A Rare Complication of Laparoscopic Nissen Fundoplication: Gastric Volvulus

Background: Gastric volvulus is defined as a rotation of the stomach greater than 180 degrees, and can be classified based on its etiology as primary/idiopathic, which represents 10-30% of cases and it is associated with adhesions and abnormalities of the gastric ligaments. Secondary volvulus is associated with defects of the diaphragmatic anatomy, mostly due to paraesophageal hernias, tumors, after fundoplications, and gastric banding. It can also be classified based on the rotation of its axis. Type I is organo-axial, in which rotation occurs along the axis connecting the pylorus and the esophageal-gastric junction, occurring in 59% of cases. Type II is mesenteric-axial, in which rotation occurs connecting the lesser and greater curvatures, occurring in 29% of cases. A third type has been reported, consisting of a combination of both, occurring in approximately 2% of cases. In adults, secondary gastric volvulus is most commonly associated with paraesophageal hernias and traumatic diaphragmatic injury. Symptoms are nonspecific; however, the most common are postprandial epigastric or chest pain, early fullness, dysphagia, nausea, and vomiting. Diagnosis is usually made by endoscopy and contrast-enhanced radiological studies. Treatment is surgical, with the goals of reducing the volvulus, resection of the hernial sac, repair of the diaphragmatic defect, and fundoplication if the patient requires it. Clinical Case: A 24-year-old male with no chronic diseases, an active smoker with a consumption of one cigarette per day, with occasional alcohol consumption, a surgical history of septoplasty performed 13 years earlier and laparoscopic Nissen fundoplication in 2019. The patient began with exertional precordial pain of 1 day duration, unresponsive to analgesics, in addition to diaphoresis, intolerance to oral intake, and sialorrhea, for which he came to the Emergency Department in February 2021. Initially, an endoscopy was performed, evidencing changes after an intact complete fundoplication, acute erosive gastritis in the fundus, ecchymotic changes suggestive of gastric volvulus with ischemia. He was managed with intravenous fluid resuscitation and analgesia. Emergency laparoscopic surgery was performed for gastric detorsion and reduction of the volvulus. Hiatal plasty was performed using poly 4-hydroxybutyrate (P4HB) mesh, followed by a Nissen fundoplication; no gastropexy was performed. Intraoperative video panendoscopy was performed after laparoscopic fundoplication, which revealed postoperative changes, an intact fundoplication without overriding phenomena, erosive gastritis in the fundus, and a negative pneumatic test. The surgical time was 1 hour and 15 minutes, with intraoperative blood loss of 200 cc, without complications, and a hospital stay of 2 days. Conclusions: Gastric volvulus as a complication of laparoscopic fundoplication is quite rare; it should be highly suspected in patients with symptoms of gastric obstruction. Surgical treatment should be focused on correcting the underlying cause and restoring anatomy.