https://orcid.org/0009-0002-0973-9453
Abstract
Gastric volvulus is a rare but potentially life-threatening complication following Nissen fundoplication, with delayed diagnosis increasing the risk of gastric ischemia, necrosis, and perforation. We report the case of a 72-year-old man who presented on postoperative Day 10 with progressive dysphagia, severe epigastric pain, and intolerance to oral intake following robot-assisted laparoscopic Nissen fundoplication. Computed tomography and upper gastrointestinal contrast study demonstrated marked gastric distension with obstruction at the gastroesophageal junction. Urgent diagnostic laparoscopy revealed a complete retroesophageal organoaxial gastric volvulus around an intact fundoplication wrap. The patient subsequently underwent robot-assisted gastric decompression, reduction of the volvulus, takedown of the fundoplication, and posterior gastropexy. Postoperative recovery was uneventful. This case highlights the importance of maintaining a high index of suspicion for gastric volvulus in patients with persistent obstructive symptoms after fundoplication and demonstrates that prompt minimally invasive surgical intervention can prevent catastrophic complications.
Introduction
Gastric volvulus is a rare but potentially life-threatening condition characterized by abnormal rotation of the stomach along its longitudinal (organoaxial) or transverse (mesenteroaxial) axis. Acute gastric volvulus is a surgical emergency; delayed diagnosis may result in ischemia, necrosis, perforation, and hemodynamic instability [1–4]. Although most commonly associated with paraesophageal hernias and diaphragmatic defects, gastric volvulus is an exceptionally uncommon complication following Nissen fundoplication [1, 2, 5]. Its presentation often resembles expected postoperative symptoms, so diagnosis may be delayed, emphasizing the importance of a high index of suspicion. We report a rare case of acute retroesophageal organoaxial gastric volvulus around an intact fundoplication, managed with diagnostic laparoscopy followed by robot-assisted reduction, fundoplication takedown, and posterior gastropexy.
Case report
A 72-year-old man with coronary artery disease status post angioplasty, arrhythmia, hypertension, hyperlipidemia, type 2 diabetes, and reflux disease with a hiatal hernia underwent robot-assisted laparoscopic Nissen fundoplication. His immediate postoperative course was unremarkable, and he was discharged on postoperative Day 1. On postoperative Day 10, he presented with progressive dysphagia, severe postprandial epigastric pain, recurrent vomiting, and inability to tolerate oral intake, describing food lodging in the distal esophagus, with pain relieved by emesis. He was hemodynamically stable apart from systolic hypertension (172 mmHg), with mild distension and epigastric tenderness.
Computed tomography (CT) of the abdomen with intravenous contrast showed expected postoperative changes, moderate distal esophageal distension, and marked gastric distension with an abrupt transition to a collapsed antrum, raising concern for volvulus (Fig. 1). An upper GI contrast study showed persistent contrast retention in the distal esophagus without passage into the stomach (Fig. 2). Esophagogastroduodenoscopy (EGD) revealed severe edema, ulceration, and tight narrowing at the gastroesophageal junction that even an ultraslim endoscope could not traverse (Fig. 3).
CT abdomen with intravenous contrast. (A) Dilated, fluid-filled esophagus and stomach with tapering at the hiatus. (B) Distended gastric body transitioning to a collapsed antrum. (C) Marked gastric body distension with abrupt antral collapse. (D) Antrum extending to the normally positioned pylorus and duodenal bulb.
Upper gastrointestinal contrast study demonstrating retained contrast above the gastroesophageal junction without passage into the stomach.
EGD demonstrating severe gastroesophageal junction erythema, stricture, and ulceration.
The patient underwent urgent diagnostic laparoscopy with robot-assisted exploration. The stomach was markedly distended, obscuring the gastroesophageal junction and fundoplication, while the distal stomach, pylorus, and duodenum remained normally positioned. A small gastrostomy was created for decompression; the gastric body was then found herniating posteriorly through the retroesophageal window, consistent with complete organoaxial volvulus around an intact fundoplication (Fig. 4).
Schematic illustration depicting the intraoperative findings. (A) Intact Nissen fundoplication with a normally positioned pylorus. (B) Progressive retroesophageal rotation of the gastric body around the intact fundoplication. (C) Complete organo-axial gastric volvulus with marked gastric distension obscuring the intact fundoplication.
The stomach was reduced through the retroesophageal window, restoring normal orientation; the fundoplication was taken down to assess viability. Intraoperative endoscopy identified a few superficial gastric ulcers distal to the angle of His without transmural necrosis. Indocyanine green fluorescence imaging revealed reduced perfusion in a few focal areas of the gastric body and near the angle of His; these were reinforced with interrupted imbricating sutures. Given the acute volvulus and recurrence risk, the fundoplication was not recreated; a posterior gastropexy was performed instead. Postoperative contrast study showed no leak or obstruction; recovery was uneventful, with diet advancement before discharge.
Discussion
Gastric volvulus is a rare but potentially life-threatening complication following Nissen fundoplication [1, 2]. Although fundoplication is well established for reflux disease and hiatal hernia, postoperative alterations in gastric anatomy and fixation may rarely predispose to abnormal rotation [1, 3]. The literature consists almost exclusively of isolated case reports [2–4]. Presentations range from intermittent obstructive symptoms to acute outlet obstruction, ischemia, necrosis, and perforation, underscoring the importance of early recognition and prompt intervention [3, 5, 6].
Our review of previously reported cases (Table 1) identified gastric volvulus after various anti-reflux and hiatal hernia repairs, with onset ranging from 2 months to 5 years postoperatively. Despite heterogeneous presentations, most patients required surgical intervention, with favorable outcomes when diagnosis was prompt and treatment preceded irreversible ischemia.
Review of reported cases of gastric volvulus following fundoplication.
| Study | Age/Sex | Index surgery | Presentation | Diagnosis | Interval | Operative findings | Predisposing factor | Management |
|---|---|---|---|---|---|---|---|---|
| Golash 2005 [1] | 23/M | Lap Nissen | Severe upper abdominal & chest pain, retching, distension | CT: 2 air–fluid levels; gastroscopy | 1 yr | Intrathoracic volvulus, adhesions, left crus rupture, caudate lobe herniation | Crus rupture, adhesions | Lap reduction, adhesiolysis, sac excision, redo Nissen + mesh, anterior gastropexy |
| Baty et al. 2002 [2] | 38/M | Lap Nissen | Acute abdominal pain, vomiting | EGD: early gastric ischemia | 8 mo | Volvulus from thick adhesion between xiphoid cannula site & hilus hepatis | Adhesions | Failed endoscopic detorsion → laparotomy & adhesiolysis |
| Vasconcelos et al. 2025 [3] | 53/F | Lap HH repair + Nissen | Pain, nausea, vomiting | CT: mesenteroaxial volvulus; EGD torsion | 1 yr | Near-complete mobilization of greater curvature; adhesion between wrap & right liver | Adhesions | Diagnostic lap → open reduction, adhesiolysis, anterior gastropexy |
| Albandar et al. 2025 [4] | 36/M | Lap HH repair + Nissen | Epigastric/LUQ pain, vomiting, obstipation | CT: intrathoracic stomach; organoaxial volvulus, pleural effusion | 3 yrs | Entire stomach migrated into chest; organoaxial volvulus; ischemic stomach | Diaphragmatic defect | Open gastrectomy + RYGB, defect repair, chest tube |
| Namata et al. 2024 [5] | 28/M | Lap Nissen | Severe epigastric pain, distension, inability to vomit | CT: pneumoperitoneum, dilated stomach | 10 mo | Organoaxial volvulus (180°), necrosis along greater curvature, perforation | Etibhond sutures as foreign body | Ex-lap, sleeve gastrectomy, anterior gastropexy |
| Gill et al. 2024 [6] | 74/F | HH repair + Nissen | Abdominal pain, nausea, vomiting | CT: volvulus; UGI: 90° rotation | 5 yrs | Herniation of gastric body under antrum/pylorus; mesenteroaxial volvulus under absent gastrohepatic ligament | Absent gastrohepatic ligament; over-mobilized greater curvature | Lap reduction, G-tube gastropexy, pyloric Botox injection |
| Savolainen et al. 2015 [7] | 60/F | HH repair | Vomiting, severe epigastric pain, nausea | CT: massive stomach, suspected volvulus | 4 mo | Volvulus without adhesions | Ligamentous laxity | Lap reduction → open hiatus repair & peritoneal fixation |
| Rajkumar et al. 2017 [8] | 43/M | Lap Nissen | Acute abdominal pain, retching | CT: organoaxial volvulus | 14 mo | Hiatal repair disruption; anterior adherent under gastrohepatic ligament gap | Adhesions | Lap hiatus repair, closure of pars flaccida gap, sham GJ |
| Chang et al. 2024 [9] | 75/F | RA Nissen | Acute abdominal pain, PO intolerance | CT: subdiaphragmatic volvulus; EGD ischemic foci | 6 mo | Torsed stomach; adhesions at fundoplication stitch–crus junction | Adhesions | Lap adhesiolysis, takedown, reduction, gastropexy |
| Reyes-Zamorano 2014 (Case 1) [10] | 29/F | Lap Nissen | Severe epigastric hematemesis, PO intolerance | EGD bleeding; UGI organoaxial volvulus | 4 mo | Organoaxial volvulus; fibrotic band from gastrocolic ligament to wrap; wrap fixed to right crus | Adhesions | Lap reduction, gastrorrhaphy, redo 270° wrap, gastropexy |
| Reyes-Zamorano 2014 (Case 2) [10] | 40/F | Lap Nissen | Severe epigastric distension, vomiting | UGI: mesenteroaxial volvulus | 6 mo | Mesenteric torsion; pylorus/antrum/omentum passed through wrap → trans-fundoplication hernia | Trans-fundoplication internal hernia | Lap detorsion, redo Nissen, closure of defect |
| Suwal et al. 2020 [11] | 57/F | Lap diaphragm repair + Nissen | Acute dysphagia, epigastric pain | CT: intrathoracic wrap migration; EGD tight wrap, mucosal ischemia | 7 mo | Incarcerated intrathoracic wrap with necrotic fundus | Intrathoracic wrap migration | Lap subtotal gastrectomy, mediastinal drainage, defect closure |
| Koh et al. 2011 [12] | 81/F | Lap fundoplication + mesh | Acute abdominal pain | CT: perforated mesenteroaxial volvulus | 2 mo | Perforated mesenteroaxial volvulus | Not specified | Laparotomy, gastrectomy |
| Chattopadhyay et al. 2011 [13] | 38/F | Lap Nissen | Upper abdominal persistent vomiting | EGD: paraesophageal hernia; CT: distended esophagus, displaced fundus | 3 mo | Cephalad internal herniation of anterior gastric body under attenuated wrap | Trans-fundoplication internal hernia | Lap reduction, Toupet fundoplication |
Mechanism of postoperative gastric volvulus
Pathogenesis is likely multifactorial, including postoperative adhesions, recurrent paraesophageal herniation, intrathoracic migration of the stomach or wrap, trans-fundoplication internal herniation, and laxity of gastric ligamentous attachments [1–4, 6–8]. Adhesions were the most frequently reported finding, creating fixed points around which the stomach rotated; recurrent herniation and intrathoracic migration were also common with organoaxial volvulus [2, 4, 6]. Increased gastric mobility after fundal mobilization and short gastric vessel division may diminish ligamentous restraint and, with acute distension as a precipitant, permit pathological rotation.
In the present case, complete retroesophageal organoaxial volvulus developed around an intact fundoplication without recurrent hernia, wrap disruption, or intrathoracic migration. We propose the intact wrap acted as a fixed fulcrum while increased gastric mobility and acute distension triggered volvulus.
Diagnosis
Diagnosis remains challenging because symptoms—nausea, vomiting, dysphagia, epigastric pain, distension, and oral intolerance—overlap with expected postoperative complaints, delaying recognition [2–4, 7]. Delay increases risk of ischemia, necrosis, perforation, and need for resection [5–7]. CT is the preferred initial modality, rapidly demonstrating abnormal gastric orientation, outlet obstruction, recurrent herniation, and features of ischemia [3, 4, 6]. Upper GI contrast studies complement CT by confirming obstruction or volvulus [3, 4, 6]. EGD adds value by excluding mechanical obstruction and assessing mucosal viability, but should not delay definitive imaging and surgery [9–11, 13].
Operative management
Treatment depends on acuity, anatomic abnormality, and gastric viability, generally involving reduction of the volvulus, correction of the defect, repair of recurrent hernia when present, and restoration of fixation via gastropexy, with or without wrap revision [1, 3, 4]. Delayed diagnosis or ischemia may necessitate gastrectomy [5–7]. In our case, the stomach remained viable, permitting successful laparoscopic reduction. The fundoplication was taken down to assess viability; since the wrap was intact with no recurrent hernia, redo fundoplication was deferred given concern for recurrent herniation. Posterior gastropexy was performed instead.
Gastropexy and clinical implications
Routine gastropexy is not recommended after Nissen fundoplication for uncomplicated reflux disease, since the wrap provides fixation and postoperative volvulus is exceedingly rare [2]. It is reserved for high-risk scenarios—large paraesophageal hernia repair, recurrent or concurrent volvulus, and unfavorable anatomy such as >30% gastric herniation or a crural defect >4 cm [14]. A recent review similarly concluded gastropexy should be used selectively, not routinely, in most paraesophageal hernia repairs [15].
Conclusion
Gastric volvulus following Nissen fundoplication is a rare but potentially life-threatening complication requiring a high index of suspicion, as its presentation often mimics expected postoperative symptoms. Prompt diagnosis with CT and timely surgical intervention are essential to prevent ischemia, necrosis, and other complications. This case highlights a unique mechanism of retroesophageal organoaxial volvulus around an intact fundoplication, demonstrating that early recognition and appropriate management yield excellent outcomes.
Acknowledgements
No financial or non-financial support was received for this work.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Funding
This study received no external funding.
Ethical approval
Ethical approval was not required for this case report in accordance with institutional policy.
Consent
Written informed consent for publication of this case report.
Guarantor
Nishchal Bogati is the guarantor of this manuscript.
