Gastric Torsion Research Articles

Does Omentopexy Make a Difference in Laparoscopic Sleeve Gastrectomy for Obesity Treatment? A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.

S2660 Incomplete Gastric Obstructive Torsion Representing Esophagogastric Outflow Obstruction Reduced by Endoscopy

S2660 Incomplete Gastric Obstructive Torsion Representing Esophagogastric Outflow Obstruction Reduced by Endoscopy

Gastric Torsion following Sleeve Gastrectomy: A rare case and surgical management

Gastric torsion is a rare but potentially life-threatening complication that can occur following sleeve gastrectomy, characterized by the rotation of the stomach along its axis. This case report presents the clinical presentation, diagnostic approach, surgical management, and postoperative outcomes of a patient who developed gastric torsion after previous sleeve gastrectomy. Early recognition and prompt surgical intervention are crucial in effectively managing this uncommon complication.

Herbal Treatment for Gastric Dilatation Volvulus in Animals

Gastric dilatation volulus, also known as gastric dilation, twisted stomach, or gastric torsion, is a medical condition that affects animals in which the stomach becomes overstretched and rotated by excessive gas content

BLOOD CHEMISTRY PARAMETERS IN DOGS WITH ACUTE GASTRIC DILATION SYNDROME DURING THE PREOPERATIVE PERIOD

Acute gastric dilation syndrome is a condition that occurs with a significant increase in the stomach volume, which can also beaggravated by twisting the stomach around its axis (gastric torsion). Acute dilation syndrome and gastric torsion is deadly conditions that require immediate veterinary care and intensive therapy. Mortality from this pathology ranges from 10 to 50%, most of the fatal cases occur during postoperative period, and possible complications can affect almost all body systems. The purpose of the presented study was to evaluate and analyze the most common changes in blood biochemical parameters in dogs with acute gastric dilation syndrome, as well as a retrospective review of methods for choosing the resolution of the acute gastric dilation syndrome (surgical intervention or gastric intubation intubation and lavage). Based on the data obtained, a statistical analysis was carried out in order to identify the most prognostically significant parameters. During the study, the regularities of the choice of the treatment method were revealed – for dogs with a live weight of more than 33 kg, in 80% of cases, surgical intervention with subsequent gastropexy was chosen as treatment method. The survival rate of dogs with the choice of surgery as treatment method was 60% (n=10), and for dogs with probing and gastric lavage as treatment method – 50% (n=10). There were also significant (p<0.05) increases in total bilirubin levels and aspartate aminotransferase activity in the group of dogs with a fatal outcome (n=9) when compared with the group of dogs with a benign outcome (n=11). The activity of aspartate aminotransferase in the group of dogs with a benign outcome was 111.52 ± 69.34 IU/l, and in the group of dogs with a fatal outcome 270.46 ± 179.11 IU/l. The total bilirubin level was 3.27 ± 1.19 μmol/l and 5.34 ± 2.31 μmol/l, respectively.

Diagnosis and treatment of splenic torsion in children: preoperative thrombocytosis predicts splenic infarction

BackgroundPediatric splenic torsion is a rare entity, and the most common cause is wandering spleen. This study aimed to summarize our clinical experience in the diagnosis and surgical treatment pediatric patients with splenic torsion, and to use preoperative thrombocytosis as a preoperative predictive factor for splenic infarction.MethodsFrom January 1st, 2016 to December 31st, 2021, 6 children diagnosed as splenic torsion were included. All patients were surgically treated and followed up. The clinical data was collected including clinical presentations, laboratory tests, imaging results, surgical procedures, and prognosis. Clinical experience of diagnosis and surgical treatment were summarized.ResultsThere were 4 females and 2 males, with median age at surgery 102.6 (range 9.4–170.7) months. Abdominal pain and abdominal mass were the most common presentations. The diagnosis of splenic torsion depended on imaging studies, and adjacent organ involvement (gastric and pancreas torsion) was observed on contrast CT in one patient. Five patients were diagnosed as torsion of wandering spleen, and one was torsion of wandering accessory spleen. Emergent laparoscopic or open splenectomy was performed in all patients. Pathology revealed total splenic infarction in 4 patients, partial infarction in 1 patient, and viable spleen with congestion and hemorrhage in 1 patient. Preoperative platelet counts were elevated in all 4 patients with splenic infarction, but normal in the rest 2 with viable spleen. Postoperative transient portal vein branch thromboembolism occurred in one patient.ConclusionsImaging modalities are crucial for the diagnosis of pediatric splenic torsion and adjacent organ involvement. Preoperative thrombocytosis may predict splenic infarction. Spleen preserving surgery should be seriously considered over splenectomy in patients with a viable spleen.

Outcomes of dogs undergoing surgery for gastric dilatation volvulus after rapid versus prolonged medical stabilization.

To compare the outcomes of dogs surgically treated for gastric dilatation volvulus (GDV) after rapid versus prolonged medical stabilization. Prospective cohort study, monoinstitutional. One hundred and sixty-two dogs with GDV. Dogs presenting with a GDV were allocated to 1 of 2 groups, immediate or delayed. In the immediate group, dogs were stabilized for 90 min prior to undergoing surgery. In the delayed group, dogs underwent surgery after at least 5h of stabilization. Medical stabilization included gastric decompression and placement of an indwelling nasogastric tube to prevent further gastric dilatation in all dogs. Short-term outcomes were compared between surgical timings by univariate and multivariate analyses. Dogs (n=89) in the immediate group underwent surgery a median time of 2.1h after presentation (range 1.9-2.5h), whereas those in the delayed surgery group (n=73) were operated a median time of 9.8h (range 5.4-13.7h) after presentation. Survival rates did not differ between dogs undergoing immediate or delayed surgery at discharge (70/89 and 60/73, respectively) or at 1 month postoperatively (68/89 and 55/73, respectively). The degree of gastric torsion was differently distributed between the 2 groups (P=.05). In the immediate group, 19, 52, and 9 dogs had a 0°, 180° and 270° gastric torsion respectively, whereas in the delayed group, 27, 32, and 5 dogs had a 0°, 180° and 270° gastric torsion respectively. Hyperlactatemia 24 h after initiation of fluid therapy was associated with an increased in-hospital mortality risk and at 1 month postoperatively. No survival benefit was detected as a result of proceeding to surgery after either a rapid or a prolonged medical stabilization. The aggressive stabilization and monitoring protocol described here can be considered as an alternative to stabilize dogs with GDV prior to surgery within 13.7h of presentation. Further research is required to investigate the potential risks and benefits of prolonged over rapid stabilization and to identify candidates for each approach.

Protein C activity in dogs with gastric dilatation and volvulus

Protein C activity, a novel prognostic marker, was evaluated in patients with gastric dilatation and volvulus in relation to mortality and severity of the disease. Data on the mortality, duration of clinical signs, degree of gastric torsion, gastric necrosis, splenectomy and occurrence of disseminated intravascular coagulopathy were recorded. Blood samples were obtained at selected time periods: T0 = no longer than 30 min before surgery; T1 = first day after surgery; T2 = second day after surgery. In addition to protein C activity assessment, haematological and haemostaseological analysis was also performed. The mean protein C activity was the lowest at T1 and the highest at T2. No significant relationship between protein C activity and mortality, duration of clinical signs, degree of gastric torsion, gastric necrosis, splenectomy and disseminated intravascular coagulopathy was found in patients with gastric dilatation and volvulus. All patients that died during hospitalisation after surgery were patients with decreased protein C activity at T1. Although protein C activity was not found to be a reliable preoperative prognostic marker in patients with gastric dilatation and volvulus, the study results show it might be a promising marker in postoperative monitoring of these patients.

Impact of Gastropexy/Omentopexy on Gastrointestinal Symptoms after Laparoscopic Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become a single-step operation for the management of severe obesity. A statistically significant number of participants who undergo this procedure experience nausea, vomiting, and reflux symptoms early after the operation. The objectives of this study were to measure the positive or negative effect of gastropexy on reducing distressing postoperative LSG-related gastrointestinal symptoms.Patients and MethodsThis was a comparative randomized study conducted from January 2018 to January 2021. The study was carried out in the general surgery department at Menoufia University Hospital, Menoufia Faculty of Medicine in Egypt. Two hundred participants were included randomly during this trial. The participants were divided into two groups, with 100 patients in each group. Patients in group A underwent gastropexy, and patients in group B underwent LSG without gastropexy.ResultsThere was no significant difference between the groups in age or sex (p > 0.05). There was no significant difference in the length of hospital stay (p > 0.05). There was a significant difference between the two groups regarding nausea, vomiting, reflux symptoms, and the amount and frequency of antiemetics used (p < 0.001). There was also a significant difference in hospital readmissions (p < 0.05) and in clinic visits during the postoperative period.ConclusionsPatients who underwent gastropexy showed a significant reduction in antiemetic consumption and a significantly lower incidence of postoperative nausea, vomiting, gastroesophageal reflux disease symptoms and gastric torsion than those who did not undergo gastropexy.Graphical abstract

Gastric volvulus is a rare and life-threatening abdominal pain

Gastric volvulus is a rare and life-threatening abdominal pain condition resulting from the stomach twisting on its own longitudinal (organo-axial) or transverse (mesentero-axial) axis. Gastric volvulus can be primary or secondary. Secondary is most commonly related to para-esophageal hernia. Gastric volvulus can have an acute or chronic presentation, the acute form presents abdominal pain with a risk of gastric ischemia with subsequent perforation. Diagnosis is made by imaging studies such as barium contrast studies in the upper digestive tract or abdominal and chest computed tomography (CT). CT of the abdomen and thorax is very useful in the diagnosis as it can demonstrate the abnormal position and gastric torsion The goal in the definitive treatment of gastric volvulus is resolution of gastric obstruction and prevention of recurrence. Performing volvulus reduction, repair of the concomitant cause (para-esophageal hernia), fundoplication and/or gastropexy to the anterior abdominal wall. Gastropexy is considered safe and effective in elderly patients with high surgical risk.

Successful revision surgery for very late-onset stomal obstruction following Gomez gastroplasty: a case report

BackgroundGomez gastroplasty, which was developed in the 1970s as one of the gastric restrictive surgeries for severe obesity, partitions the stomach using a stapler from the lesser towards the greater curvature at the upper gastric body, leaving a small channel. This procedure is no longer performed due to poor outcomes, but surgeons can encounter late-onset complications even decades after the surgery. Here, we report a case of very late-onset stomal obstruction following Gomez gastroplasty which was successfully treated by revision surgery.Case presentationA 58-year-old man was referred to our institution with sudden-onset nausea and vomiting. He underwent weight loss surgery in the USA in 1979, but the details of the surgery were unclear. Esophagogastroduodenoscopy demonstrated a stoma at the greater curvature of the upper gastric body, and fluoroscopy showed retention of contrast medium in the fundus and poor outflow through the stoma. Abdominal computed tomography revealed a staple line partitioning the stomach. Considering these preoperative investigation findings and the period during which the surgery was performed, the patient was diagnosed with very late-onset stomal obstruction following Gomez gastroplasty. Supporting the preoperative diagnosis, the surgical findings revealed a staple line extending from the lesser towards the greater curvature of the upper gastric body and a channel reinforced by a running seromuscular suture on the greater curvature. Moreover, gastric torsion caused by the enlarged proximal gastric pouch was found. Re-gastroplasty involving wedge resection of the original channel was performed followed by construction of a new channel. Postoperative course was uneventful, and the patient no longer had symptoms of stomal obstruction after revision surgery.ConclusionsRe-gastroplasty was safe and feasible for very late-onset stomal obstruction following Gomez gastroplasty. Accurate preoperative diagnosis based on the patient’s interview and the investigation findings was important for surgical planning. A careful follow-up is required to prevent excessive weight regain after revision surgery.

Paraesophageal hernia repair can decrease BNP levels.

Although the main manifestation of giant paraesophageal hernia (PEH) is disordered meal passage due to gastric torsion, the contents of the hernia sometimes squeeze the heart and lungs and induce the symptoms of respiratory or heart failure. Furthermore, the quality of life (QOL) of patients with a heavy cardiac load deteriorates. In this study, changes in a heart failure marker and symptoms of cases with a giant PEH from before to after laparoscopic surgery were examined. Levels of brain natriuretic peptide (BNP) as a heart failure marker were measured before and after radical laparoscopic surgery in cases of type III, IV type of giant PEH. Changes of the symptoms due to heart failure were also investigated. A total of 75 hiatal hernia surgeries were performed in 2012-2019. Of them, 50 had a giant PEH, and 20 (40.0%) had heart failure symptoms such as fatigue and exertional dyspnea. In the giant PEH cases, BNP could be measured before and after surgery to evaluate the presence of heart failure in 23 cases; postoperative BNP levels decreased from the preoperative values in 18 of them. Furthermore, in many cases, chest symptoms also improved. Radical laparoscopic surgery can reduce heart failure due to giant PEH. Therefore, in addition to conventional surgical indication criteria such as vomiting and food loss, increased cardiac load may be added to the new surgical indication criteria.

Intrathoracic gastric torsion following surgical management of a type IV hiatal hernia

A five-month-old French bulldog was referred for assessment and management of regurgitation. Investigations suggested a type IV hiatal hernia, with the stomach and spleen found to be within the thorax. This was surgically managed with a phrenoplasty and fundic gastropexy. The dog recovered well and was free from clinical signs for four months, at which point he presented with sudden onset tachypnoea and increased respiratory effort. Radiographs identified a distended stomach within the thorax. An emergency coeliotomy identified that the stomach had torsed 180° around the gastropexy and herniated, along with the spleen, through the oesophageal hiatus. A sternotomy was required to decompress and subsequently reduce the stomach and spleen into the abdomen. The gastric torsion was corrected, and a right-sided gastropexy, a phrenoplasty and oesophagopexy were performed. The dog was doing well with no evidence of regurgitation four months following surgery.

Average Life Expectancy, the Most Common Cause of Death and Illness of Giant Dog Breeds

AbstractThe aim of this study was to analyze the most common diseases and genetic defects that occur during the lifetime of giant dog breeds, to determine the average lifespan and the cause of death/euthanasia. Data were obtained through a survey and concerned the health of 241 individuals of giant dog breeds held in the Czech Republic. Evaluated items involved an average lifespan, an average lifespan per gender, cause of death, reasons for euthanasia, cause of mortality (especially in selected Mastiff type breeds), life expectancy per breed and incidence of diseases among giant breeds during the lifetime. The average lifespan in giant breed dogs was found to be 7.60 years. A significant difference (P ˂ 0.05) was found between life expectancies in males and females, with female dogs reaching 1.42 year higher age (8.10 years) than males (6.68 years). The most common cause of spontaneous death among giant breeds was gastric dilatation and torsion (28% of dogs) and for euthanasia osteosarcoma (38% of dogs). The cause of mortality especially in selected Mastiff type breeds of dogs was gastric dilatation and torsion (30% of dogs). This is the first broad analytical study concerning this topic published in the Czech Republic.

P73 CONTRIBUTION TO THE IMPROVEMENT OF CARDIAC LOAD BY RADICAL SURGERY FOR ADVANCED ESOPHAGEAL HIATAL HERNIA

Abstract Aim The aim of this study is to clarify whether radical surgery for advanced esophageal hiatal hernia contribute to the improvement of cardiac load. Background &amp; Methods In Japan, endoscopic surgery for esophageal hiatal hernia is increasing. In many cases, patients with mixed type hernia have the main symptom of meal passage disorder due to gastric torsion. On the other hand, there are cases in which the contents of hernia squeeze the heart and lung and the symptoms of respiratory and circulatory system get worse. And there are cases where cardiac load is exacerbated and QOL is got worse. Therefore, in addition to conventional surgical adaptation criteria such as vomiting and food loss, cardiac load aggravation may be added to the new surgical adaptation criteria. In this study, we measured BNP before and after surgery in the case of mixed type hiatal hernia who underwent surgery at our hospital, and examined changes in cardiac load. Our surgical procedure of laparoscopic fundoplication is basically toupet fundplication. In the elderly patients, the formation of toupet fundplication is about half a cycle, which is slightly looser than usual, in order to avoid passage obstruction of the wrap. If the esophageal hiatus is too large and it is difficult to suture closure, try to reduce the air pressure of laparoscopic surgery as much as possible to reduce the resistance to the suture closure. And we try not to damage the diaphragm leg. Results We experienced 70 esophageal hiatal hernia surgeries in 2012-2018 and 45 patient had mixed type hiatal hernia. In mixed type hiatal hernia case, 18 cases (40.0%) had chest symptoms such as fatigue and dyspnea on exertion. And there were 12 cases in which BNP could be measured before and after surgery as an evaluation for the presence of cardiac load. Postoperative BNP decreased in 11 of 12 cases from preoperative values. Almost all cases chest symptoms improved. In the above 45 cases, there have been no cases of reoperation and very few cases have taken proton pump inhibitors after surgery. Conclusion Surgical cases of giant hiatal hernia may increase in the future, especially in the elderly. Surgery for giant hiatal hernia can contribute to the improvement of cardiac load.

Saint`s triade with diverticulosis of jejunum – rare variety of the syndrome

The objective was to present the case report of the patient with rare clinical finding – Saint`s triade. The examination diagnosed giant paraesophageal hernia (III type) with gastric torsion and cholelithiasis. The 72-years old woman was admitted to hospital with complaints of acute dysphagia. During the laparotomy operation, jejunal diverticulosis was also detected. The patient underwent crural repair, fundoplication, and cholecystectomy. The postoperative period was uneventful. She was discharged on the 14th day after surgery with recovery. The features of the presented case were the prevalence of the clinical picture of complicated hiatal hernia and the localization of diverticula in the jejunum. The clinical significance of the Saint`s triade was to assess the probability of this combination in identifying one of the components.

Comparative Study between the Complications of Sleeve Gastrectomy versus the Complications of Gastric Bypass

Background: obesity means having too much body fat. Causes of obesity includes: diet, sugar overload, genetics, insufficient sleep, social determinants, environment, and stress. Complications of obesity includes: type II diabetes mellitus, heart diseases, metabolic syndrome, hyperlipidemia, respiratory diseases, male sexual dysfunction, neurological diseases, gastrointestinal diseases, rheumatic diseases, urological diseases, psychological abnormalities, trauma, pancreatic diseases, gall bladder diseases, diverticulitis and hernia. Sleeve gastrectomy is an excellent procedure for management of morbid obesity. Complications of Sleeve gastrectomy includes: Hemorrhage, leakage, nutritional deficiencies, ineffective EWL and weight regain, cholelithiasis, stenosis, gastroesophageal reflux disease GERD and hiatus hernia, gastric torsion, gastro-bronchial fistula and venous thrombosis. Complications with Roux-en-Y Gastric Bypass includes: Hemorrhage, leakage, nutritional deficiencies, ineffective excess weight loss EWL and weight regain, trocar site hernia, cholelithiasis, dumping syndrome, Internal hernia, obstruction of the biliopancreatic limb, intussusceptions volvulous, gastrogastric fistula, marginal ulceration and gastrojejunostomy anastomotic stricture. Aim:To compare complications associated with Sleeve Gastrectomy versus complications associated with open or laparoscopic Gastric Bypass and its effects on patients' life and to know which procedure is better. Patients and Methods: group (A): includes 15 cases underwent sleeve gastrectomy. With inclusion criteria of obese patients with body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2with associated co morbidity (hypertension, Diabetes mellitus, hyperlipidemia, arthritis, cardiac diseases, etc.) and exclusion criteria of patients with previous bariatric surgery, previous upper gastrointestinal surgery, hiatus hernias, heavy sweet eaters, drug and/or alcohol addiction, psychiatric disorders and patients >60 years old or 40 kg/m2 or BMI > 35 kg/m2 with associated comorbidity (hypertension, Diabetes mellitus, hyperlipidemia, arthritis, cardiac diseases, etc.) and heavy sweet eaters and exclusion criteria of patients with previous bariatric surgery, previous upper gastrointestinal surgery apart from laparoscopic cholecystectomy. Patients with hiatus hernias, drug and/or alcohol addiction, psychiatric disorders and patients >60 years old or <18 years old were excluded. Results: three complications developed with sleeve gastrectomy 20% as follows 1 case of hemorrhage 6.6% , 1 case of leakage 66% and one case of gall bladder stones while gastric bypass complications resembles 2 cases 13.3% as follows:1case of deep venous thrombosis 6.6% and one case of gall bladder stones 6.6%. Conclusion: obesity is a common disease affecting more than 300 million adults worldwide. It is defined as a body mass index greater than 30 kg/m2. The laparoscopic sleeve gastrectomy was adopted as a primary procedure and over time it has become the most popular bariatric operation worldwide and it is effective for weight loss and results in improvement and even resolution of co-morbidities like type 2 diabetes. Laparoscopic gastric bypass surgery is another safe and simple surgical intervention for treating morbid obesity and diabetes mellitus and is now being performed more frequently Recommendations: both sleeve gastrectomy SG and roux-en-y gastric bypass RYGB are safe, short, simple and effective bariatric operations. Our study showed Roux-en-y gastric bypass has less complication than Sleeve gastrectomy. Further prospective studies have to be applied to a larger number of patients for longer periods of follow up are needed.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass.

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution. Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed. Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n = 36), for weight recidivism (n = 11), or for complications related to SG (n = 42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2years (11.4years) and median BMI at the time of revision was 43.2kg/m2. A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15months. Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.

Avoiding diagnostic errors in psychosomatic medicine: a case series study

BackgroundNon-organic lesions or diseases of unknown origin are sometimes misdiagnosed as “psychogenic” disorders or “psychosomatic” diseases. For the quality of life and safety of patients, recent attention has focused on diagnostic error. The aim of this study was to clarify the factors that affected misdiagnoses in psychosomatic medicine by examining typical cases and to explore strategies that reduce diagnostic errors.Case presentationThe study period was from January 2001 to August 2017. The data of patients who had visited the Department of Psychosomatic Medicine, Kindai University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, presenting symptoms, initial diagnosis, final diagnosis, sources of re-diagnosis and types of diagnostic errors were retrospectively analyzed from the medical charts of 20 patients. Among them, four typical cases can be described as follows. Case 1; a 79-year-old woman, initially diagnosed with psychogenic vomiting due to depression that was changed to gastric torsion as the final diagnosis. Case 2; a 24-year-old man, diagnosed with an eating disorder that was later changed to esophageal achalasia. Case 10; a 60-year-old woman’s diagnosis changed from conversion disorder to localized muscle atrophy. Case 19; a 68-year-old man, appetite loss from depression due to cancer changed to secondary adrenal insufficiency, isolated ACTH deficiency (IAD).ConclusionThis study showed that multiple factors related to misdiagnoses were combined and had a mutual influence. However, they can be summarized into two important clinical observations, diagnostic system-related problems and provider issues. Provider issues contain mainly cognitive biases such as Anchoring, Availability, Confirmation bias, Delayed diagnosis, and Representativeness. In order to avoid diagnostic errors, both a diagnostic system approach and the reduction of cognitive biases are needed. Psychosomatic medicine doctors should pay more attention to physical symptoms and systemic examination and can play an important role in accepting a perception of patients based on a good, non prejudicial patient/physician relationship.

茎捻転をきたした胃GISTの1例

症例は83歳，女性．腹部腫瘤・腹痛・発熱を主訴に受診し，腹部正中左寄りに圧痛を伴う小児頭大の腫瘤を触知した．腹部造影CTでは腹腔内に最大径20cmの巨大腫瘍を認めた．腫瘍は胃穹窿部に連続し，茎部にて捻転していた．入院後に腹痛の増悪を認めたため手術を実施した．開腹すると，網嚢内に発育する表面平滑，淡褐色の巨大腫瘍を認めた．腫瘍は脾上極付近の胃穹窿部から発育していた．基部を起点に360°捻転していた．捻転を解除し，腫瘍基部を含む胃穹窿部を自動縫合器にて切除した．切除標本は巨大な嚢胞状腫瘍であり内腔は旧血様の液体で満たされていた．H.E.染色では充実部分に紡錘形細胞の束状の増生を認めた．KITおよびCD34が陽性であり，gastrointestinal stromal tumor （GIST）と診断した．非常に稀な病態ではあるが，腹痛を伴う巨大胃GISTでは破裂や出血だけでなく茎捻転も考慮すべきである．