Laparoscopic Gastropexy for Congenital Organoaxial Gastric Volvulus in an Adult with Severe Intestinal Malabsorption

Abstract

A 62 year old male with malabsorption, malnutrition, and multiple comorbidities underwent laparoscopic gastropexy for congenital organoaxial vovulus, an uncommon lesion. The patient was well until 18 months prior, when he developed non-bloody diarrhea (> 20 stools per day), and progressive weight loss of over 120 lbs (>1/3 total body weight). Upper endoscopy and colonoscopy with biopsies were nondiagnostic. His cardiac function deteriorated, with dilated cardiomyopathy, and atrial fibrillation requiring pacemaker/defibrillator placement within 1 year. He underwent 72 hour fecal fat (75% absorption), followed by endoscopic retrograde cholangiopancreatography (“normal”), complicated by acute heart failure with collapse. During subsequent admission, work-up showed normal fecal elastase, and negative genotype for Celiac disease, infection, and PCR for Whipple's disease in blood. Upper GI demonstrated organoaxial gastric volvulus. He was treated empirically for Whipple's, made NPO with full parenteral nutrition, and referred for surgery. Repeat upper endoscopy and biopsies showed increased intraepithelial lymphocytes, and amyloidosis of duodenal vessels (IgM, IgG, IgD, IgA, κ, λ, amyloid A and B negative). At laparoscopy, the liver appeared normal, spleen was slightly enlarged. The stomach was suspended at a normal gastroesophageal junction, but had rotation of the body and fundus with a volvulus that was mostly posterior and a midline pylorus. Liver biopsy, resection of incidental Meckel's diverticulum, gastropexy, and gastrostomy were accomplished laparoscopically without complication. Postoperatively, the patient was started on peptide feeds, but continued to have malabsorption at discharge one week later. He was re-admitted within 4 weeks for Enterobacter gergoviae sepsis, intraabdominal free air/possible peritonitis. Mesenteric angiogram was normal. Over the 6 week admission, complicated by recurrent ventricular tachycardia, TPN was used until optimal weight achieved, then weaned as continuous peptide feeds increased. These were well tolerated with only 2 stools per day, and negative fecal fat, pH, and reducing substances on full GT feeds/low fat diet, upon discharge. The patient remains well 6 months after discharge.