be required to facilitate reduction of the stom¬ ach and to prevent impending gastric ischemia. In adults, preoperative nasogastric tube decompression is used routinely. However, this maneuver is potentially fatal in children because of perforation risks. Therefore, intraop¬ erative decompression may be required. Gastrostomy tubes serve this purpose well. Repositioning may be nec¬ essary for long-term decompression and fixation after re¬ turn of the stomach to its normal configuration. Earlier reports advocated trocar decompression, but mortality
Fig 4. —Ligamental attachments of the stomach include the gastrophrenic, gastrohepatic, gastrocolic, and gastrosplenic. Interiorly, the stomach is anchored by the second portion of the duodenum. Axes of the stomach include the mesenteroaxial (short) and the or¬ ganoaxial (long).
(33%) curtailed its use.8 Also, endoscopie decom¬ pression has been used in adults, but should be avoided risks
in children because of perforation risks.23 Surgical correction should include reduction, primary repair of associated anatomical defects, and fixation of the stomach. An abdominal approach is recommended, even in the presence of an intrathoracic stomach, to ensure identification of all associated anatomical defects and to facilitate reduction of the dilated stomach. Gastric fixation is required to prevent recurrence; two of the three patients with operative recurrences underwent reduction alone. In children, a gastrostomy tube serves the purpose of fixa¬ tion well and also provides a means of postoperative de¬ compression and feeding.15 Of the patients described in the literature, there were no recurrences in those under¬ going gastrostomy fixation, and it was performed in our
patients without complications. Gastroenterostomies or major gastric resections are usually not necessary in chil¬ dren.24 However, ischémie
area can
as
in
our
first case, resection of
an
usually be accomplished without com¬
promising the dilated stomach. Since 1950, only four deaths (7%) have occurred in 56 reported cases of acute gastric volvulus in the pédiatrie population. Before 1950, the mortality rate was 57%. This significant decrease in mortality is attributed to earlier recognition of this uncommon entity, improved periop¬ erative care, and the introduction of antibiotics.
Prompt operative treatment after appropriate resusci¬ tation is recommended for acute gastric volvulus in chil¬ dren. Diagnostic delays lead to gastric ischemia, perfora¬ tion, and death. The use of preoperative nasogastric tubes is not advocated. Exploration should be performed transabdominally to facilitate reduction of the stomach and lo¬ cation of associated defects. Gastric fixation is required to
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
11. Mitchell EA, Wojciechowski AH, Younghusband JD. Acute volvulus in childhood. Br JClin Pract. 1977;31:61-62. 12. Asch MJ, Sherman NJ. Gastric volvulus in children:
prevent recurrence. In children, especially infants, gas¬ trostomy tubes serve this purpose well and also provide a means
of
postoperative decompression.
report of two
appreciate the secretarial assistance of Pamela F. Miller and Cynthia M. Pasquale in preparing the manuscript and the artwork We
13.
J Pediatr Surg. 1977;12:1059-1062. Neonatal gastric volvulus. AJR Am JRoent-
cases.
Campbell JB.
genol. 1979;132:723-725. 14. Ziprkowski MN, Teele RL. Gastric volvulus in childhood. AJR Am JRoentgenol. 1979;132:921-925. 15. Idowu J, Aitken DR, Georgeson KE. Gastric volvulus in the newborn. Arch Surg. 1980;115:1046-1049. 16. Aoyama K, Tateishi K. Gastric volvulus in three children with a splenic syndrome. J Pediatr Surg. 1986;21:307-310. 17. Schindler AM, Widzer SJ. Persistent jaundice and failure to thrive. Hosp Pract. 1986;21:22-24.
of Peter Stone.
References 1. Wastell C, Ellis H. Volvulus of the stomach: a review with a report of 8 cases. Br JSurg. 1971;58:557-562. 2. Berti A. Singolare attortigliamento dell'esofago col duodeno sequito da rapida morte. Gazz Med Ital Prov Ver. 1866;9:139. 3. Berg J. Zwei Falle von Axendrehung des Magens: Opera-
tion; Heilung. Nord Med Arkiv. 1897;30:1.
18. Iko BO. Volvulus of the stomach: an African series and review. J Natl Med Assoc. 1987;79:171-176. 19. Cameron AE, Howard ER. Gastric volvulus in childhood. J Pediatr Surg. 1987;22:944-947. 20. Mizrahi S, Vinograd I, Schiller M. Neonatal gastric volvulus secondary to rectal atresia. Clin Pediatr. 1988;27:302-304. 21. Bonadio WA, Wood BP. Intrathoracic stomach with volvulus. AJDC. 1989;143:503-504. 22. Borchardt M. Zur Pathologie und Therapie des Magne\x=req-\ volvulus. Arch Klin Chir. 1904;74:243-260. 23. Patel NM. Chronic gastric volvulus: report of a case and review of the literature. Am J Gastroenterol. 1985;80:170-173. 24. Gean AD, Deluca SA. Acute gastric volvulus. AFP Radio-
4. Oltmann H. Kiel. 1899. Inaugural discussion. 5. Dalgaard JB. Volvulus of the stomach: case
a
report and Scand.1952;103:131-153. survey. Acta Chir 6. Tanner NC. Chronic and recurrent volvulus of the stomach with late results of 'colonic displacement.' Am J Surg.
1968;115:505-515. 7. Gwinn JL, Lee FA. Volvulus of the stomach. AJDC. 1970;120:551-552. 8. Cole BC, Dickison SJ. Acute volvulus of the stomach in infants and children. Surgery. 1971;70:707-717. 9. Kilcoyne RF, Babbitt DP, Sakaguchi S. Volvulus of the stomach. Radiology. 1972;103:157-158. 10. Campbell JB, Rappaport LN, Skerker LB. Acute mesenteroaxial volvulus of the stomach. Radiology. 1972;103:153-156.
graphic Highlights. 1986;34:99-100.
In Other AMA
Journals
ARCHIVES OF NEUROLOGY
Vegetative State After Closed-Head Injury:
A Traumatic Coma Data Bank Report Harvey S. Levin, PhD; Christy Saydjari; Howard M. Eisenberg, MD; Mary Foulkes, PhD; Lawrence F. Marshall, MD; Ronald M. Ruff, PhD; John A. Jane, MD; Anthony Marmarou, PhD To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury avail¬ able for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious sur¬ vivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury compli¬ cated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state. (Arch Neurol. 1991;48:580-585).
Reprint requests to the Division of Neurosurgery D-73,
(Dr Levin)
the
University
of Texas Medical Branch, Galveston, TX 77550
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