Mimatsu K.a · Kano H.a · Oida T.a · Kawasaki A.a · Fukino N.a · Kida K.a · Kuboi Y.a · Amano S.b

Author affiliations
aDepartment of Surgery, social Insurance Yokohama central Hospital, Yokohama, and bDepartment the Breast and Endocrine Surgery, Nihon University college of Medicine, Tokyo, Japan
Kenji Mimatsu

Department the Surgery, social Insurance Yokohama central Hospital

268 Yamashita-cho, Naka-ku, Yokohama, Kanagawa, 231-8553 (Japan)

E-Mail mimatsu.kenji

Abstract

We report the rare situation of an elderly patient v an progressed gastric cancer emerging from an upside-down stomach through a paraesophageal hiatal hernia (PEH). One 82-year-old man presented v appetite loss and also anemia. Top gastrointestinal endoscopy revealed a kind 1 tumor located in the middle body of the stomach. An upper gastrointestinal series and computed tomography verified organoaxial rotation the the stomach, i beg your pardon was situated in the mediastinum, with a PEH, describe an upside-down stomach. The preoperative diagnosis was gastric cancer emerging from one upside-down stomach through a PEH. The patient underwent full gastrectomy through lymph node dissection and also closure that the hernial orifice. Back a big PEH is a chronic disorder, gastric malignancies should be considered in patients v PEH manifested as an upside-down stomach as result of its anatomical characteristics, and careful preoperative diagnosis is mandatory.

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Introduction

Paraesophageal hiatal hernia (PEH) is a problem in which intra-abdominal organs herniate right into the thoracic space through the esophageal hiatus. It is the many common kind of diaphragmatic hernia. Back the an exact sequence of events leading to PEH development is not totally understood, the is most likely that the procedure involves steady weakening and also stretching the the phrenoesophageal membrane together with weakening and also enlargement of the diaphragmatic hiatus. PEH most frequently affects infants and also the elderly. In infancy, congenital defects trigger this disease, whereas in adults, weakening of the supportive organization of the reduced esophagus or high ab pressure connected with a humpback and also obesity may reason this event. Since their an initial description in 1926 by Akerlund <1>, translocations of the stomach along its lengthy axis with the esophageal diaphragmatic hiatus have actually been share into 4 types: sliding (type I), paraesophageal (type II), mixed-form (type III) and also upside-down stomach (type IV) hiatal diaphragmatic hernia. Upside-down stomach is just one of the significant forms the PEH classified by Bettex and also Kuffer <2>, and it explains a problem wherein a big part of the stomach is migrated into the thoracic space accompanied through gastric organoaxial rotation. A PEH incarcerated with an intrathoracic gastric volvulus is common; however, an upside-down stomach is a rare kind of PEH. Gastric cancer is often complex by PEH; however, advanced gastric cancer developing from one upside-down stomach linked with PEH is exceptionally rare <3,4>. This report describes the instance of one elderly patient with an progressed gastric cancer arising from an upside-down stomach with a PEH; in addition, we existing a short review the the relevant literature.

Case Report

An 82-year-old man was admitted come our hospital since of appetite loss and anemia. His medical history included chronic obstructive pulmonary disease and dementia. On physics examination, he was 150 centimeter tall and weighed 45 kg. His abdomen was soft and flat and also showed no palpable masses. Activities tests revealed hypohemoglobinemia (Hb 7.5 g/dl) and also hypoproteinemia (albumin 2.5 g/dl); all various other results were normal. Top gastrointestinal endoscopy proved a kind 1 hemorrhagic tumor situated in the center body the the stomach, although observation of the entire stomach was impossible since of extreme transformation. An top gastrointestinal series showed organoaxial rotation that the human body of the stomach with the whole stomach located in the mediastinum, i m sorry is indicative the upside-down stomach. The tumor was existing in the upside-down stomach with a PEH (fig. 1a). Pathological analysis of biopsy specimens revealed moderately differentiated tubular adenocarcinoma. Coronal computed tomography images showed an organoaxial gastric volvulus and sliding up with a PEH (fig. 1b). A gastric tumor to be detected in the upside-down stomach through the PEH and also lymph node metastases were observed surrounding the stomach; however, liver metastases and also peritoneal dissemination were not observed. Preoperative staging follow to the TNM group of gastric cancer was T3N2M0, phase IIIA. On the basis of the preoperative diagnosis that gastric cancer occurring from one upside-down stomach v a PEH, the patience underwent operation treatment.


a
upper esophagogastric series. The body of the stomach to be located above the fundus, situated on the cephalic side, showing organoaxial rotation, and also the entire stomach was situated in the mediastinum, which indicated upside-down stomach. The gastric tumor (arrows) was discovered in the top body that the stomach. b Coronal computed tomography pictures revealed the the whole stomach (arrows) was herniated into the mediastinum with the esophageal diaphragmatic hiatus.


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Surgery to be performed via a typical laparotomy incision. The entire stomach was uncovered to be herniated with the big dilated hiatus right into the left thorax along with the better omentum (fig. 2a). The hernial orifice was approximately 5 centimeter in diameter (fig. 2b). After ~ the incarcerated stomach had been untwisted and also reduced earlier into the abdomen, the tumor was found to be located in the center body of the stomach; however, the short esophagus to be not found in the state of esophagus. After palliation of the abdominal muscle contents native the thoracic cavity, a total gastrectomy v a Roux-en-Y reconstruction and dissection that the lymph nodes neighboring the stomach was performed. The crura that the diaphragm were approximated through interrupted nonabsorbable sutures for closure that the hernial orifice. The jejunum just under the anastomosis to be sutured come the crus to permanently deal with the esophagojejunal anastomosis in an abdominal position (fig. 2c). In factor to consider of the patient"s age and also preoperative performance status, a jejunostomy was constructed as a course of enteral nutrition after ~ surgery.


Operative findings. a The entire stomach was found to it is in herniated through the enormously dilated hiatus right into the left thorax along with the better omentum. b The hernial orifice was uncovered to be approximately 5 centimeter in diameter ~ the incarcerated stomach had been reduced earlier into the abdomen. c The crura of the diaphragm to be closed and the jejunum just under the anastomosis was sutured come the crus come permanently deal with the esophagojejunal anastomosis in an abdominal muscle position.


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The resected specimen revealed a kind 1 hemorrhagic tumor measuring roughly 7.7 × 7.4 centimeter (fig. 3). Histopathological check revealed a moderate tubular adenocarcinoma with vascular invasion and also metastasis in 3 lymph nodes bordering the stomach, and the last clinical stage was IIIA (T3N2M0) follow to the TNM classification.


Macroscopic finding proved a form 1 big tumor in ~ the tiny curvature in the middle and upper body of the stomach.


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The postoperative course to be uneventful. Roentgenography showed good passage there is no leakage that the anastomosis, and oral intake was initiated top top postoperative work 7, although no increase in food intake was achieved. Therefore, the energy deficit was sustained by enteral nutrition with the jejunostomy. The patient to be discharged 35 days after surgery, and there to be no recurrence the cancer or hernia throughout 1-year follow-up.

Discussion

Although gastric cancer complicated by PEH is common, gastric cancer presenting in an upside-down stomach with the PEH is an extremely rare condition, and only 13 such instances have been formerly reported <3,4,5,6,7,8,9,10,11,12,13,14,15>. Among these cases, including the current one (table 1), the median patient age was 78.9 years and a greater incidence was found among women (male:female ratio = 3:11). The chief complaints were abdominal symptoms such as nausea and also vomiting, and also epigastralgia and thoracic symptoms such as heartburn, dyspnea and also palpitations, which were not regarded as particular clinical symptom in this pathological condition. The beforehand detection of gastric cancer may be delayed since the symptom of gastric cancer, consisting of epigastric pain, nausea and weight loss, may be hidden by a huge PEH <14>. Gastric cancer arising through an upside-down stomach through a PEH often tends to be advanced (advanced type:early type = 76.9:23.1%), and 46.1% of patients show stage III and IV tumors. The tumor often tends to it is in relatively big (mean diameter 69.8 mm) at the time of early stage diagnosis, as testimonial is frequently delayed since the symptoms are thought come arise native the coexisting big PEH. On histopathology, 42.8% of together patients have moderately distinguished adenocarcinoma, 35.7% have actually poorly identified adenocarcinoma and 7.1% have well-differentiated adenocarcinoma, signet ring cabinet carcinoma or large-cell neuroendocrine carcinoma. The surgical treatment is composed of relocation the the herniated stomach, conventional treatments because that gastric cancer according to the phase of cancer progression and repair that the hernial orifice. Amongst the 14 reported patients, including the current one, 7 underwent total gastrectomy, 5 underwent distal gastrectomy, 1 underwent proximal gastrectomy and also 1 was administered chemotherapy. The average diameter the the hiatus to be 64.1 mm. Closure the the hernial orifice was performed in 12 cases among the 13 situations treated surgically. Anastomotic leakage arisen in 1 instance each that total and proximal gastrectomy. Anastomotic dehiscence may have actually resulted native the readjust in negative and confident pressures brought about by breathing after closure the the hernial orifice, i beg your pardon may influence the anastomotic site <12>. However, whether closure the the hernial orifice affect anastomotic dehiscence is unclear since anastomotic leakage arisen in 1 patient who underwent hernial orifice closure and also in 1 patient in whom it was not closed <4>.


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The relationship between PEH and also gastric cancer remains controversial. Chronic reflux, additionally known together gastroesophageal reflux disease, is arising as among the the strongest risk factors for adenocarcinoma of the esophagus and also gastric cardia <16>. MacDonald and MacDonald <17> reported the patients with such cancers present a high prevalence of coexisting PEH. Chow et al. <18> reported a far-reaching two-fold or higher risk the adenocarcinoma the the esophageal and also gastric cardia linked with a background of sensible reflux of gastric juice into the esophagus, hiatal hernia, esophagitis, esophageal ulcer and dysphagia. Lagergren et al. <19> additionally evaluated the association between weekly reflux frequency and risk that adenocarcinoma the the esophagus in a swedish study. Reflux symptoms arising much more than three times per week were connected with one odds proportion of 16.7 (95% trust interval 8.7-28.3) compared with the absence of reflux symptoms. Gastroesophageal reflux was only weakly associated with hazard of adenocarcinoma of the gastric cardia (odds proportion 2.3, 95% confidence interval 1.2-4.3; >3 times/week vs. None). Moreover, Wu et al. <20> reported a relationship between hiatal hernia with symptoms the gastric juice reflux and carcinomas of the esophageal and also gastric cardia. The physicochemical stimulation that gastric juice reflux as result of reflux esophagitis is an important factor in the breakthrough of carcinoma; however, there is no straight evidence because that such a relationship in between gastric carcinogenesis and PEH <21>. Therefore, several studies said that constant follow-up examinations by top gastrointestinal endoscopy are crucial in patients v PEH to evaluate the possible occurrence that gastroesophageal malignancies <3,4,8,12>.

In conclusion, back PEH is a common chronic disorder, an upside-down stomach is a rare kind of PEH. Moreover, gastric cancer occurring from one upside-down stomach through a PEH is exceptionally rare. Early detection of gastric cancer might be delayed because the symptoms of gastric cancer are covert by large PEH, and also precise diagnosis of gastric cancer and also observation of the whole stomach utilizing endoscopy might be impossible since of too much gastric transformation. We should take into consideration gastric malignancies in patients v a PEH and perform mindful regular follow-up examinations by top gastrointestinal endoscopy.

Disclosure Statement

There are no jae won or various other relations that could lead to a conflict of interest.

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Akerlund A: Hernia diafragmatica hiatus oesophagei vom anatomischen und röntgenologischen Gesichts-punkt. Acta Radiol 1926;6:3-22.
Bettex M, Kuffer F: long-term results the fundoplication in hiatus hernia and also cardio-esophageal chalasia in infants and children. Report that 112 continually cases. J Pediatr Surg 1969;4:526-530.
Iso Y, Tagaya N, Nemoto T, Kita J, Sawada T, Kubota K: Incarceration of a huge cell neuroendocrine carcinoma occurring from the proximal stomach through an organoaxial gastric volvulus through an esophageal hiatal hernia: report the a case. Surg now 2009;39:148-152.
Kominami H, Kawasaki K, Tanaka K, Kaneji S, Fujino Y, Tominaga M: A instance of advanced gastric cancer through hiatal hernia linked with the upside down stomach (in Japanese through English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2012;73:3129-3134.
Izumi Y, Tsuchiya K, Maeda H, Mukubou M, Asahara M, Sakaguchi T: A situation of gastric cancer complex with esophageal hiatal hernia through upside-down stomach (in Japanese). Gekashinryo 1993;9:1181-1185.
Narayan D, Soybes D, Salem RR: Pyloric carcinoma presenting together intrathoracic volvulus. J Clin Gastroenterol 1994;18:260-261.
Sato K, Midorikawa Y, Kamiga M, Kumbota Y: A case of gastric cancer linked with esophageal hiatus hernia presenting through upside down stomach (in Japanese). Nihon Shokakibyo Gakkaizasshi 1996;93:26-29.
Matsuda M, Aikawa T, Sekikawa T, Karikomi K, Iizuka H, Fujii H, et al: progressed gastric carcinoma within ‘upside-down-stomach" because of mixed esophageal hiatal hernia - report the a case (in Japanese through English abstract). Nihon Syokakigeka Gakkaizasshi (Jpn J Gastroenterol Surg) 1997;30:994-998.
Seshimo T, Ito M, Monden K, Mizukami T: A instance of advanced gastric cancer within sliding hiatal hernia linked with organoaxial gastric volvulus (in Japanese with English abstract). Nihon Syokakigeka Gakkaizasshi (Jpn J Gastroenterol Surg) 1999;32:2243-2247.
Kawai S, Matsuura Y, Kouno H, Kitagawa Y, Yamanaka H, Hiramatsu K: A situation of quadruple gastric cancer within upside under stomach as result of esophageal hiatal hernia (in Japanese through English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2001;62:376-380.
Horiba K, Yamashita K, Tanaka N, Kyono S, Yokoi K, Higuchi K, et al: A case of gastric cancer connected with esophageal hiatus hernia presenting horizontal torsion the the stomach (in Japanese with English abstract). Prog Digest Endosc 2001;59:48-51.
Tsutani Y, Kurita A, Aogi K, Kubo Y, Tanada M, Takashima S: A instance of gastric cancer in one ‘upside down stomach" due to esophageal hiatal hernia (in Japanese v English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2003;66:1328-1332.
Shibuya M, Teraoka H, Nakao S, Mashita K, Hara J, Nitta A: A situation of gastric cancer connected with big esophageal hiatus hernia presenting with upside under stomach and incarcerated colon (in Japanese). Rynshogeka 2010;65:1049-1053.
Takahashi M, Kodera K, Fujiwara H, Chiba T, Sasaki A, Wakabayashi G: A situation of gastric cancer resection in a patient through an esophageal hiatal hernia and an upside down stomach (in Japanese v English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2010;71:1501-1506.
Toyokawa T, Teraoka H, Kitayama K, Nomura S, Kanehara I, Nishio H: Laparoscopic surgical treatment for gastric cancer and esophageal hiatal hernia complicated by an ‘upside under stomach" - a situation report. Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2013;74:931-935.
Mayne ST, Navarro SA: Diet, obesity and also reflux in the etiology the adenocarcinomas that the esophagus and gastric cardia in humans. J Nutr 2002;132(11 suppl):3467S-3470S.
mc donalds WC, macdonald JB: Adenocarcinoma that the esophagus and/or gastric cardia. Cancer 1987;60:1094-1098.
Chow WH, Finkle WD, McLaughlin JK, Frankl H, Ziel HK, Fraumeni JF Jr: The relationship of gastroesophageal reflux disease and its therapy to adenocarcinomas of the esophagus and gastric cardia. JAMA 1995;274:474-477.
Lagergren J, Bergstrom R, Lindgren A, Nyren O: Symptomatic gastroesophageal reflux together a risk factor for esophageal adenocarcinoma. N Engl J Med 1999;340:825-831.
Wu AH, Tseng CC, Bernstein L: Hiatal hernia, reflux symptoms, human body size, and risk the esophageal and also gastric adenocarcinoma. Cancer 2003;98:940-948.
Zheng T, Mayne ST, Holford TR, Boyle P, Liu W, Chen Y, Mador M, Flannery J: the time trend and also age-period-cohort effects on incidence the adenocarcinoma of the stomach in Connecticut indigenous 1955-1989. Cancer 1993;72:330-340.

Kenji Mimatsu

Department of Surgery, society Insurance Yokohama main Hospital

268 Yamashita-cho, Naka-ku, Yokohama, Kanagawa, 231-8553 (Japan)

E-Mail mimatsu.kenji
yokochu.jp


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Akerlund A: Hernia diafragmatica hiatus oesophagei vom anatomischen und röntgenologischen Gesichts-punkt. Acta Radiol 1926;6:3-22.
Bettex M, Kuffer F: long-term results that fundoplication in hiatus hernia and cardio-esophageal chalasia in infants and also children. Report the 112 continually cases. J Pediatr Surg 1969;4:526-530.
Iso Y, Tagaya N, Nemoto T, Kita J, Sawada T, Kubota K: Incarceration of a big cell neuroendocrine carcinoma arising from the proximal stomach with an organoaxial gastric volvulus through an esophageal hiatal hernia: report of a case. Surg now 2009;39:148-152.
Kominami H, Kawasaki K, Tanaka K, Kaneji S, Fujino Y, Tominaga M: A situation of progressed gastric cancer through hiatal hernia connected with the upside down stomach (in Japanese with English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2012;73:3129-3134.
Izumi Y, Tsuchiya K, Maeda H, Mukubou M, Asahara M, Sakaguchi T: A case of gastric cancer complicated with esophageal hiatal hernia v upside-down stomach (in Japanese). Gekashinryo 1993;9:1181-1185.
Narayan D, Soybes D, Salem RR: Pyloric carcinoma presenting together intrathoracic volvulus. J Clin Gastroenterol 1994;18:260-261.
Sato K, Midorikawa Y, Kamiga M, Kumbota Y: A instance of gastric cancer associated with esophageal hiatus hernia presenting with upside down stomach (in Japanese). Nihon Shokakibyo Gakkaizasshi 1996;93:26-29.
Matsuda M, Aikawa T, Sekikawa T, Karikomi K, Iizuka H, Fujii H, et al: advanced gastric carcinoma within ‘upside-down-stomach" as result of mixed esophageal hiatal hernia - report the a case (in Japanese v English abstract). Nihon Syokakigeka Gakkaizasshi (Jpn J Gastroenterol Surg) 1997;30:994-998.
Seshimo T, Ito M, Monden K, Mizukami T: A case of advanced gastric cancer within sliding hiatal hernia linked with organoaxial gastric volvulus (in Japanese v English abstract). Nihon Syokakigeka Gakkaizasshi (Jpn J Gastroenterol Surg) 1999;32:2243-2247.
Kawai S, Matsuura Y, Kouno H, Kitagawa Y, Yamanaka H, Hiramatsu K: A case of quadruple gastric cancer in ~ upside down stomach as result of esophageal hiatal hernia (in Japanese with English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2001;62:376-380.
Horiba K, Yamashita K, Tanaka N, Kyono S, Yokoi K, Higuchi K, et al: A instance of gastric cancer linked with esophageal hiatus hernia presenting horizontal torsion that the stomach (in Japanese through English abstract). Prog Digest Endosc 2001;59:48-51.
Tsutani Y, Kurita A, Aogi K, Kubo Y, Tanada M, Takashima S: A situation of gastric cancer in an ‘upside under stomach" because of esophageal hiatal hernia (in Japanese v English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2003;66:1328-1332.
Shibuya M, Teraoka H, Nakao S, Mashita K, Hara J, Nitta A: A situation of gastric cancer connected with huge esophageal hiatus hernia presenting v upside under stomach and also incarcerated colon (in Japanese). Rynshogeka 2010;65:1049-1053.
Takahashi M, Kodera K, Fujiwara H, Chiba T, Sasaki A, Wakabayashi G: A instance of gastric cancer resection in a patient with an esophageal hiatal hernia and also an upside under stomach (in Japanese v English abstract). Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2010;71:1501-1506.
Toyokawa T, Teraoka H, Kitayama K, Nomura S, Kanehara I, Nishio H: Laparoscopic surgical procedure for gastric cancer and also esophageal hiatal hernia complex by an ‘upside under stomach" - a situation report. Nihon Rinshyogeka Igakkaizasshi (J Jpn Surg Assoc) 2013;74:931-935.
Mayne ST, Navarro SA: Diet, obesity and reflux in the etiology of adenocarcinomas the the esophagus and gastric cardia in humans. J Nutr 2002;132(11 suppl):3467S-3470S.
mc donalds WC, mcdonald s JB: Adenocarcinoma of the esophagus and/or gastric cardia. Cancer 1987;60:1094-1098.
Chow WH, Finkle WD, McLaughlin JK, Frankl H, Ziel HK, Fraumeni JF Jr: The relationship of gastroesophageal reflux disease and its treatment to adenocarcinomas that the esophagus and also gastric cardia. JAMA 1995;274:474-477.
Lagergren J, Bergstrom R, Lindgren A, Nyren O: Symptomatic gastroesophageal reflux as a risk aspect for esophageal adenocarcinoma. N Engl J Med 1999;340:825-831.
Wu AH, Tseng CC, Bernstein L: Hiatal hernia, reflux symptoms, human body size, and risk that esophageal and also gastric adenocarcinoma. Cancer 2003;98:940-948.
Zheng T, Mayne ST, Holford TR, Boyle P, Liu W, Chen Y, Mador M, Flannery J: the time trend and also age-period-cohort effects on incidence that adenocarcinoma of the stomach in Connecticut from 1955-1989. Cancer 1993;72:330-340.