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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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Table of Contents   
LETTERS TO THE EDITOR
Year : 2019  |  Volume : 24  |  Issue : 3  |  Page : 229-230
 

Eventration of diaphragm with gastric volvulus: Lesson learned


1 Department of Pediatric Surgical Superspeciality, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication6-Jun-2019

Correspondence Address:
Dr. Basant Kumar
Department of Pediatric Surgical Superspeciality, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_186_18

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How to cite this article:
Kumar B, Upadhyaya VD, Kirti NM, Poddar B. Eventration of diaphragm with gastric volvulus: Lesson learned. J Indian Assoc Pediatr Surg 2019;24:229-30

How to cite this URL:
Kumar B, Upadhyaya VD, Kirti NM, Poddar B. Eventration of diaphragm with gastric volvulus: Lesson learned. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Jun 24];24:229-30. Available from: http://www.jiaps.com/text.asp?2019/24/3/229/259755




Sir,

Gastric volvulus can be classified on the basis of the underlying etiology into primary or secondary. In approximately 70% of cases, it occurs secondary to anatomical or functional disorders of the stomach or the adjacent structures such as spleen and diaphragm.[1] Eventration of diaphragm associated with gastric volvulus is an uncommon condition and needs prompt attention and urgent surgical interventions. Delayed intervention may lead to series of complications and morbidity, especially in emergent situations.

A 3-year-old female child weighing 10 kg was presented with abdominal pain, recurrent vomiting, fever, and upper abdominal distension for the last 5 days. Her general condition was low and she looks pale, dehydrated, and toxic. She was tachypneic, and there was no breath sound on the left side of the chest. The upper abdomen was distended and had tenderness with guarding. She had retching instead of vomiting, and nasogastric tube could not be negotiating into the stomach. Plain X-ray showed a very high position of left diaphragm in the chest with air-fluid level without any free gas in the abdomen. She was rapidly resuscitated and operated. There was organo-axial gastric volvulus leading to complete gangrene of the whole stomach involving lower end of the esophagus and pylorus. Stomach was distended, and there was associated malrotation of gut. The spleen, pancreatic tail, colon, left lobe of the liver, and part of small bowel were also lying high in thorax [Figure 1]. The left lung was hypoplastic. After correction of malrotation, total gastrectomy was performed with excision of the lower end of the esophagus. Duodenal stump was closed, and a roux-limb of jejunum was with lower end of the esophagus (Roux-en-Y Esophagojejunostomy) after excision of the whole stomach and distal 3 cm of the esophagus. Bowel continuation was achieved by jejuno-jejunal anastomosis [Figure 2]a. Part of floppy diaphragm was excised and repaired. Left-sided intercostal drain was placed, and feeding jejunostomy (FJ) was performed.
Figure 1: Operative pictures showing distended gangrenous stomach (a) through incision and reduced contents (b)

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Figure 2: Diagrammatic presentation of final bowel alignments after first (a) and final (b) surgery. (EC: Esophago-colic anastomosis; JC: Jejuno-colic anastomosis; JJ: jejuno-jejunostomy; CC: Colo-colic anastomosis FJ: Feeding jejunostomy)

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Anastomotic leak occurred at esophago-jejunostomy site leading to left-sided pyothorax along with wound infection / dehiscence in postoperative period. Persistent respiratory distress needed ventilatory support and tracheostomy. Later, left thoracotomy and decortications along with end esophagostomy were performed. After prolonged ventilation and hospitalization with the use of parenteral nutrition and FJ feeds, the condition of the patient improved. Finally, she was discharged on full FJ feed. After 5 months, retrosternal, antiperistaltic colonic transposition based on the middle colic artery was performed as there was no stomach and esophagus [Figure 2]b. There was a leak on cervical anastomosis in the postoperative period, which was managed by conservative means. Later, FJ tube was removed in follow-up. Patient is under follow-up for the last 2 years without any complaint. She is feeding well and gaining weight.

Eventration of diaphragm can be complicated by acute gastric volvulus, chronic gastric volvulus, or chronic recurrent volvulus of the splenic flexure of the colon. Gastric volvulus in eventration of diaphragm is rare, and it was first described by Berti in 1866 in autopsied patient, and the first operation was performed by Berg in 1897.[2],[3] Approximately, over 400 cases have been reported in literature, in which, at least two-thirds are of chronic or recurring type.[3] Organo-axial volvulus is more common and occurs in 60% of cases.[3] Mesentero-axial variant of gastric volvulus is less commonly encountered and is not usually associated with diaphragmatic anomalies.[1],[2],[3] The third and rarest form of gastric volvulus is when the stomach rotates about both the organo-axial and mesentero-axial resulting in a combined volvulus.[1],[2],[3] Borchardt's triad of severe epigastric pain, retching, and inability to pass a nasogastric tube is present in 70% of cases and is believed to be diagnostic for acute gastric volvulus[1],[2],[3] as occurred in our case.

Our patient presented late with gastric gangrene as in case one reported by Shukla RM et al.[2] and operated in suboptimal emergency situation. A series of complications, including anastomotic leak, pyothorax, wound infection/dehiscence, and sepsis, made the condition worse, leading to multiple major surgeries including esophageal replacement by colonic transposition. It causes prolonged hospitalization and financial/mental burden. Complications include gastric ischemia, gangrene, perforation, pancreatic necrosis, omental avulsion, and even splenic rupture in few cases.[1],[2],[3] Rarity of the disease accounts for the associated high mortality (30%–50%) and hence requires high index of clinical suspicion.[3] A prompt and correct diagnosis, followed by immediate surgery, remains the key factor in reducing the morbidity and mortality. To the best of our knowledge, very few cases of gastric volvulus requiring total gastrectomy have been reported in the literature.[1],[2],[3]

In conclusion, to prevent this very high morbidity due to the complications of gastric volvulus in a case of eventration of diaphragm, early diagnosis of the condition, early surgical referral, and urgent surgical intervention after proper optimization of patient are advised. Any deviation from standard protocol may lead to complications, and a minor complication may result in further major surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank all the paramedical staffs, parents of patient, and all financial donators for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Teague WJ, Ackroyd R, Watson DI, Devitt PG. Changing patterns in the management of gastric volvulus over 14 years. Br J Surg 2000;87:358-61.  Back to cited text no. 1
    
2.
Shukla RM, Mandal KC, Maitra S, Ray A, Sarkar R, Mukhopadhyay B, et al. Gastric volvulus with partial and complete gastric necrosis. J Indian Assoc Pediatr Surg 2014;19:49-51.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Sinwar PD. Gastric mesenteroaxial volvulus with partial eventration of left hemidiaphragm: A rare case report. Int J Surg Case Rep 2015;9:51-3.  Back to cited text no. 3
    


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