Gastrojejunostomy: a simple method of

Annals of the Royal College of Surgeons of England (1986) vol. 68
Gastrojejunostomy: a simple method of
treatment of gastric volvulus
A G FARKAS NlB BS
Senior House Officer
L R CELESTIN FRCS
Consultant Surgeon
Department of General Surgery, Frenchay Hospital, Bristol
Key words: GASTROE{INTEROSTOMY; STOMACH, VOlNVIULUS; SURGERY
Summary
Ten patients treated for gastric volvulus over eleven years are reviewed.
Nine were treated successfully by gastrojejunostomy. The '1)
advantages of this simple procedure are discussed. Changes occurring
in the position of the pylorus may predispose to this condition.
Introduction
Gastric volvulus is an unusual condition involving rotation
of the stomach around either its longitudinal (organo-axial)
or transverse (mesentcro-axial) axis (Fig. 1). It may present
cither acutely or chronically and be either total or partial.
The condition was described by Berti in 1866 (1) present-
to
ing classically as Borchardt's triad (2): (i) retching with
inability to vomit,Borchardtgstriad (2) (ii) etchinability to
pass a nasogastric tube. It usually occurs in association
with large hiatus herniae (3). Other recognised associations
are with ligamentous laxity of the stomach attachments,
congenital bands traumatic diaphragmatic hernia and
eventration of the diaphragm (6).
Many reports of this condition have described a multitude
of treatments (4-7). Tanner (6) enumerated these:
repair of diaphragmatic hernia, division of adherent bands,
gastropexy, gastropexy with colonic displacement, partial
gastrectomy, gastrojcjunostomy, fundo-antral gastrogastrostomy,
repair of eventration of diaphragm. In addition
endoscopy has been used (8).
Gastrojejunostomy was first described as a successful A
treatment by Neumann in 1906 (9). Individual cases have
been reported since, most recently by Thorpe in 1981 (10).
We report our experience of this condition in ten patients.
Patients and methods
Over the past eleven years ten patients, all female, with
gastric volvulus have been treated surgically. All were
associated with large para-oesophagael hiatus herniae. The
axis of rotation was recorded in seven cases. Five had
organo-axial rotation and two mesentero-axial.
An abdominal approach was used in all cases. The
principal treatment in nine was retrocolic gastrojejunostomy.
This was performed by anastomosing the greater
curve of the stomach to the jejunum as closely as possible to
the duodeno-jejunal flexure. A two layer anastomosis of
continuous chromic catgut and interrupted linen was used.
F IG. I Above, organo-axial rotation of stomach around longitudin-
Correspondence to: Dr A G Farkas, 11, Myrtle Road, Bristol al axis; below, mesentero-axial rotation of stomach around trans-
BS2 8BL verse axis.

108 A G Farkas and L R Celestin
TABLE I. Details of the ten patients treated.
Age
Case Sex Presentation Treatment Outcome
1 82F Pain and Gastrojejunostomy Symptoms relieved
vomiting Repair of hiatus Alive
2 68F Vomiting Total gastrectomy Died of anastomotic
dehiscence
3 82F Pain and Gastrojejunostomy Well until unrelated
vomiting death 2 years
4 69F Pain and Gastrojejunostomy Well until died of
vomiting Repair of hiatus carcinoma of stomach
4 years
5 81F Haematemesis Gastrojejunostomy Symptoms relieved
Excision gastric Died of adhesive
ulcer obstruction 2 months
6 83F Pain and Gastrojejunostomy Well until unrelated
vomiting death 3 months
7 75F Pain Gastrojejunostomy Symptoms relieved
Repair of hiatus Alive
8 81F Haematemesis Gastrojejunostomy Symptoms relieved
Repair of hiatus Alive
9 58F Haematemesis Gastrojejunostomy Symptoms relieved
Splenectomy Alive
10 68F Dysphagia Gastrojejunostomy Symptoms relieved
Repair oesophageal Alive
tear
The hiatus was repaired in four cases using interrupted
nylon sutures.
In case 2 difficult mobilization of the stomach resulted in
gastric perforation necessitating thoraco-abdominal gastrectomy.
In case 5 a bleeding gastric ulcer was excised. In
case 9 splenectomy was carried out and in case 10 an
oesophageal tear repaired following difficulties in mobilising
the stomach.
Results
The ten cases are summarised in Table I. All nine patients
treated by gastrojejunostomy had relief of symptoms following
surgery and are either alive or have died from unrelated
causes. The only perioperative mortality among all patients
FIG. 2 Radiograph of organo-axial rotation.
was in case 2 following total gastrectomy. Case 5 died
following a laparotomy for adhesions two months after
gastrojejunostomy and excision of gastric ulcer; case 6 died
of unrelated causes 3 months after surgery.
We have not encountered any recurrence of symptoms in
this group of patients.
Discussion
The significance of the axis about which the stomach
rotates has been discussed extensively (7, 11). The pylorus is
normally situated to the right of the midline at the level of
the first lumbar intervertebral space. In volvulus the pylorus,
as found at surgery, is in the midline at the level of the
body of LI (Figs. 2 and 3). In para-oesophageal herniation
FiG. 3 Diagram of radiograph in Fig. 2 showing movement of
greater curve A to A' and lesser curve B to B'. Pylorus P moves
upwards and to the midline P'.

migration of the stomach into the chest is a factor leading to
movement of the pylorus and duodenum across the midline.
We suggest that though herniation is the aetiological factor,
migration of the pylorus may predispose to volvulus, as it
only occurs when the distance between cardia and pylorus
is such as to allow abnormal mobility of the stomach.
The aim of surgical correction is relief of symptoms and
prevention of recurrence. The average age in our series was
74: any procedure in this elderly population should be as
simple as possible. The diaphragmatic hiatus was repaired
in cases when it was readily accessible but was felt to be of
secondary importance and not to warrant more extensive
surgery. Symptoms of reflux oesophagitis are rare, due to an
increased oesophago-gastric angle (6). Gastrojejunostomy
at the fixed point of the duodeno-jejunal juction tethers the
untwisted stomach in the abdomen and prevents recurrent
volvulus. This procedure carries the further advantage of
preventing the not infrequent migration of the transverse
colon into the chest anterior to the stomach. Fixation by
anastomosis does not break down as may happen in simple
gastropexy (6).
Gastrojejunostomy is a simple and effective treatment for
gastric volvulus. Morbidity and mortality in this series has
been associated with extensive gastric mobilization or the
performance of surgical procedures in addition to gastrojejunostomy.
We suggest that these should be avoided when
possible.
Notes on books
Atlas of Human Anatomy by J A Gosling, P F Harris, J R
Humpherson, I Whitmore and P L T Wilan. Illustrated.
1985. Gower Medical Publishing Limited, London. £19.50.
Originating from the Manchester University Department of Anatomy
this folio volume comprises high quality colour photographs
of cadaver dissections accompanied by a coloured line diagram of
the photograph fully labelled. A succinct text accompanies the
illustrations.
The photographs are of outstanding quality and there can be
few students of anatomy who will fail to enjoy studying this
vilume. It complements existing texts and should have a ready sale
in view of the remarkably low price.
Radiation Protection in Hospitals by Richard F Mould.
201 pages, illustrated. 1985. Adam Hilger, Bristol. £19.50.
Personnel in the Departments of Nuclear Medicine, Diagnostic
Radiology and Radiotherapy ali need to know the principles and
importance of radiation protection. This book tells all. It has
evolved over many years of lecturing on the topic of radiation
protection to a wide spectrum of hospital staff and is written in a
most readable style. Numerous illustrations, including the judicious
use of cartoons, enliven the pages.
Head and Neck Cancer edited by Robert E Wittes. 350
pages, illustrated. 1985. John Wiley, Chichester. £37.50.
Selected areas of current interest in head and neck cancer comprise
this volume. Epidemiology, staging, treatment and prevention,
cells in culture and methodology are the headings of the five
sections covered. Particularly emphasised is the increasing use of
combined modality treatment. Fully referenced and handsomely
produced.
Congenital Heart Surgery: Current Techniques and
Controversies edited by Anthony L Moulton. 347 pages,
illustrated. Butterworths, London. £95.00.
Forty-two authors from 8 different countries describe their
approaches to 7 different congenital heart defects. With more than
500 illustrations and many tables the different surgical approaches
are detailed together with extinwive references to the literature.
A simple method of treatment of gastric volvulus 109
References
I Berti A. Singalore attortigliamento dele'esofago col duodeno
seguita rapida morte. Gazz Med Ital Prov Veneti 1866;9:139.
2 Borchardt M. Zun Pathalogie and Therapie des Magenvolvulus.
Arch Klin Chir 1904;74:243.
3 Vernhet J, Carabalona JP, Carabalona P. Les volvulus intrathoraciques
de l'estomac au cours des hernies hiatales.
Chirurgie 1980; 106:756-4.
4 Dalgard BJ. Volvulus of the stomach. Acta Chir Scanda
1952; 103:131-53.
5 Buchanan J. Volvulus of the stomach. Br J Surg 1932;18:99-
112.
6 Tanner NC. Chronic and recurrent volvulus of the stomach.
Am J Surg 1968; 115:505-15.
7 Wastell C, Ellis H. Volvulus of the stomach. Br J Surg
1971 ;58:557-62.
8 Patel NM. Endoscopic correction chronic gastric volvulus.
Gastrointest Endosc 1983;29:63.
9 Neumann. Uber den Volvulus des Magens. Dtsch Z Chir
1906;85: 136-50.
10 Thorpe JAC. Chronic gastric volvulus-aetiology and treatment.
BrJ Clin Pract 1981;35:161-2.
11 Carter R, Brewer LA, Hinshaw DB. Acute gastric volvulus.
AmJ Surg 1980;140:99-106.
12 Askew AR. Treatment of acute and chronic gastric volvulus.
Ann R Coll Surg Eng 1978;60:326-8.
Manual on the AO/ASIF Tubular External Fixator by
G Hierholzer, Th Ruedi, M Allgower and J Schatzker. 100
pages, illustrated. Springer-Verlag, Berlin. DM 86.
This is a specialized book for orthopaedic surgeons. It outlines the
principal features of the tubular system of external fixation which
was developed by the Working Group for Osteosynthesis of the
AO/ASIF. It is copiously illustrated and handsomely produced on
high quality paper.
Surgical Endoscopy edited by Thomas L Dent, William E
Strodel, Jeremiah G Turcotte and Mary L. Harper. 536
pages, illustrated. 1985. Year Book Medical Publishers,
Chicago. £57.
Diagnostic and therapeutic endoscopy of the gastrointestinal tract
and biliary tree, together with bronchoscopy, arthroscopy, cystoscopy
and laparoscopy are covered in this concentrated text. Thirty
three chapters comprise essays presented at a postgraduate symposium
held in May 1985 in Michigan. Topical, readable and
recommended.
Surgical Care II by Robert E Condon and Jerome De
Cosse. 431 pages, illustrated. 1985. Lea and Febiger, Philadelphia.
$71.
Applied surgical physiology is emphasised throughout this wideranging
volume which covers such diverse subjects as gastrointestinal
motility, massive intestinal resection, cerebrovascular disorders,
the pathology of sepsis and wound healing. The volume is
intended as a reference text for students as well as the practising
surgeon. Each of the twenty one chapters is well referenced and
the book is attractively produced on art paper.
1985 Year Book of Plastic and Reconstructive Surgery
edited by FrederickJ McCoy. 320 pages, illustrated. 1985.
Year Book Medical Publishers, Chicago. £49.50.
This is the sixteenth annual volume of a well-known series. It
abstracts important articles published during the last few months
and adds substantive editorial comments. Required reading for all
plastic surgeons.