Acute Intrathoracic Stomach: Complicated Paraesophageal Hernia associated with Distal Gastrointestinal Obstruction. Report of Two Cases and Review

Abstract

The intrathoracic or upside-down stomach (UDS) is associated with the risk of incarceration and volvulus, which can be complicated by acute gastric obstruction and strangulation, leading to sepsis. Two cases of complicated UDS are reported, with a review of the relevant literature, to highlight the diagnostic challenges and management of this devastating condition. Two case reports are presented and the literature from 1995 to the present is reviewed regarding the etiology, incidence, presentation, diagnosis and treatment of complicated large paraesophageal hernia (PEH) and acute UDS. Two patients with cases of known large PEH and severe comorbidities, a man aged 88 years (case I) and a woman aged 78 years (case II), underwent emergency operation for volvulus and strangulation of UDS, after intense resuscitation. Case I had a prepyloric lesion revealed by gastroscopy. Case II also had an incarcerated abdominal incisional hernia producing bowel obstruction, and was in septic shock. X-ray and CT of the chest and abdomen helped the diagnosis of complicated PEH. Operative findings: In Case I, the entire stomach was found in the mediastinum with volvulus and distal ischemia; distal gastrectomy, gastrojejunostomy, cruroraphy and fundopexy were performed. In Case II, after freeing the incarcerated viable bowel, UDS was identified in the mediastinum, with ischemic antrum and necrotic, ruptured gastric fundus; total gastrectomy was performed with esophageal and duodenal stapling, and a feeding jejunostomy was constructed. Both patients were transferred intubated to the intensive care unit (ICU). Case I was extubated on day 4 and discharged on day 28; histology revealed antral ischemia and obstructive prepyloric pT2 adenocarcinoma. Case II was never stabilized, and died 50 hours after surgery; histology demonstrated gastric necrosis. Obstructive conditions distal to large PEHs may cause life-threatening complications in the contents of the hernial sac. In patients who are in unstable condition, with complicated large PEH or UDS with gastric compromise, emergency open surgery is required for reduction and resection of the necrotic parts of the stomach and possibly other organs. In other patients, who respond well to resuscitation after endoscopic gastric decompression, semi-urgent or early elective repair may be programmed.