A rare presentation of gastric outlet obstruction following a robotic-assisted Nissen fundoplication: a case report

Introduction

Post-operative morbidity following anti-reflux operations range from 5–20% (1). Short- and long-term failure is usually seen within the first 24 months after the operation and is commonly due to mechanical failure. Mechanical failure is the most common postoperative finding and comprise of multiple structural complications following anti-reflux surgery. Structural complications include complete or partial wrap disruption, intrathoracic wrap herniation, wrap slippage, tight wrap and/or crural disruption (2,3). Surgical revision is indicated in the setting of recalcitrant gastroesophageal reflux disease (GERD) or severe obstruction. Although several mechanisms of structural failure have been described, there are very few case studies that report gastric volvulus following a robotically approached Nissen fundoplication. There is little evidence to support a rate change of structural complications following the robotic approach for anti-reflux operations. We present a case that describes the occurrence of a subdiaphragmatic gastric volvulus following robotic Nissen fundoplication. Our report highlights the rarity of this occurrence, despite the wide adoption use of the robotic platform for anti-reflux operations. We present this article in accordance with the CARE reporting checklist (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-10/rc).

Case presentation

A 75-year-old female with a history of GERD, underwent a robotic-assisted Nissen fundoplication (Intuitive, Sunnyvale, CA, USA) for symptomatic type III paraesophageal hernia. Her immediate postoperative course was unremarkable and her preoperative complaints of early satiety, dysphagia and fatigue resolved.

Six months after her index operation, she returned to the emergency room with complaints of acute abdominal pain, per oral intolerance, nausea, and emesis. A computed tomography (CT) chest was performed and revealed subdiaphragmatic gastric volvulus (Figure 1). She had no evidence of leukocytosis or lab evidence of metabolic derangement. Based on her symptomology and radiographic findings, she was emergently transferred to the operating room.

Figure 1 CT axial and coronal views demonstrating gastric volvulus. CT, computed tomography.

An esophagogastroduodenoscopy (EGD) was performed and there were several ischemic foci within the fundoplicated portion of the stomach (Figure 2A). The EGD could not safely transverse the entire stomach. Given the endoscopic evidence of gastric malperfusion, a laparoscope was inserted and revealed a torsed stomach (Figure 2B). Adhesiolysis was performed to mobilize the stomach, and there was an adhesion that served a lead point between the fundoplication stitches on the stomach and the decussation of the crus. The stitches and adhesion band were lysed and the stomach was successfully detorsed to the in situ position (Figure 2C). A repeat endoscopy was performed and the gastric perfusion significantly improved and the pylorus and first portion of the duodenum were visualized. The hiatal closure from the index operation, was left intact. A gastropexy was performed using multiple sutures (Endostitch, Medtronic) (Figure 2D). Due to the foci of necrosis and concern for ischemia, the decision was made not to redo the fundoplication. She experienced immediate symptomatic relief and was discharged on post-operative day three in stable condition. An esophagram was performed at time of discharge (Figure 3). All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 2 Intraoperative evaluation at time of diagnosis and surgical repair. (A) Endoscopic view of the fundoplicated portion of the stomach with evidence of ischemic changes. (B) Volvulized stomach with transmural discoloration. (C) In situ position of stomach following detorsion. (D) Gastropexy.

Figure 3 Post-operative esophagram demonstrating adequate repair.

Discussion

Our case report describes a rare occurrence of gastric volvulus following a robotic Nissen fundoplication. There are limited reports of gastric volvulus following laparoscopic Nissen fundoplication, and no existing study on the incidence of this phenomenon following robotic antireflux surgery. More importantly, this presentation was not a primary gastric volvulus with axial rotation of the entire stomach, that is seen commonly in acute gastric outlet obstruction.

Adhesions, crural dehiscence, wrap transmigration and gastrostomy tubes have been cited as possible etiologies of gastric volvulus following laparoscopic Nissen fundoplication (3,4). The robotic approach to anti-reflux operations has become widely adopted over the last decade and is safe approach to anti-reflux surgery. There is limited data to suggest that the robotic approach is superior to the laparoscopic approach for antireflux surgery. The robotic-assisted approach have been shown to have longer operative time and equivalent short terms outcomes in comparison to the traditional laparoscopic approach, but long term outcomes and rates of failure are limited (5).

In this case, the adhesive communication between the fundoplication and the base of the crus served as lead point for the volvulus. Adequate mobilization of the stomach and restoring normal anatomy are the principles of re-operative anti-reflux operation. Adherence to these principles of re-do surgery, allowed us to restore the stomach in situ and complete a gastropexy (6).

A low threshold for gastric volvulus following anti-reflux operation must be held, in a patient presenting with per oral intolerance, food aversion, emesis and abdominal pain. Due to these symptoms, it was not safe to get an esophagram because of aspiration risk, thus CT imaging and her exam were objective measures used to proceed to surgery. Although this complication is not commonplace after anti-reflux surgery, it should be considered based on the presentation in our report.

Conclusions

To date, there are no proven studies that favor a specific minimally invasive approach to anti-reflux surgery. Given the rarity of subdiaphragmatic gastric volvulus following anti-reflux surgery, the threshold for immediate surgery must remain low in patients presenting with late gastric outlet obstruction.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-10/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-10/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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