Endoscopic gastropexy with transabdominal suturing for gastric volvulus. Gastric volvulus is rare and can present as acute or chronic volvulus, with 70% of acute cases presenting with Brochard's triad, consisting of severe, sudden epigastric pain, intractable retching without vomiting, and an inability to pass a nasogastric tube. The majority of cases occur secondary to diaphragmatic hernias, predominantly paraesophageal hernias, where the diaphragm serves as a fulcrum for torsion. Endoscopically, volvulus secondary to paraesophageal herniation can be seen with the skull passing through the GE junction, with the red arrow pointing to the orifice of the twisted gastric body within the paraesophageal hernia, with food proximally in the fundus. The most feared complication is ischemia, which is an indication for gastrectomy. If there is no ischemia, or the patient has chronic symptomatic volvulus, then the operative risk is evaluated, and in high-risk cases, endoscopic gastropexy can be offered. Endoscopic gastropexy comprises of the placement of two gastrostomy tubes at separate sites to prevent creating a fulcrum on which a recurrent volvulus can occur. Endoscopic transabdominal wall suturing has been described in literature since 2002 for closing refractory gastrocutaneous fistulas. Here, we propose a novel use of endoscopic transabdominal wall suturing for gastric volvulus, where rather than using pegs for gastropexy, sutures are placed across the abdominal wall using angiocatheters, sutures, and cholangioscopy forceps. We present a case of a 50-year-old male with a past medical history of a rare muscular dystrophy, pulmonary fibrosis, and restrictive lung disease who had 1.5 months of intermittent nausea, vomiting, severe abdominal pain, and torsion of his stomach, which he would manually untwist with his hands. His imaging was consistent with recurrent gastric volvulus. On exam, he was bedbound, contracted with diffuse muscle wasting with a scaphoid abdomen. Given his comorbidities, he was deemed a poor surgical candidate and was referred for endoscopic management of his chronic gastric volvulus. Our patient only agreed to one peg placement. Thus, we offered him endoscopic transabdominal suturing as the second point of gastropexy. First, a 20 French gastrostomy tube is placed along the rater curvature of the stomach. Adjacent to this, a 14-gauge angiocatheter is advanced into the gastric body. Cholangioscopy forceps loaded with 2.0-micro sutures are advanced through the angiocatheter. Hot biopsy forceps are used to grasp the suture. Lateral to this, a second angiocatheter is inserted, and cholangioscopy forceps are advanced through the angiocatheter, and the suture is exchanged from the hot biopsy forceps to the cholangioscopy forceps. This suture is reinforced with a 2.0-silk suture in a similar fashion, and then both angiocatheters are removed from the gastric body. Internally, the two points of gastropexy look like this, and externally, the two points are seen here. For two years, the patient did well without recurrent gastric volvulus and tolerated oral intake without nausea or vomiting. However, he had ongoing peg site discomfort and wanted the peg removed. Therefore, we offered him peg removal with repeat trans-abdominal suturing for gastropexy reinforcement and fistula closure. The previously placed gastrostomy tube is seen here. The tube was cut externally and removed with a snare in order to minimize trauma to the fistula. Adjacent to the fistula, the stomach was trans-illuminated, and a 14-gauge angiocatheter was inserted. On the opposite side of the fistula, a second angiocatheter was inserted. Through the first angiocatheter, 2.0-vicral sutures were advanced and grasped with hot biopsy forceps. Chalangioscopy forceps were used through the second angiocatheter to grasp the suture and pull it through the abdominal wall. Then both angiocatheters were removed in order to lay the first set of sutures. In a similar fashion, a second set of sutures were laid perpendicular to the first set of sutures. The sutures were tied externally, and the final appearance of the gastropexy can be seen here. In our case, we showed that this technique is low-cost and effective. This technique has potential to benefit patients such that surgery and laparoscopic suturing for gastropexy can be avoided. Additionally, patients can be more comfortable without multiple gastrostomy tubes. To conclude, two-point endoscopic gastropexy with transabdominal sutures can be offered for non-ischemic gastric volvulus patients with high operative risk. Further studies are needed to evaluate the durability of this technique.

Endoscopic gastropexy

transabdominal suturing

gastric volvulus

abdominal wall sutures

recurrence prevention