Evaluation of Short-term Outcome of Uncut Roux-en-Y Gastrojejunostomy for Distal Gastric Cancer in a Tertiary Care Hospital

Background: Gastric cancer is the fifth most common malignancy worldwide and the third leading cause of cancer death. Gastric cancer is one of the most common malignant tumors of the gastrointestinal tract, and it poses a serious threat to people’s survival. Objective: The aim of the study to evaluate the short-term outcomes of Uncut Roux-en-Y Gastrojejunostomy for distal gastric cancer.Material & Methods:This observational study was conducted in the Department of surgical oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka. A total number of 51 cases were included for the study. Purposive sample technique was used. All patients received prophylactic antibiotic using cefuroxime just before the induction of anaesthesia and continued postoperatively for 5 days. All the data were analyzed statistically by using Statistical Package for the Social Sciences (SPSS-26).Results:The mean age of the study subject was 58.58±9.85 years. Majority (42%) of the study subjects were in 51-60 years age group. Among the study cases 37 (74%) were male and 13 (26%) were female. The mean total operation time was 173.70±20.35min. The mean estimated blood loss was 174.30±40.67 ml. The mean time of first flatus pass after operation was 2.08±0.75 days and the mean duration of hospital stay was 9.64±2.67 days. Post-operative complications were observed among 08 (16%) cases. The mean preoperative Hb level of the study subjects was 10.86±0.61 gm/dl and the mean preoperative albumin level of the study subjects was 3.76±0.61 gm/dl. Two patients were lost at final follow up (at 6 months). Among these 48 cases at final follow up poor outcome was observed among 15.69% cases. Conclusions:After analyzing the results of present study, it can be concluded that Uncut Roux-en-Y Gastrojejunostomy is a safe and favorable procedure for treatment of distal gastric cancer.

Negative Feedback Mechanism of Entero-gastric Inhibitory in Delayed Gastric Emptying Following Surgery for Stomach Cancer / 肿瘤防治研究

Delayed gastric emptying (DGE) is a common complication following upper gastrointestinal surgery, especially following distal gastrectomy and partial pancreaticoduodenectomy (Whipple procedure). Its underlying mechanism remains unclear and needs to be elucidated. Through negative feedback mechanisms, duodenal distension inhibits gastric emptying. In our experience in performing a gastrojejunostomy, we speculate that this mechanism may still exist in the proximal jejunum and is activated by jejunal distension or stretching. There are many surgical factors leading to this mechanism activation. When a jejunal anastomosis is created by a relative large caliber of a circular stapling device, the mucosa may suffer from a circumferential scratch or bruising injury resulting in local inflammation. Afferent loop twisting may also lead to distal duodenum and/or jejunal distension. In addition, a mild/slight tension may exist on the mesenteric side of the gastrojejuostomy, especially when the antecolic route for reconstruction of the gastrojejunostomy has been performed. The inflammatory mucosa may keep the jejunum circumferentially distended, the bowel twist might compromise the lumen patency, and tension on gastrojejuostomy would stretch the jejunal wall. Any of these factors might contribute to the mechanisms of DGE by the negative feedback mechanisms.

Comparative study of outcome and complications of surgical management of benign gastric outlet obstruction

Background: Gastric outlet obstruction (GOO) implies complete or incomplete obstruction of the distal stomach, pylorus, or proximal duodenum. There are many causes of benign GOO like acid ingestion, pyloric stenosis, peptic ulcer etc. The main aims of this study were to compare the perioperative morbidity and short and long term complications of different procedures for benign gastric outlet obstruction.Methods: This non-randomised retrospective study was undertaken in the department of General Surgery, SMIMER Hospital, Surat, Gujarat, India from August 2016 to July 2019. Thirty patients had been operated during this period and included in the study. Records of all 30 patients were retrieved and analysed. All these patients underwent pre-operatively upper GI scopy with biopsy and CECT abdomen.Results: Nausea and Vomiting was most common symptoms at time of presentation in our study. Incidence of wound infection in open Gastrojejunostomy group was very high i.e. 25% and hospital stay was also very high in open Gastrojejunostomy group. Post-operative PPI dependence was more common in Gastro-jejunostomy group in all follow up and there was no any requirement of PPI in Heineke-Mikukicz and Finney’s pyloroplasty group.Conclusions: On comparison of different surgical modalities for management of benign GOO, all surgeries performed laparoscopically were safe and carried comparatively less morbidities (perioperative, short term and long term) in comparison to open methods. Among all three laparoscopic procedures, outcome of laparoscopic pyloroplasty, both H-M pyloroplasty and Finney’s pyloroplasty were better than laparoscopic gastro-jejunostomy.

Annular pancreas in adults: single unit experience from a tertiary care centre of Northern India

Annular pancreas is a rare congenital anomaly which usually presents with gastrointestinal symptoms early in life. In adults mostly it remains asymptomatic or may present with abdominal or features of duodenal obstruction the increased diagnosis of which is attributed to the improved imaging modalities. We hereby report our experience of adult annular pancreas in whom clinical presentation initially mimicked gastric or duodenal outlet obstruction. Adult annular pancreas was diagnosed with the aid of computed tomography of the abdomen and treated successfully with Roux-en-Y isoperistaltic gastrojejunostomy.

Clinical value of X-ray guided endoscopic gastrojejunostomy using stent ( with video) / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of X-ray guided endoscopic gastrojejunostomy using stent in treatment of malignant gastric outlet obstruction ( GOO ) . Methods Six hospitalized patients with malignant GOO underwent X-ray guided endoscopic gastrojejunostomy using stent in the department of gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University between March 2017 and June 2017. The technical success rate, clinical success rate, procedure time, adverse events and follow-up were recorded and analyzed in this retrospective study. Results The stent was successfully placed in the 6 patients with 100％ ( 6/6) technical success rate. The mean procedure time was 91. 7±51. 8 min. After the procedure, all patients were fed liquid or semi-liquid diet, and the GOO score system was increased from 0-1 before operation to 2-3 after operation. The clinical success rate was 100％(6/6). Peritonitis was observed in 2 patients during operation, and resolved by abdominal drainage. Gastrointestinal bleeding occurred in 1 patient after operation, which was resolved with conservative treatment. During a mean follow-up period of 78. 6 days (range 32-100 days), there was no recurrence of obstruction symptoms except that 1 patient died because of tumor progress 60 days after procedure. Conclusion The X-ray guided endoscopic gastrojejunostomy using stent is feasible and safe to treat malignant GOO with a reliable short-term efficacy.

Incidence Of Jejunogastric Intussussception Following Gastric Surgery In Our Hospital

INTRODUCTION:Jejuno gastric intussusception as a complication following gastrectomy occurs at an incidence of 0.1%. It follows several types of gastric surgeries like Billroth 2 and gastro jejunostomy. The mortality of the patient usually confirms to the 10% range but a high mortality of 50% has been reported in cases of delayed diagnosis paired with late intervention. In order to bypass the morbidity of the condition timely surgical invervention is the rule of the day. Though the history of gastric surgery may point towards the diagnosis, preoperative anticipation or the same has proven to be difficult in most of the cases AIMS AND OBJECTIVES: To study the incidence of jejunogastric intussusception following gastric surgery in KAPV medical college Tiruchirappalli during 10 years period from 2006 to 2016.The need for early intervention to prevent mortality and investigations needed to diagnose intussusception. METHODS AND MATERIALS: 50 patients who underwent gastrojejunostomy in KAPV medical college Tiruchirappalli during the period 2006 to 2016 were taken up for study. . Patient demographics, clinical presentation, diagnosis, investigations, operative notes, management and histopathology reports were reviewed and data was collected from case records from medical records department. RESULTS AND OBSERVATIONS: There were 5 cases of JGI. All were males. The mean age at presentation was 54.69 years (range 46–62). All patients presented with hematemesis or coffee ground vomiting. In addition, 3 patients had pain abdomen and 2 patients had malena. . All patients underwent surgical management. Most common type was Type II (efferent loop) seen in 3 patients. Type III (combined type) was seen in 1 patient. One patient had Type I (afferent loop). CONCLUSION: JGI is a rare complication after gastrojejunostomy. Upper gastrointestinal endoscopy is diagnostic. Ultrasound and computed tomography of abdomen can of additional help. This complication can occur years after surgery. High index of suspicion is required for diagnosis. Prompt surgical intervention, still remains the main stay of treatment.

Application of enhanced recovery after surgery in total laparoscopic uncut Roux-en-Y gastrojejunostomy / 中国现代普通外科进展

Objective:To evaluate the safety and feasibility of enhanced recovery after surgery (ERAS) in total laparoscopic Uncut Roux-en-Y gastrojejunostomy after distal gastrectomy.Methods:The clinical data of 42 patients who were divided into ERAS group (n=20) and control group (n=22) were collected.Observation indicators included operation condition,postoperative clinical indexes and postoperative serum stress indexes.Measurement data with normal distribution were presented as-x±s and analyzed by T test.Count data were analyzed by the chi-square test.Results:The operative time,volume of intraoperative blood loss and number of patients with conversion to open surgery shown no statistically significant difference between the 2 groups(P＞0.05).Postoperative clinical indexes:time for initial anus exhaust,time for initial liquid diet intake,time for out-of-bed activity,duration of hoSpital stay of patients without complications in the ERAS group were lower than in the control group,with statistically significant differences between the 2 groups (P＜0.05).But the time to initial defecation,time of abdominal drainage-tube removal and the early postoperative complications between the 2 group had no statistically difference(P＞0.05). Postoperative complications:at the first days and the third days after operation,WBC,CRP and I L-6 in ERAS group were lower than in the control group,the differences were statistically significant (P＜0.05).Conclusion:The perioperative ERAS program in total laparoscopic Uncut Roux-en-Y gastrojejunostomy after distal gastrectomy is safe and effective and should be popularized,meanwhile,it can also reduce duration of hospital stay and improve the comfortable degree and satisfaction of patients.

Laparoscopic gastrojejunostomy versus duodenal stenting in unresectable gastric cancer with gastric outlet obstruction

PURPOSE: To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival. METHODS: Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status. RESULTS: Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004). CONCLUSION: DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.

Retrospective Study of Surgical Gastrojejunostomy versus Gastroduodenal Stenting for Malignant Gastroduodenal Obstruction

Background: We retrospectively compared endscopic gastroduodenal stenting with gastrojejunostomy as a means of palliating malignant gastric and duodenal obstruction. Methods: This retrospective study investigated patients treated for malignant gastric and duodenal obstruction from April 2011 to April 2015 at Shikoku Cancer Center. Results: Of the 40 patients in this study, 25 underwent gastroduodenal stenting and 15 had operative gastrojejunostomy. Comparing the stenting and operative patients, technical success rate was 100% in both group, clinical success rate was 84% in stenting patients and 93% in operative patients. The median time to fluid intake was significantly shorter in stenting patients than operative patients(0 day vs 2 days, p=0.0003), and the median time to intake of solids was also significantly shorter in stenting patients(1day vs 3 days, p<0.0001).The median hospital stay was significantly shorter in stenting patients(9 days vs 23 days, p=0.0116). Median cost of hospitalization is more expensive in operative patients than stenting patients(¥1,106,170 vs ¥752,290, p=0.0052). Conclusion: Our study suggested that gastoroduodenal stent was less length of time to fluid/solid intake, and less costly than gastrojejunostomy.

Superior Mesenteric Artery Syndrome Treated with Percutaneous Radiologic Gastrojejunostomy / 대한소화기학회지

Superior mesenteric artery (SMA) syndrome is a rare condition that must be differentiated from other gastrointestinal diseases manifesting as upper abdominal pain, nausea, or vomiting. The description of SMA syndrome is compression of the third portion of the duodenum by the SMA and the abdominal aorta. SMA syndrome is managed with nasoenteral nutrition or surgical strategies such as laparoscopic duodenojejunostomy. However, SMA syndrome treated using enteral nutrition by percutaneous radiologic gastrojejunostomy has not been reported. Here, we report our experience of successfully managing a case of SMA syndrome with percutaneous radiologic gastrojejunostomy.

T-Fastener Migration after Percutaneous Gastropexy for Transgastric Enteral Tube Insertion

BACKGROUND/AIMS: To determine the prevalence and time-course of t-fastener migration after gastropexy deployment. METHODS: We reviewed our procedural database for all percutaneous gastrostomy and gastrojejunostomy tube insertions performed over a 14-month period using a widely accepted t-fastener kit for gastropexy (Kimberly-Clark). Of 201 patients, 71 (41 males, 30 females; mean age, 56 years) underwent subsequent abdominal computed tomography (CT) imaging. The location and associated findings of each t-fastener were retrospectively recorded for each CT scan performed after the tube insertion. RESULTS: A total of 153 t-fasteners were deployed during 71 procedures with subsequent CT follow-up. In the short term (within 4 weeks after deployment), 5.1% of the t-fasteners had detached and were no longer present; 59.5% were intraluminal or within the gastric wall; and 35.5% were within the anterior abdominal wall musculature or subcutaneous. In the long term (>3 months), 48.6% of the t-fasteners had detached and were no longer present, 25.0% were intraluminal or within the gastric wall, and 26.4% were within the anterior abdominal wall musculature or subcutaneous. No t-fastener-related complications, such as abscesses, fluid collections, or fistulae, were identified. CONCLUSIONS: Following gastropexy for percutaneous transgastric feeding tube placement, t-fastener migration into the abdominal wall frequently occurred soon after the tube insertion. Therefore, recent t-fastener deployment does not guarantee an intact gastropexy.

Totally Laparoscopic Roux-en-Y Gastrojejunostomy after Laparoscopic Distal Gastrectomy: Analysis of Initial 50 Consecutive Cases of Single Surgeon in Comparison with Totally Laparoscopic Billroth I Reconstruction

PURPOSE: Roux-en-Y reconstruction (RY) in laparoscopic distal gastrectomy for gastric cancer is a more complicated procedure than Billroth-I (BI) or Billroth-II. Here, we offer a totally laparoscopic simple RY using linear staplers. MATERIALS AND METHODS: Each 50 consecutive patients with totally laparoscopic distal gastrectomy with RY and BI were enrolled in this study. Technical safety and surgical outcomes of RY were evaluated in comparison with BI. RESULTS: In all patients, RY gastrectomy using linear staplers was safely performed without any events during surgery. The mean operation time and anastomosis time were 177.0+/-37.6 min and 14.4+/-5.6 min for RY, respectively, which were significantly longer than those for BI (150.4+/-34.0 min and 5.9+/-2.2 min, respectively). There were no differences in amount of blood loss, time to flatus passage, diet start, length of hospital stay, and postoperative inflammatory response between the two groups. Although there was no significant difference in surgical complications between RY and BI (6.0% and 14.0%), the RY group showed no anastomosis site-related complications. CONCLUSION: The double stapling method using linear staplers in totally laparoscopic RY reconstruction is a simple and safe procedure.

Superior Mesenteric Artery Syndrome in Patient with Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder that causes progressive muscular weakness, severe weight loss, and ultimately death. Gastrostomy or nasogastric tube is beneficial for ALS patients with severe weight loss and dysphagia. However, the development of superior mesenteric artery (SMA) syndrome in ALS patients when the enteral feeding time is delayed is rarely reported. We report herein the first case of SMA syndrome in a Korean ALS patient who showed improvement after percutaneous endoscopic gastrojejunostomy(PEGJ).

Gastrojejuno-colic fistula after gastrojejunostomy / 대한외과학회지

Gastrojejunocolic fistula is a rare condition after gastrojejunostomy. It is severe complications of gastrojejunostomy, which results an inadequate resection or incomplete vagotomy during peptic ulcer surgery. The symptoms are diarrhea, upper abdominal pain, bleeding, vomiting and weight loss. A 55-year-old man with chronic diarrhea and weight loss for 6 months visited Dankook University Hospital. The patient had received a truncal vagotomy and gastrojejunostomy for duodenal ulcer obstruction 15 years previously. The patient underwent gastroscopy and upper gastrointestinal series evaluations, which detected the gastrojejunocolic fistula. After improving of malnutrition, an exploratory laparotomy was undertaken, which revealed that the gastrojejunostomy site and the T-colon formed adhesion and fistula. En block resection of the distal stomach and T-colon included the gastrojejunocolic fistula, and Roux-en-Y gastrojejunostomy was performed. Recovery was uneventful and the patient remained well at the follow-up. We report a gastrojejunocolic fistula, which is a rare case after gastrojejunostomy.

Laparoscopic treatment of annular pancreas in adults: report of a case

The annular pancreas in adults is a rare congenital anomaly that is detected after development of complications, such as gastric outlet obstruction, recurrent pancreatitis, and peptic ulcer. Duodenal bypass is the procedure of choice for treating duodenal obstruction caused by the annular pancreas in both children and adults. Duodenoduodenostomy is routinely performed in neonates and children. In adults, duodenojejunostomy or gastrojejunostomy are recommended, because the duodenum is less mobile. We report a case of annular pancreas in a 33-year-old male that was successfully treated with laparoscopic gastrojejunostomy.

Using Multidetector-Row CT for the Diagnosis of Afferent Loop Syndrome Following Gastroenterostomy Reconstruction

PURPOSE: To assess the clinical manifestations and multidetector-row computed tomography (MDCT) findings of afferent loop syndrome (ALS) and to determine the role of MDCT on treatment decisions. MATERIALS AND METHODS: From January 2004 to December 2008, 1,100 patients had undergone gastroenterostomy reconstruction in our institution. Of these, 22 (2%) patients were diagnosed as ALS after surgery that included Roux-en-Y gastroenterotomy (n=9), Billroth-II gastrojejunostomy (n=7), and Whipple's operation (n=6). Clinical manifestations and MDCT features of these patients were recorded and statistically analyzed. The presumed etiologies of obstruction shown on the MDCT were correlated with clinical information and confirmed by surgery or endoscopic biopsy. RESULTS: The most common clinical symptom was acute abdominal pain, presenting in 18 patients (82%). We found that a fluid-filled C-shaped afferent loop in combination with valvulae conniventes projecting into the lumen was the most common MDCT features of ALS. Malignant causes of ALS, such as local recurrence and carcinomatosis, are the most common etiologies of obstruction. These etiologies and associated complications can be predicted 100% by MDCT. CONCLUSION: Our results suggest that MDCT is a reliable modality for assessing the etiologies of ALS and guiding treatment decisions.

Retrograde Jejunogastric Intussusception: A Case Report.

Jejunogastric Intussusceptions is a rare but potentially life threatening complication of a previous gastrectomy or gastrojejunostomy. A 70 years old man presented with severe epigastric pain followed by haematemesis, 8 years after truncal vagotomy and gastrojejunostomy for pyloric stenosis. Ultrasonography revealed dilated stomach with a large intragastric mass which has minimal peristaltic movement. Endoscopy of upper GIT revealed prolapsed segment of jejunal loops through the gastrojejunostomy stoma. Laparotomy disclosed a retrograde type II jejunogastric intussusception and was managed by reduction of jejunogastric intussusception, resection of gangrenous segment and end to end anastomosis. Post operative recovery was uneventful. Retrograde jejunogastric intussusceptions is a rare condition and around 200 cases has been reported since its first description in 1914. Urgent recognition and surgical treatment is mandatory to reduce the mortality rate from this complication.

Updates on Percutaneous Radiologic Gastrostomy/Gastrojejunostomy and Jejunostomy

Gastrostomy placement for nutritional support for patients with inadequate oral intake has been attempted using surgical, endoscopic, and, more recently, percutaneous radiologically guided methods. Surgical gastrostomy has been superseded by both endoscopic and radiologic gastrostomy. We describe herein the indications, contraindications, patient preparations, techniques, complications, and aftercare with regard to radiologic gastrostomy. In addition, we discuss the available tube types and their perceived advantages. There remain some controversies regarding gastropexy performance and primary percutaneous gastrojejunostomy. Percutaneous jejunostomy is indicated for patients whose stomach is inaccessible for gastrostomy placement or for those who have had a previous gastrectomy.

Multilevel Duodenal Injury after Blunt Trauma

Duodenal trauma is an uncommon injury associated with significant mortality and morbidity. Upper gastrointestinal radiological studies and computed tomography may lead to the diagnosis of blunt duodenal trauma. Exploratory laparotomy remains as the ultimate diagnostic test if a high suspicion of duodenal injury continues even in the face of absent or equivocal radiographic signs. The majority of duodenal injuries may be managed by simple repair of the injured site. More complicated injuries require more sophisticated techniques. Here, we report a case of multilevel blunt duodenal injury successfully managed with duodenal diverticulization, Roux-en-Y gastrojejunostomy and catheter duodenostomy.

Circular Stapled Gastrojejunostomy after Radical Subtotal Gastrectomy: Anastomotic Bleeding and Prevention

PURPOSE: Circular stapled gastrectomy has been the favored procedure with its feasibility and the shortened operative time, but anastomotic leakage, stenosis and bleeding have been reported as problems. The aim of this study was to identify what can be done to supplement the safety of this technique by examining the potential complications of performing circular stapled gastrojejunosomy after radical subtotal gastrectomy. MATERIALS AND METHODS: As subjects, this study selected 1,391 patients who underwent gastrojejunostomy after radical subtotal gastrectomy because of gastric cancer at our Department of Surgery from Jan. 1998 to Dec. 2007. The patients were divided into Group I (n=479) who underwent hand-sewn gastrojejunostomy, Group II (n=48) who underwent linear stapled gastrojejunostomy and Group III (n=864) who underwent circular stapled gastrojejunostomy. Group III was re-divided into two subgroups on the basis of the point of time that a visual check was intraoperatively performed at the anastomotic site: Group III-A (n=198) before and Group III-B (n=666) after. The characteristics and complications of the patients were then compared. RESULTS: For the comparison of the complications between Group I, Group II and Group III, anastomotic leakage was found in 7 cases (1.5%) in Group I, in 1 case (2.0%) in Group II and in 10 case (1.2%) in Group III, and anastomotic stenosis were found in 4 cases (0.8%) in Group I, 1 case (2.0%) in Group II and 5 case (0.6%) in Group III. Anastomotic bleeding was found in 32 cases (6.7%) in Group I, in 5 cases (10.4%) in Group II and in 67 cases (7.7%) in Group III. For the comparison of complications between Group III-A and Group III-B, anastomotic bleeding was found in 57 cases (28.8%) in Group III-A and 10 cases (1.5%) in Group III-B and the difference was statistically significant (P=0.037). CONCLUSION: Circular stapled gastrojejunostomy after radical subtotal gastrectomy is recommended because of the safety and feasibility of this technique, but bleeding at the anastomotic site may be the critical issue. In conclusion, direct inspection for bleeding at the anastomotic site during the operation will improve the safety of performing circular stapler anastomosis.