Acute Gastric Volvulus Associated with Wandering Spleen and Diaphragmatic Eventration in a 5-month-old Girl

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BSTRACT

The triad of gastric volvulus (GV), wandering spleen (WS), and diaphragmatic eventration (DE) is extremely uncommon and only two cases have been reported in the current pediatric literature. In this paper, we aim to describe the diagnostic and surgical management of a 5-month-old baby with this pathological triad and to present the other cases reported in pediatric literature. A 5-month-old baby was referred to our hospital because of vomiting and inconsolable crying from 12 h. The X-ray study demonstrated a severely distended stomach and a left diaphragmatic elevation. Swallow fluoroscopy revealed no passing contrast in duodenum and abdomen ultrasound showed splenic malposition. Computed tomography scan confirmed GV and WS. The patient underwent an urgent laparoscopy that revealed ischemia of the gastric antrum, thrombosis of the right gastroepiploic vein, and eventration of the left hemidiaphragm. After laparotomic conversion due to hemodynamic instability, derotation of the stomach allowed appreciation of splenic 360° twisting within the diaphragmatic defect. The spleen was untwisted, placed in a fashioned retroperitoneal pocket, and covered with the splenocolic ligament. The stomach was anchored to the large omentum and the diaphragm was plicated. Our case is the first one describing this pathological triad in such a little infant. This association is probably the result of a developmental defect of left upper abdomen ligaments and must be considered a cause of upper gastrointestinal obstruction. In case of diaphragmatic defects, if gastric malposition or ectopic spleen are identified, we suggest early diaphragmatic plication, prophylactic gastropexy, and splenopexy to prevent GV and WS torsion, which can lead to gastric necrosis with perforation and splenic infarction. Although laparoscopy may be useful, operative laparotomy is necessary in case of hemodynamic instability.