Recurrent Upside-Down Stomach after Endoscopic Repositioning and Gastropexy Treated by Laparoscopic Surgery
An 88-year-old woman with periodic vomiting and inability to eat was admitted to our hospital on three separate occasions where she received conservative treatment for a few days. Upside-down stomach was diagnosed. Because of her advanced age, complications (bedridden state, left hemiplegia after cerebral infarction, heart failure) and poor general condition, the minimally invasive method of endoscopic repositioning and gastropexy was performed. The stomach was reduced to the normal anatomic position, and the anterior stomach wall was fixed to the abdominal wall in three places as widely as possible (fig. ). She became symptom-free and was discharged on postoperative day 12.\nThree months later, she was hospitalized again because of vomiting. Chest and abdominal computed tomography showed the gastric fornix in the abdominal cavity, but the gastric corpus was above the diaphragm with organoaxial volvulus (fig. ). She was then diagnosed with a recurrent upside-down stomach after endoscopic repositioning and gastropexy. She was initially managed conservatively and had a nasogastric tube inserted, but her condition did not improve.\nAlthough her anterior stomach wall had been fixed to the abdominal wall in three places as widely as possible in the last hospitalization, she again presented with upside-down stomach. We concluded that it was impossible to prevent the recurrence of an upside-down stomach by endoscopic therapy. Therefore, we treated the condition with a laparoscopic repair of hernias and gastropexy.\nUsing a laparoscope, we observed that the anterior stomach wall was adhered to the abdominal wall in three places from the antrum to the lower corpus of the stomach (fig. ). The upper corpus of the stomach was rotated and herniated into the esophageal hiatus (fig. ). The herniated part of the stomach was repositioned easily. However, it quickly returned into the esophageal hiatus with rotation because of the adhesion between the omentum and the esophageal hiatus (fig. ). This adhesion was peeled off and the crura were closed by a primary suture (fig. ). The cardial part of the stomach wall was fixed to the crura, and the anterior stomach wall was fixed in three places to the abdominal wall widely from the upper corpus to the antrum (fig. ).\nOral ingestion was started the day after surgery. After rehabilitation, the patient was discharged 18 days after the operation. The suture used for fixing the stomach wall was removed 44 days after the operation. Three months after removal of the suture, the patient remained asymptomatic.