Pitfalls in therapy of upside-down stomach

The upside-down stomach (UDS) is a special form of gastric organoaxial volv ulus in a supradiaphragmatic hernial sac. The authors report five cases tre ated between 1979 and 1998, and seek to point out possible problems and pit falls in the surgical management of this uncommon anomaly. Retrospective analysis of these cases shows that brachyesophagus as describ ed is not a problem in UDS, as the esophagus is of normal length. The hiatu s, on the other hand, is always very large and needs proper narrowing, whic h may be achieved through a transabdominal approach more easily than throug h a transthoracic access. A common esophago-aortal hiatus is often present. In conclusion, the authors recommend a hiatal repair and gastropexy, i.e. f undophrenopexy and corpoventropexy along the esophageal axis to prevent rec urrent gastric herniation or torsion. Transabdominal access should be chose n since brachyesophagus is not expected. Beware of a common hiatus when pre paring the hiatal crura. An antireflux procedure is not necessary as gastro -esophageal reflux usually resolves spontaneously after hiatal repair and g astropexy.