Gastric infarction secondary to small bowel obstruction: A preventable complication after Nissen fundoplication

doi:10.1016/S0022-3468(87)80595-X

Journal of Pediatric Surgery

Volume 22, Issue 10, October 1987, Pages 941-943

https://doi.org/10.1016/S0022-3468(87)80595-X Get rights and content

Two infants who required a Nissen fundoplication for severe gastroesophageal reflux developed small bowel obstruction 5 and 21 months postoperatively. Their inability to belch or vomit, coupled with inappropriate airway management during resuscitation led to massive gastric dilation, and eventual infarction of their stomach, duodenum, and small intestines. These complications are preventable with appropriate management.

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Cited by (24)

Partial gastrectomy for stomach necrosis in a 13-year-old child four years after Nissen fundoplication
2022, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
In a second phase, a feeding jejunostomy and a controlled fistulation were performed at different occasions before a reconstruction by esophagojejunal anastomosis [9]. Two cases of gastric ischemia on occlusive syndrome on tissue adhesions, probably aggravated by the gas bloat syndrome and the inability to vomit, have also been described with early death of the patients [6]. In the literature, in adults, the recommended management is a total gastrectomy with esophagojejunostomy in one stage [3,5], more or less associated with feeding jejunostomies [4], or in two stages [7].
NISSEN fundoplication is a common procedure for the management of gastroesophageal reflux disease. It can have the side effect of a "gas bloat syndrome", an accumulation of air responsible for functional symptoms and gastric distension. Gastric necrosis due to gastric distension is a rare event, but with a high mortality rate in case of delayed diagnosis.
We describe the surgical management of a partial necrosis of the stomach in a 13-year-old boy with mental retardation. Exploratory laparotomy revealed extensive gastric necrosis without perforation. We performed a partial gastrectomy, without removal of the NISSEN, with reinstatement of gastrostomy, drainage and antibiotic therapy. A posterosuperior gastric fistula appeared in following, leading us to perform a feeding jejunostomy.
After three months, the patient was able to return home, fed on the jejunostomy.
This is the first pediatric case of partial necrosis of the stomach in the aftermath of a NISSEN, managed by partial gastrectomy. In case of suspected gastric necrosis, an emergency laparotomy associated with a digestive resection procedure seems to be the most indicated. Our case proves that even in case of extensive necrosis, a partial gastrectomy more or less associated with a controlled fistulation can be attempted.
Does retching matter? Reviewing the evidence—Physiology and forces
2019, Journal of Pediatric Surgery
Citation Excerpt :
At the severe end of the spectrum, gastric dilatation owing to severe gas-bloat or obstruction does not generate pressures that cause a wrap to separate. Instead, in both adults and children who develop intestinal obstruction postfundoplication and who are unable to expel vomit, the development of acute gastric dilatation, with relatively modest but sustained intragastric pressure rises of only 20–30 cmH2O, leads to venous congestion and ischemia of the gastric wall [38] with consequent necrosis and perforation while the wrap remains intact [39,40]. In contrast, there is a growing body of evidence that diaphragmatic stressors and an increased abdominothoracic pressure gradient do lead to wrap failure.
Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure.
Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking.
Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown.
Retching needs to be addressed if we are to reduce the incidence of wrap failure.
Level of Evidence V.
Diseases of the Pediatric Stomach and Duodenum
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth Edition
An autopsy case of sudden death due to acute gastric dilatation without rupture
2008, Forensic Science International
Citation Excerpt :
Alcohol level was 0.01% in heart blood. Severe dilatation of the stomach accompanied by gastric necrosis has been reported in patients who cannot belch or vomit after a Nissen fundoplication and as a complication of pyloric stenosis causing altered gastric emptying [31,32]. Acute gastric dilatation with infarction is recognized complication of trauma [33].
We report the first autopsy case of fatal gastric dilatation without rupture. A 31-year-old woman who lived alone was found dead in her living room. Despite being very thin, she showed marked abdominal distention. Autopsy and histological findings revealed that a severely distended stomach, of which walls notably thin and displayed transmural necrosis, occupied the entire abdominal cavity. Severe congestion was observed in the intestine and cecum. Theses findings suggest that bulimia nervosa together with anorexia nervosa resulted in rapid dilation of the stomach. We conclude that the cause of death was acute circulatory failure from hypovolemic shock that occurred following compression of the inferior vena cava and superior mesenteric vein, and by loss of circulatory volume to the third space.
Diseases of the Pediatric Stomach and Duodenum
2007, Textbook of Gastrointestinal Radiology
Gastric necrosis associated with acute gastric dilatation and small bowel obstruction
2003, Gynecologic Oncology
While acute gastric dilation is a postoperative complication familiar to most surgeons, massive dilatation with necrosis and rupture is a very rare event. We performed a computer search in the MEDLINE database for the years 1966–2001 for articles published in any language using the key words gastric dilation, gastric necrosis, intestinal obstruction, and gynecologic surgery. Our search yielded no reports of massive gastric dilation and ischemic necrosis from a small bowel obstruction following gynecologic surgery.
A 76-year-old woman developed massive gastric dilatation with ischemic necrosis associated with small bowel obstruction following gynecologic surgery for benign disease.
Gynecologists should be aware of the entity. Early diagnosis and treatment are essential to minimize morbidity and mortality.

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¹: From the Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, and Pediatric Surgical Associates, Jacksonville, FL.

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Gastric infarction secondary to small bowel obstruction: A preventable complication after Nissen fundoplication

Am J Surg

J Thorac Cardiovasc Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Thorac Cardiovasc Surg

Complications in surgery of the esophagus

Fundoplication for reflux esophagitis: Misadventures with the operation of choice

Ann Surg