Serious gastrointestinal diseases, such as intestinal perforation and intestinal torsion (including gastric and splenic volvulus), prior to diaphragmatic repair have been reported in several cases of CDH , and they cause catastrophic conditions . However, in the present case, unexpected postoperative gastric and splenic volvulus were observed. Furthermore, even after the gastric and splenic volvulus were surgically detorted, the gastric volvulus recurred and required gastropexy.
The stomach is firmly held in place by the gastric ligament, esophageal hiatus, and retroperitoneal fixation of the duodenum. Gastric volvulus is defined as abdominal rotation of all or part of the stomach around one of its axes due to abnormalities, such as inadequate attachment or elongation of the gastric ligament . In organo-axial gastric volvulus, which is the most common type and was observed in our case, the stomach rotates on its long axis, and the large curvature lies anteriorly. Gastric volvulus may occasionally occur acutely in older children, whereas chronic cases may be more common in neonates and infants . In chronic cases in infancy, it has been noted that gastric volvulus can be released by repositioning or decompression of the stomach. Conservative treatment is often used, but some reports recommend early surgery in recurrent cases , and the treatment of chronic gastric volvulus depends on the symptoms [9, 10].
A wandering spleen is a rare disorder in which the ligamentous attachment to the stomach and the posterior abdominal wall is absent or weak, resulting in an abnormal spleen position . Associated complications, such as splenic infarction, gastric volvulus, and intestinal obstruction, have been reported [2, 12]. The creation of a retroperitoneal pocket for splenopexy is considered useful for treatment. Although gastric and splenic volvulus each are rare malformations, multiple studies have shown that they often occur simultaneously because the stomach and spleen are in close proximity and share a few common ligaments.
Intrathoracic gastric and splenic volvulus have occasionally been reported in association with diaphragmatic hernia [1, 13]. Once the stomach or spleen has herniated into the thoracic cavity, the surrounding ligaments attached to them may be absent or lax, increasing the range of motion of the organs and causing volvulus [14, 15].
However, intra-abdominal volvulus of the stomach or spleen after diaphragmatic hernia repair is very rare [2,3,4,5]. In our case, it was unclear whether gastric volvulus occurred first, resulting in subsequent splenic volvulus or vice versa. At the time of CDH repair, as discussed in the case presentation, tight direct closure of the diaphragm reduced the space for the normal placement of the spleen and stomach beneath the left diaphragm. The spleen was placed in the left upper abdomen and the stomach was placed medially, but each organ appeared to deviate from its normal anatomical position. We presumed that the reduced space induced the rare complications of splenic torsion and gastric volvulus, which caused gastric obstruction immediately after diaphragmatic closure.
On the first re-opening of the abdomen, 180° volvulus of the spleen was also observed. The gastric volvulus could be resolved once splenic volvulus was detorted. The retroperitoneum was vulnerable; therefore, only splenic detorsion, without splenopexy or gastropexy, was performed. When the gastric volvulus recurred for the second time, there was no abnormality in the spleen. However, the stomach adhered to the surrounding tissues, which was thought to inhibit spontaneous resolution, and gastropexy was required. Considering the clinical course of this case, at the initial surgery patch closure to make the dome of the diaphragm, rather than tight direct closure, may have been a better choice, or gastropexy should have been performed at an earlier stage.