in cases of paraesophageal hiatal hernia with gastric volvulus , which is referred to as upside - down stomach , the first choice is surgical treatment . in high - surgical - risk patients ,
endoscopic repositioning and gastropexy is useful to ensure a good quality of life . however , there are no detailed reports regarding recurrent cases of upside - down stomach after endoscopic treatment ; therefore , the risks of recurrence are unknown .
we had a case of recurrent upside - down stomach after endoscopic repositioning and gastropexy that indicated the limits of endoscopic treatment and the risk of recurrence , as reported here .
an 88-year - old woman with periodic vomiting and inability to eat was admitted to our hospital on three separate occasions where she received conservative treatment for a few days .
because of her advanced age , complications ( bedridden state , left hemiplegia after cerebral infarction , heart failure ) and poor general condition , the minimally invasive method of endoscopic repositioning and gastropexy was performed .
the stomach was reduced to the normal anatomic position , and the anterior stomach wall was fixed to the abdominal wall in three places as widely as possible ( fig .
chest and abdominal computed tomography showed the gastric fornix in the abdominal cavity , but the gastric corpus was above the diaphragm with organoaxial volvulus ( fig .
she was then diagnosed with a recurrent upside - down stomach after endoscopic repositioning and gastropexy .
she was initially managed conservatively and had a nasogastric tube inserted , but her condition did not improve .
although her anterior stomach wall had been fixed to the abdominal wall in three places as widely as possible in the last hospitalization , she again presented with upside - down stomach .
we concluded that it was impossible to prevent the recurrence of an upside - down stomach by endoscopic therapy .
therefore , we treated the condition with a laparoscopic repair of hernias and gastropexy . using a laparoscope
, we observed that the anterior stomach wall was adhered to the abdominal wall in three places from the antrum to the lower corpus of the stomach ( fig .
the upper corpus of the stomach was rotated and herniated into the esophageal hiatus ( fig .
however , it quickly returned into the esophageal hiatus with rotation because of the adhesion between the omentum and the esophageal hiatus ( fig .
this adhesion was peeled off and the crura were closed by a primary suture ( fig .
the cardial part of the stomach wall was fixed to the crura , and the anterior stomach wall was fixed in three places to the abdominal wall widely from the upper corpus to the antrum ( fig .
the suture used for fixing the stomach wall was removed 44 days after the operation .
a paraesophageal hiatal hernia is a herniation of the gastric fundus anterior to a normally positioned esophagogastric junction . in large paraesophageal hernias
, the entire stomach can be herniated with volvulus , which we refer to as upside - down stomach .
surgical intervention comprising reduction of the stomach in the gastric lodge and calibration of the hiatus adding a gastropexy or antireflux procedure is the first choice of treatment for this condition .
although publications describe the results of retrospective studies , the hospital stay after laparoscopic repair of paraesophageal hiatal hernias was shorter than that after conventional surgery .
the morbidity reported in patients treated by conventional surgery exceeded the morbidity reported in laparoscopically operated patients , and follow - up was longer for conventional surgery .
the recurrence rate after laparoscopic repair for large hiatal hernias was higher than after conventional repair .
reoperative findings were intraluminal mesh erosion , esophageal stenosis , dense fibrosis , esophageal perforation and intragastric migration [ 5 , 6 ] .
considering the recurrence and reoperation rates , the differences between mesh repair and primary repair were small and perhaps clinically inconsequential . in our case , the esophageal hiatus was not so large and could be closed easily ; therefore , we did not use mesh .
the addition of a fundoplication in the laparoscopic repair of paraesophageal hiatal hernia minimized postoperative reflux symptoms . when no objective evidence of reflux was seen preoperatively , an antireflux procedure was not necessary . in our case ,
a fundoplication , therefore , was not performed and reflux symptoms were not observed following the procedure . for upside - down stomach , preventing recurrence of volvulus , a gastropexy is added to repair the paraesophageal hiatal hernia . in our case ,
the anterior stomach wall was fixed in three places to the abdominal wall widely from the upper corpus to the antrum .
many patients with upside - down stomach are not candidates for surgical therapy because of advanced age or comorbid conditions . for these patients , endoscopic repositioning and fixation by percutaneous endoscopic gastrostomy ( peg ) can be performed [ 10 , 11 ] . in our case ,
one reason is the narrow range where the stomach wall can be fixed endoscopically , although the fixation was performed as widely as possible .
therefore , performing endoscopic gastropexy fixation of the stomach by 2 pegs is recommended [ 12 , 13 ] . in our case ,
the anterior stomach wall was fixed to the abdominal wall in three places as widely as possible . however , as observed with a laparoscope , the anterior stomach wall was adhered only from the antrum to the lower corpus of the stomach , and the upper corpus of the stomach was rotated and herniated into the esophageal hiatus . in endoscopic gastropexy ,
the stomach wall is fixed by penetrating the peg tube or stomach wall fixture through the stomach wall and the abdominal wall . to avoid penetrating the chest wall and the lungs , the range of abdominal wall which can be fixed to the stomach wall
since the stomach wall can not be pulled caudally , unlike in the surgical approach , the range of stomach wall which can be fixed to the abdominal wall is limited from the antrum to the lower corpus of the stomach . as a result
the other reason for recurrence is the adhesion between the omentum and the esophageal hiatus .
therefore , a repeated case has risks of recurrence of upside - down stomach after endoscopic treatment . in conclusion
, although endoscopic repositioning and gastropexy for upside - down stomach can be a useful alternative method in high - risk patients , some cases may recur .
repeated upside - down stomach caused by adhesions has risks of recurrence after endoscopic treatment . to use this therapy more effectively
, we hope that more cases will be reported and the risks of recurrences revealed .
 patients with an upside - down stomach usually receive surgical treatment . in high - risk patients , endoscopic 
 repositioning and gastropexy can be performed . however , the risk of recurrence after endoscopic treatment is not known . 
 we treated a case of recurrent upside - down stomach after endoscopic therapy that indicated the limits of endoscopic treatment and risk of recurrence . 
 an 88-year - old woman was treated three times for vomiting in the past . 
 she presented to our hospital with periodic vomiting and an inability to eat , and a diagnosis of upside - down stomach was made . 
 endoscopic repositioning and gastropexy were performed . 
 the anterior stomach wall was fixed to the abdominal wall in three places as widely as possible . following treatment 
 , she became symptom - free . 
 three months later , she was hospitalized again because of a recurrent upside - down stomach . 
 laparoscopic repair of hernias and gastropexy was performed . using a laparoscope , two causes of recurrence 
 were found . 
 one cause was that the range of adherence between the stomach and the abdominal wall was narrow ( from the antrum only to the lower corpus of stomach ) , so the upper corpus of stomach was rotated and herniated into the esophageal hiatus . 
 the other cause was adhesion between the omentum and the esophageal hiatus which caused the stomach to rotate and repeatedly become herniated . 
 although endoscopic treatment for upside - down stomach can be a useful alternative method in high - risk patients , its ability to prevent recurrence is limited . 
 moreover , a repeated case caused by adhesions has risks of recurrence . 