Beyond restrictive: Sleeve Gastrectomy to Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy as a spectrum of one single procedure.

INTRODUCTION: Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S) is a restrictive/hypoabsorptive procedure recommended for patients with obesity class 3. For safety reasons, SADI-S can be splited into a two-step procedure by performing a sleeve gastrectomy (SG) first. This stepwise approach also provides an unprecedented opportunity to disentangle the weight loss mechanisms triggered by each component. The objective was to compare weight trajectories and postprandial endocrine and metabolic responses of patients with obesity class 3 submitted to SADI-S or sleeve gastrectomy (SG) as the first step of SADI-S. METHODS: Subjects submitted to SADI-S (n=7) or SG (n=7) at a tertiary referral public academic hospital, underwent anthropometric evaluation and a liquid mixed meal tolerance test (MMTT) pre-operatively and at 3, 6, and 12 months post-operatively. RESULTS: Anthropometric parameters, as well as metabolic and micronutrient profiles, were not significantly different between groups, neither before nor after surgery. There were no significant differences in fasting or post-prandial glucose, insulin, C-peptide, ghrelin, insulin secretion rate (ISR) and insulin clearance during the MMTT between subjects submitted to SADI-S and SG. There was no lost to follow-up. CONCLUSIONS: The restrictive component seems to be the main driver for weight loss and metabolic adaptations observed during the first 12 months after SADI-S, given that the weight trajectories and metabolic profiles do not differ from SG. This data provides support for a surgeons' choice of a two-step SADI-S without jeopardizing the weight loss outcomes.

Adjuvant Botulinum Toxin Type A on the Management of Giant Hiatal Hernia: A Case Report.

The management of giant hiatal hernias (HHs) remains challenging and is associated with a high risk of recurrence. Currently, several strategies are used to reduce recurrence, and a newly proposed trend is the administration of adjuvant botulinum toxin type A (BTX), a procedure already performed in complex ventral hernias. Here, we present a case of a 63-year-old man with a giant paraesophageal HH type IV containing the entire stomach and transverse colon with loss of domain, who underwent adjuvant BTX and subsequently laparoscopic hiatoplasty with a biological mesh with partial fundoplication. At six months' follow-up, the patient reported a significant improvement in the quality of life without dysphagia or gastroesophageal reflux and with a good respiratory function. A control computed tomography was performed, which documented a partial recurrence of HH, completely asymptomatic. This clinical case showed the successful treatment of a giant HH using adjuvant BTX injection to increase abdominal wall compliance as had already been described in the treatment of complex ventral hernia. Thus, the use of BTX is a promising strategy for selected cases of giant HHs mainly if there is a loss of domain; however, more case series and controlled trials are needed to show the reproducibility of the benefit of this strategy.

JAGGER localization and function are dependent on GPI anchor addition.

KEY MESSAGE: GPI anchor addition is important for JAGGER localization and in vivo function. Loss of correct GPI anchor addition in JAGGER, negatively affects its localization and function. In flowering plants, successful double fertilization requires the correct delivery of two sperm cells to the female gametophyte inside the ovule. The delivery of a single pair of sperm cells is achieved by the entrance of a single pollen tube into one female gametophyte. To prevent polyspermy, Arabidopsis ovules avoid the attraction of multiple pollen tubes to one ovule-polytubey block. In Arabidopsis jagger mutants, a significant number of ovules attract more than one pollen tube to an ovule due to an impairment in synergid degeneration. JAGGER encodes a putative arabinogalactan protein which is predicted to be anchored to the plasma membrane by a glycosylphosphatidylinositol (GPI) anchor. Here, we show that JAGGER fused to citrine yellow fluorescent protein (JAGGER-cYFP) is functional and localizes mostly to the periphery of ovule integuments and transmitting tract cells. We further investigated the importance of GPI-anchor addition domains for JAGGER localization and function. Different JAGGER proteins with deletions in predicted ω-site regions and GPI attachment signal domain, expected to compromise the addition of the GPI anchor, led to disruption of JAGGER localization in the cell periphery. All JAGGER proteins with disrupted localization were also not able to rescue the polytubey phenotype, pointing to the importance of GPI-anchor addition to in vivo function of the JAGGER protein.

HISTONE DEACETYLASE19 Controls Ovule Number Determination and Transmitting Tract Differentiation.

The gynoecium is critical for the reproduction of flowering plants as it contains the ovules and the tissues that foster pollen germination, growth, and guidance. These tissues, known as the reproductive tract (ReT), comprise the stigma, style, and transmitting tract (TT). The ReT and ovules originate from the carpel margin meristem (CMM) within the pistil. SHOOT MERISTEMLESS (STM) is a key transcription factor for meristem formation and maintenance. In all above-ground meristems, including the CMM, local STM downregulation is required for organ formation. However, how this downregulation is achieved in the CMM is unknown. Here, we have studied the role of HISTONE DEACETYLASE 19 (HDA19) in Arabidopsis (Arabidopsis thaliana) during ovule and ReT differentiation based on the observation that the hda19-3 mutant displays a reduced ovule number and fails to differentiate the TT properly. Fluorescence-activated cell sorting coupled with RNA-sequencing revealed that in the CMM of hda19-3 mutants, genes promoting organ development are downregulated while meristematic markers, including STM, are upregulated. HDA19 was essential to downregulate STM in the CMM, thereby allowing ovule formation and TT differentiation. STM is ectopically expressed in hda19-3 at intermediate stages of pistil development, and its downregulation by RNA interference alleviated the hda19-3 phenotype. Chromatin immunoprecipitation assays indicated that STM is a direct target of HDA19 during pistil development and that the transcription factor SEEDSTICK is also required to regulate STM via histone acetylation. Thus, we identified factors required for the downregulation of STM in the CMM, which is necessary for organogenesis and tissue differentiation.

Simultaneous stoma closure and type IV parastomal hernia repair after botulinum toxin and progressive pneumoperitoneum.

Surgery is the only treatment for parastomal hernia (PH). When possible, stoma closure is the best way to manage this type of hernia, however, whether to perform it in a single approach with abdominal wall reconstruction (AWR) is still debatable. A 58-year-old woman with a type IV PH with loss of domain was submitted to preoperative optimization [botulinum toxin type A and progressive pneumoperitoneum (PPP)], followed by simultaneous stoma closure and AWR. Hospital discharge was on the eighth day with no complications. Six months later, no clinical evidence of recurrence or other complication was observed. Large PHs are technically challenging. Stoma closure and simultaneous AWR increase surgical risk. Preoperative optimization with a combination of adjuvants (including PPP) is feasible in PH and may overcome technical complexity, even though patient selection remains the key when choosing a PH repair with synchronous stoma closure.

AGPs as molecular determinants of reproductive development.

BACKGROUND AND AIMS: Morphogenesis occurs through accurate interaction between essential players to generate highly specialized plant organs. Fruit structure and function are triggered by a neat transcriptional control involving distinct regulator genes encoding transcription factors (TFs) or signalling proteins, such as the C2H2/C2HC zinc-finger NO TRANSMITTING TRACT (NTT) or the MADS-box protein SEEDSTICK (STK), which are important in setting plant reproductive competence, feasibly by affecting cell wall polysaccharide and lipid distribution. Arabinogalactan proteins (AGPs) are major components of the cell wall and are thought to be involved in the reproductive process as important players in specific stages of development. The detection of AGPs epitopes in reproductive tissues of NTT and other fruit development-related TFs, such as MADS-box proteins including SHATTERPROOF1 (SHP1), SHP2 and STK, was the focus of this study. METHODS: We used fluorescence microscopy to perform immunolocalization analyses on stk and ntt single mutants, on the ntt stk double mutant and on the stk shp1 shp2 triple mutant using specific anti-AGP monoclonal antibodies. In these mutants, the expression levels of selected AGP genes were also measured by quantitative real-time PCR and compared with the respective expression in wild-type (WT) plants. KEY RESULTS: The present immunolocalization study collects information on the distribution patterns of specific AGPs in Arabidopsis female reproductive tissues, complemented by the quantification of AGP expression levels, comparing WT, stk and ntt single mutants, the ntt stk double mutant and the stk shp1 shp2 triple mutant. CONCLUSIONS: These findings reveal distinct AGP distribution patterns in different developmental mutants related to the female reproductive unit in Arabidopsis. The value of the immunofluorescence labelling technique is highlighted in this study as an invaluable tool to dissect the remodelling nature of the cell wall in developmental processes.

The Predictive Value of Glasgow-Blatchford Score: The Experience of an Emergency Department.

INTRODUCTION: Upper gastrointestinal bleeding (UGB) is a common emergency and a major cause of morbidity and mortality worldwide. An early and accurate assessment at admission is essential to estimate the severity of each case, assisting in the management of patients. The Glasgow-Blatchford score (GBS) is currently recommended for risk stratification of UGB in the emergency department (ED), helping triage patients to in-hospital vs. ambulatory management. The aim of this study was to test the validity of the GBS in an ED. METHODS: Patients who presented to the ED with a diagnosis of UGB between 2017 and 2018 were retrospectively analyzed. RESULTS: The mean GBS value of the 149 patients included in the study was 10.3. Of the patients, 4.3% had values ≤1 and 8.7% had values ≤3. The sensitivity and negative predictive value for intervention needs (98.9% and 91.7%) and complications in 30 days (100% and 100%) remained high with a threshold ≤3. In the receiver operating characteristic curves, GBS presented an area under the curve of 0.883 and 0.625, regarding the need for intervention and complications in 30 days, respectively. CONCLUSIONS: In our population, the threshold ≤2, and eventually ≤3, allows the identification of twice as many low-risk patients, manageable as outpatients, without significant increases in intervention needs or complications in 30 days.

Type II arabinogalactans initiated by hydroxyproline-O-galactosyltransferases play important roles in pollen-pistil interactions.

Arabinogalactan-proteins (AGPs) are hydroxyproline-rich glycoproteins containing a high sugar content and are widely distributed in the plant kingdom. AGPs have long been suggested to play important roles in sexual plant reproduction. The synthesis of their complex carbohydrates is initiated by a family of hydroxyproline galactosyltransferase (Hyp-GALT) enzymes which add the first galactose to Hyp residues in the protein backbone. Eight Hyp-GALT enzymes have been identified so far, and in the present work a mutant affecting five of these enzymes (galt2galt5galt7galt8galt9) was analyzed regarding the reproductive process. The galt25789 mutant presented a low seed set, and reciprocal crosses indicated a significant female gametophytic contribution to this mutant phenotype. Mutant ovules revealed abnormal callose accumulation inside the embryo sac and integument defects at the micropylar region culminating in defects in pollen tube reception. In addition, immunolocalization and biochemical analyses allowed the detection of a reduction in the amount of glucuronic acid in mutant ovary AGPs. Dramatically low amounts of high-molecular-weight Hyp-O-glycosides obtained following size exclusion chromatography of base-hydrolyzed mutant AGPs compared to the wild type indicated the presence of underglycosylated AGPs in the galt25789 mutant, while the monosaccharide composition of these Hyp-O-glycosides displayed no significant changes compared to the wild-type Hyp-O-glycosides. The present work demonstrates the functional importance of the carbohydrate moieties of AGPs in ovule development and pollen-pistil interactions.

Are SADI-S and BPD/DS bariatric procedures identical twins or distant relatives? - A case report.

Given the common anatomical features and similar short-term weight loss outcomes, Biliopancreatic Diversion with Duodenal Switch (BPD/DS) and Single-Anastomosis Duodenoileal bypass with Sleeve gastrectomy (SADI-S) are considered identical bariatric procedures, apart from technical complexity being lower for SADI-S. In the absence of prospective randomized trials or long-term comparative studies the rationale for choosing between procedures is hampered. Post-bariatric hormonal profiles could contribute to understand the underlying mechanisms and potentially be used as a decision aid when choosing between procedures. The main aim of this study was to compare the outcomes of BPD/DS and SADI-S, in genetically identical individuals exposed to similar environmental factors. Two identical twin (T) female patients, one submitted to BPD/DS (T_BPD/DS) and another to SADIS-S (T_SADI-S) were followed up to one year after surgery. Before surgery and at 3, 6 and 12 months after surgery, both patients underwent mixed meal tolerance tests (MMTT) to evaluate postprandial glucose, glucagon and GLP-1 response. In addition, 3 months after surgery, glucose dynamics were assessed using a Flash Glucose Monitoring (FGM) system for 14 days. The percentage of total weight loss (%TWL) was higher for T_BPD/DS compared to T_SADI-S (34.03 vs 29.03 %). During MMTT, T_BPD/DS presented lower glucose, glucagon, insulin and C-peptide excursions at all timepoints when compared to SADI-S; along with a greater percentage of time within the low glucose range (55.97 vs 39.93 %) and numerically lower glucose variability indexes on FGM (MAG change:0.51 vs 0.63 mmol/l×h-1). In patients with the same genetic background, BPD/DS was shown to result in greater weight loss than SADI-S. The differences in glucose and enteropancreatic hormone profiles observed after BPD/DS and SADI-S suggest that different mechanisms underlie weight loss.

New insights on the expression patterns of specific Arabinogalactan proteins in reproductive tissues of Arabidopsis thaliana.

Arabinogalactan proteins (AGPs) are hydroxyproline-rich glycoproteins containing a high proportion of carbohydrates, widely distributed in the plant kingdom and ubiquitously present in land plants. AGPs have long been suggested to play important roles in plant reproduction and there is already evidence that specific glycoproteins are essential for male and female gametophyte development, pollen tube growth and guidance, and successful fertilization. However, the functions of many of these proteins have yet to be uncovered, mainly due to the difficulty to study individual AGPs. In this work, we generated molecular tools to analyze the expression patterns of a subgroup of individual AGPs in different Arabidopsis tissues, focusing on reproductive processes. This study focused on six AGPs: four classical AGPs (AGP7, AGP25, AGP26, AGP27), one AG peptide (AGP24) and one chimeric AGP (AGP31). These AGPs were first selected based on their predicted expression patterns along the reproductive tissues from available RNA-seq data. Promoter analysis using ß-glucuronidase fusions and qPCR in different Arabidopsis tissues allowed to confirm these predictions. AGP7 was mainly expressed in female reproductive tissues, more precisely in the style, funiculus, and integuments near the micropyle region. AGP25 was found to be expressed in the style, septum and ovules with higher expression in the chalaza and funiculus tissues. AGP26 was present in the ovules and pistil valves. AGP27 was expressed in the transmitting tissue, septum and funiculus during seed development. AGP24 was expressed in pollen grains, in mature embryo sacs, with highest expression at the chalazal pole and in the micropyle. AGP31 was expressed in the mature embryo sac with highest expression at the chalaza and, occasionally, in the micropyle. For all these AGPs a co-expression analysis was performed providing new hints on its possible functions. This work confirmed the detection in Arabidopsis male and female tissues of six AGPs never studied before regarding the reproductive process. These results provide novel evidence on the possible involvement of specific AGPs in plant reproduction, as strong candidates to participate in pollen-pistil interactions in an active way, which is significant for this field of study.

Acute Pericarditis Hiding an Esophageal Perforation.

Esophageal perforations due to foreign body ingestion are uncommon; however, they can be associated with extremely high mortality rate. The most dreadful complication of this entity is the infection of adjacent structures, namely, the mediastinum and the pericardium. A prompt diagnosis and a precocious start of treatment are essential to the prognosis. Thus, a high degree of suspicion is required, especially in older patients. Therapeutic options are highly variable, depend on several factors, and should be individualized to every patient and their clinical status. Surgical treatment with esophageal exclusion and diversion, in extreme circumstances, is mandatory to control the infection source site and prevent further contamination. We report a case of esophageal perforation, presenting 48 hours after onset, that led to multifactorial shock (septic and cardiogenic) due to pericarditis with pericardial and pleural effusion.

Duodenal Switch vs. Single-Anastomosis Duodenal Switch (SADI-S) for the Treatment of Grade IV Obesity: 5-Year Outcomes of a Multicenter Prospective Cohort Comparative Study.

PURPOSE: The aims were to compare the 5-year outcomes of duodenal switch (DS) and single-anastomosis duodenal switch (SADI-S) in terms of weight loss; remission of comorbidities; nutritional status short- and long-term complications; postoperative mortality; and need for revisional surgery. MATERIALS AND METHODS: Multicenter prospective observational study of all consecutive patients undergoing DS or SADI-S in three high-volume hospitals. RESULTS: A total of 87 patients were included in the study, 43 submitted to DS and 44 to SADI-S, with similar basal characteristics, nutritional parameters, and BMI (52.9 kg/m2 DS vs. 52.5 kg/m2 SADI-S). Operative time was 152 min (± 32.6) in DS vs. 116 min (± 21.9) in SADI-S (p = 0.043). Short-term complications were similar for DS and SADI-S, both overall (11.8% vs. 11.6%), and ranged as Clavien-Dindo > II (4.5% vs. 4.7%), with no mortality. At 5 years, DS and SADI-S results were as follows: BMI 30.6 vs. 33.3 kg/m2 (p = 0.023); %EWL 80.5% vs. 68.6% (p = 0.006); and %TWL 42.1 vs. 36.0 (p = 0.006). Comorbidity remission rates for DS and SADI-S were as follows: for diabetes, 92.8% vs. 85.7% (n.s.); for hypertension, 95.2% vs. 85.1% (n.s.); for sleep apnea, 75% vs. 73.3% (n.s.); and for dyslipidemia, 76.4% vs. 73.3% (n.s.). DS showed lower levels of vitamin B12, iron, vitamin E, and zinc than SADI-S (p = < 0.005). In the long term, there were 4 surgical reinterventions (due to 1 internal hernia in the DS group and 1 internal hernia and 2 biliary refluxes in the SADI-S group) with no cases of persistent diarrhea or malnutrition. CONCLUSION: Both DS and SADI-S allowed good weight control and resolution of comorbidities. DS achieved a greater weight loss compared to SADI-S, at the expense of longer operative time and lower vitamin and mineral levels.

Hepatic Actinomycosis Mimicking Malignancy After Pancreaticoduodenectomy: A Case Report.

Abdominal actinomycosis is a rare disease caused by a Gram-positive bacillus (Actinomyces). Liver manifestation is rare and, in patients with a history of cancer, differential diagnosis with secondary malignant disease can be difficult. Microbiological result is necessary for a correct diagnosis, though not always possible in preoperative workout. The authors present a case of hepatic actinomycosis that mimicked oncological disease and led to a more aggressive surgical approach.

Paving the Way for Fertilization: The Role of the Transmitting Tract.

Angiosperm reproduction relies on the precise growth of the pollen tube through different pistil tissues carrying two sperm cells into the ovules' embryo sac, where they fuse with the egg and the central cell to accomplish double fertilization and ultimately initiate seed development. A network of intrinsic and tightly regulated communication and signaling cascades, which mediate continuous interactions between the pollen tube and the sporophytic and gametophytic female tissues, ensures the fast and meticulous growth of pollen tubes along the pistil, until it reaches the ovule embryo sac. Most of the pollen tube growth occurs in a specialized tissue-the transmitting tract-connecting the stigma, the style, and the ovary. This tissue is composed of highly secretory cells responsible for producing an extensive extracellular matrix. This multifaceted matrix is proposed to support and provide nutrition and adhesion for pollen tube growth and guidance. Insights pertaining to the mechanisms that underlie these processes remain sparse due to the difficulty of accessing and manipulating the female sporophytic tissues enclosed in the pistil. Here, we summarize the current knowledge on this key step of reproduction in flowering plants with special emphasis on the female transmitting tract tissue.

Fluorescent Immunolocalization of Arabinogalactan Proteins and Pectins in the Cell Wall of Plant Tissues.

Plant development involves constant adjustments of the cell wall composition and structure in response to both internal and external stimuli. Cell walls are composed of cellulose and non-cellulosic polysaccharides together with proteins, phenolic compounds and water. 90% of the cell wall is composed of polysaccharides (e.g., pectins) and arabinogalactan proteins (AGPs). The fluorescent immunolocalization of specific glycan epitopes in plant histological sections remains a key tool to uncover remodeling of wall polysaccharide networks, structure and components. Here, we report an optimized fluorescent immunolocalization procedure to detect glycan epitopes from AGPs and pectins in plant tissues. Paraformaldehyde/glutaraldehyde fixation was used along with LR-White embedding of the plant samples, allowing for a better preservation of the tissue structure and composition. Thin sections of the embedded samples obtained with an ultra-microtome were used for immunolocalization with specific antibodies. This technique offers great resolution, high specificity, and the chance to detect multiple glycan epitopes in the same sample. This technique allows subcellular localization of glycans and detects their level of accumulation in the cell wall. It also permits the determination of spatio-temporal patterns of AGP and pectin distribution during developmental processes. The use of this tool may ultimately guide research directions and link glycans to specific functions in plants. Furthermore, the information obtained can complement biochemical and gene expression studies.

Adenomyomatous Hyperplasia of Ampulla of Vater and a Concomitant Renal Tumor: A Case Report.

Adenomyomatous hyperplasia is an extremely rare lesion encountered in the ampulla of Vater. Less than 50 cases have been described, most of them with clinical consequences of biliary obstruction, misdiagnosing it as a malignancy. The authors present a concomitant case with a renal tumor, its diagnosis, management, and clinical relevance, as well as a brief revision of the literature. Ampullar and renal tumors were found in a 74-year-old female, in the imagiologic study of a low back pain, in the emergency department. Both were considered malign after further study, and pancreatoduodenectomy with partial nephrectomy was proposed. There is no accurate diagnostic tool to differentiate the benign nature of adenomyomatous hyperplasia and extensive operations are often performed. As an incidental finding in the study of another tumor, this case raises the concern about which and how to treat both tumors, taking into account the morbidity of the respective interventions.

Single and dual anastomosis duodenal switch for obesity treatment: a single-center experience.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking. OBJECTIVES: The aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS. SETTING: Public hospital. METHODS: Obese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared. RESULTS: The mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m2 for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances. CONCLUSION: SADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS.

Gallstone Ileus: An Improbable Cause of Mechanical Small Bowel Obstruction.

Gallstone ileus (GI) is a rare complication of cholelithiasis and a rare cause of small bowel obstruction. It usually affects elderly women and the symptoms are nonspecific, both contributing to a delay in diagnosis and a high mortality rate. It is necessary to have a high suspicion index for diagnosis and abdominal CT is the gold standard imaging for the diagnosis. We present a case report of an 87-year-old man who presented to the ED with abdominal pain and vomiting for the last 20 days. A GI was diagnosed and he underwent enterolithotomy to remove the stone. Unfortunately, the patient died on the 13th postoperative day with multiorgan failure. The treatment and the time at which it is performed must be adapted to each patient.

Gastric Volvulus: A Complication of Hiatal Hernia.

Gastric volvulus is a rare but potentially life-threatening condition, with difficult diagnosis. We present a case report of a demented woman aged 65 years that attended the emergency department with epigastric pain and vomiting for the past 10 days. The chest plain revealed a retrocardiac air-filled mass and the abdomino-pelvic computed tomography confirmed the diagnosis of gastric volvulus. The patient was admitted. A nasogastric tube was introduced, antibiotics and parenteric nutrition were started and the patient didn't eat anything. The patient was operated at fifth day of admission by laparoscopy. There weren't signs of gastric necrosis, so the stomach was mobilized for its natural position on abdominal cavity, the hiatal defect was closed and a Nissen fundoplicature was performed. The post operative period was uneventful and the patient was discharged on the third post-operative day, without any complication. This case illustrates a sub acute presentation form of gastric volvulus and a differed minimally invasive approach attending at the patient's clinical stability.