Ann Thorac Surg 2006;81:1134-1136
© 2006 The Society of Thoracic Surgeons
Case report
Retrograde Gastric Intussusception After Myotomy for Achalasia
Michael B. Ujiki, MD
a
,
Ikuo Hirano, MD
b
,
Matthew G. Blum, MD
a
,
*
a Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
b Department of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Accepted for publication February 9, 2005.
* Address correspondence to Dr Blum, Galter 10-105, 201 E Huron St, Chicago, IL 60611 (Email: mblum{at}nmh.org).
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Abstract
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Retrograde gastroesophageal intussusception has been rarely reported in the literature. Risk factors include poor fixation of the stomach due to either long or loose mesenteric attachments; high intraabdominal pressure due to retching, physical exertion, or ascites; and hiatal hernia, which can lead to the development of a large gastroesophageal opening. An attempt at endoscopic reduction is reasonable, but laparotomy and manual reduction is usually required. We report a case of retrograde gastroesophageal intussusception in a patient with long-standing achalasia and two previous Heller myotomies.
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Introduction
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Retrograde gastroesophageal intussusception, in which a portion of the stomach invaginates into the esophagus, has been rarely reported in the literature. It is difficult to obtain a true number of the cases since it is often confused with retrograde prolapse, a more common entity. Gastroesophageal intussusception involves all layers of the stomach (ie, mucosa, muscularis, and serosa), whereas retrograde prolapse typically involves only the slipping of gastric mucosa into the esophagus [1] (Fig 1). We report a case of retrograde gastroesophageal intussusception in a patient with long-standing achalasia and two previous Heller myotomies.
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Fig 1. (A) Normal gastroesophageal junction. (B) Retrograde prolapse of the gastric mucosa. (C) Retrograde intussusception involving all layers (mucosa, muscularis, and serosa).
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A 58-year-old woman with a history of myotomy for achalasia and chronic intermittent upper abdominal pain and nausea presented with a sudden onset of chest discomfort, epigastric fullness, drooling, and intractable retching. She had undergone a transthoracic Heller myotomy at age 28. At age 55 she underwent a second (laparoscopic) myotomy with Dor fundoplication. She was known to have a dilated esophagus and was undergoing outpatient evaluation for chronic nausea and slow gastric emptying. A computerized tomographic scan revealed a "target" filling defect within the distal esophagus consistent with retrograde gastroesophageal intussusception (Fig 2).
She was taken to the operating room for endoscopic reduction or exploration, or both. Flexible esophagoscopy showed an obstructing soft tissue mass in the distal esophagus (Fig 3). Air insufflation and gentle pressure did not reduce the mass. A laparotomy was performed. An intraluminal mass could be palpated extending from the proximal stomach into a patulous distal esophagus. Attempts at extraluminal reduction were unsuccessful, so a gastrotomy was performed at the corpus of the stomach. A 5-cm cigar-shaped, edematous portion of the body of the stomach was reduced. After reduction, the fundus was free and floppy with the exception of a small amount of fundus that remained tacked anteriorly from the previous Dor fundoplication. The mucosa appeared viable. A Stamm gastrostomy was performed to prevent recurrence. The patient did well and went home on postoperative day 5 without complication. At 1-year follow-up, some of her nausea had improved without recurrent intussusception.
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Fig 3. Endoscopic picture of retrograde intussusception (left). After gastrotomy the intussuscepted mass that consisted of an edematous portion of the stomach body was reduced manually (right).
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Comment
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Even though retrograde gastroesophageal intussusception is uncommon and rarely reported, each case has contributed to our understanding of its pathophysiology. One predisposing factor involves increased gastric mobility due to laxity or absence of gastrophrenic, gastrohepatic, gastrosplenic, gastrocolic, and omental attachments. Our patient had release of her gastrocolic and gastrosplenic ligaments at the time of her laparoscopic myotomy and fundoplication. One of the first descriptions of gastroesophageal intussusception was made at postmortem examination during which the patient was noted to have long mesenteric attachments [2]. Long omental attachments and an elongated gastrosplenic ligament were reported in a patient who had retrograde gastroesophageal intussusception after a transthoracic esophageal myotomy [3]. During operative reduction in a child who intussuscepted after a Nissen fundoplication, Post and colleagues [4] reported excessively long gastrocolic and gastrosplenic attachments. More recently, David and Barkin [5] postulated that the omentectomy his patient underwent for ovarian cancer was one of three causative factors when she intussuscepted.
Most patients precede an episode of gastroesophageal intussusception or retrograde prolapse with multiple episodes of vomiting or violent retching. Patients with severe vomiting or retching that are at risk for gastroesophageal prolapse or intussusception include those with bowel obstruction, eating disorders, and pregnancy [6]. Even physical exertion such as weight lifting, football, and bike racing is a risk factor, because, as with retching, it causes a sudden sustained increase in intraabdominal pressure [6].
Hiatal hernia is frequently associated with gastroesophageal intussusception [5]. Kerr [1] performed an esophagoscopy while increasing abdominal pressure by abdominal compression on his subjects. He found that 92% of patients with inducible prolapse or intussusception have an associated hiatal hernia. A lax phrenoesophageal ligament, often found in hiatal hernias, allows the gastroesophageal junction to be elevated above the diaphragm. The subsequent lack of external support around the gastroesophageal junction may result in dilatation of the gastroesophageal opening. This large opening is a predisposing factor for either prolapse or intussusception.
Patients who are treated for achalasia have the potential to have a large gastroesophageal opening develop secondary to either pneumatic dilatation or surgical myotomy. However, in reviewing the literature we found only three cases similar to this reported case [3, 7–8]. Our patient had multiple risk factors for intussusception, including dilatation of the esophagus, gastroesophageal junction, and diaphragmatic hiatus, as well as a lack of gastric attachments and retching. We treated our patient in a fashion similar to Vanker and colleagues [3] through laparotomy, reduction, and intraabdominal fixation.
Retrograde gastroesophageal intussusception may be difficult to differentiate from unreduced gastroesophageal prolapse because endoscopically both appear as an intraesophageal protrusion of gastric mucosa. Transient prolapse occurs frequently and does not require intervention. Patients with edematous unreduced mucosal prolapse or intussusception should be prepared for operative intervention, as endoscopic reduction is unlikely to be effective. The few reported cases suggest that gastric fixation with a gastrostomy is adequate. Intussusception may be one reason for intermittent nausea and abdominal pain in patients with predisposing anatomy. If diagnosed in a non-emergent setting, it may be reasonable to consider gastric fixation with elective gastrostomy.
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Acknowledgments
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We acknowledge the illustrations by Dr Mark Sisco.
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References
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- Kerr R. Mucosal prolapse and gastroesophageal intussusceptionIn: Castell D, editor. The esophagus. 2nd ed.. New York, NY: Little Brown & Co; 1997. pp. 737-755.
- Lannon J, Culiner A. Retrograde intussusception of lesser curvature of stomach, pylorus, and first part of the duodenum into the oesophagus Br J Surg 1946;33:392-394.
- Vanker EA, Crause L, Mohlala ML. Retrograde gastro-oesophageal intussusception complicating oesophageal myotomy S Afr Med J 1987;72:890.[Medline]
- Post PJ, Robben SG, Meradji M. Gastro-oesophageal intussusception after Nissen-fundoplication Pediatr Radiol 1990;20:282.[Medline]
- David S, Barkin JS. Retrograde gastroesophageal intussusception Am J Gastroenterol 1992;87:132-134.[Medline]
- Gowen G, Stoldt HS, Rosato FE. Five risk factors identify patients with gastroesophageal intussusception Arch Surg 1999;134:1394-1397.[Abstract/Free Full Text]
- Palmer E. Mucosal prolapse of esophago-gastric junction Am J Gastroenterol 1955;23:530-537.[Medline]
- Wong MD, Davidson SB, Ledgerwood AM, Lucas CE. Retrograde gastroesophageal intussusception complicating chronic achalasia Arch Surg 1995;130:1009-1010.[Abstract]
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Abstract
Introduction
