A case of gastrojejunocolic fistula with steatohepatitis.

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

Successful nutritional therapy for superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome is an uncommon cause of duodenal outlet obstruction. Symptoms and signs suggestive of this condition are nonspecific, and a high index of suspicion coupled with appropriate imaging studies are necessary for diagnosis. We present the case of a 70-year-old man who developed SMA syndrome following prolonged hospitalisation for a surgically treated bleeding duodenal ulcer. His SMA syndrome resolved after successful nonoperative management based on accepted guidelines for nutritional therapy, thus avoiding the need for reoperation and its attendant risks in a malnourished patient.

Wernicke's encephalopathy after cephalic pancreaticoduodenectomy.

Wernicke's encephalopathy is an acute neurological disorder resulting from thiamine deficiency. We report a case in a young patient who underwent a cephalic duodenopancreatectomy with a bleeding duodenal ulcer refractory to endoscopic and surgical treatment, requiring total parenteral nutrition, without thiamine supplementation.

[Correction of the motor-evacuation function of the postoperative stomach in the early postoperative period].

We conducted the analysis of the results of surgical treatment of 255 patients with duodenal ulcers. In the early postoperative period the evacuation and motility function of the postoperative stomach was corrected with the use of the autonomous electrostimulator of the gastrointestinal tract (EAS GT) in all patients - in the main group (n = 125) and drug stimulation (cerucal 2.0 intramuscularly twice a day) and in the control group (n = 130). The use of EAS GT-3 certainly reduces symptoms of dyscoordination of the motor function of the gastrointestinal tract.

Liver penetration by a duodenal ulcer in a young woman.

Liver penetration is a rare but serious complication of peptic ulcer disease. We report a case of a 33-year-old woman who took large doses of nonsteroidal antiinflammatory drugs and developed a giant duodenal ulcer that penetrated into her liver. The diagnosis was based on histologic examination of endoscopic biopsies. She was initially treated with a proton pump inhibitor, but, within 5 weeks, she developed a symptomatic postbulbar stricture that required surgical correction. We also review 11 other reported cases of endoscopically and histologically diagnosed peptic ulcer penetration into the liver.

Operations for peptic ulcer disease: paradigm lost.

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

[Laparoscopic surgery of perforated duodenal ulcer]. / Trattamento laparoscopico dell'ulcera duodenale perforata.

BACKGROUND AND AIM: Endoscopic diagnostic and therapeutic possibilities have been increased by videolaparoscopy. The method enables an immediate reliable diagnosis to be made, associated with possible surgical treatment. METHODS: The authors report their laparoscopic experience relating to the treatment of perforated duodenal ulcer from 1972 to 1995 in 8 patients divided into two groups. Jacob Palmer's laparoscopic operator was used in the first group together with Menghini's needle for the aspiration of peritoneal effusion; the operation was performed under local anesthesia with nitrogen monoxide insufflation using Taylor's technique number I. The second group underwent ulcorrhaphy with omentopexy, again using a laparoscopic route, together with abundant lavage and accurate aspiration of fibrin. RESULTS: The patients in the first group made a prompt recovery in terms of their general conditions following the remission of fever, pain, diminished leukocytes and an early renewal of canalisation; cicatrisation of the ulcer was confirmed by the endoscopic control on day 15. Patients in the second group showed early deambulation approximately 4 hours after surgery; canalisation occurred after about 6 hours and all patients were discharged on day 3. The eradication of Helicobacter pylori led to complete resolution, as was confirmed by subsequent follow-ups. CONCLUSIONS: Laparoscopy was found to be extremely useful both in the immediate diagnosis of acute abdomen following perforated ulcer and in its surgical treatment as a result of the introduction of operating laparoscopes and in particular videolaparoscopes, together with surgical instruments that allow careful abdominal cleansing and ulcorrhaphy. In the authors' opinion, the latter procedure is the most suitable for managing this pathology.

[The importance of electrogastrography in clinical practice]. / Znachennia elektrohastrohrafiï v klinichnii praktytsi.

Changes were analyzed in electrogastrogrammes (EGG) of 135 patients who had underwent a surgical treatment for gastric and duodenal ulcer. Time of restoration of bioelectrical activity of the stomach was determined, with diagnostic and prognostic value of EGG during the process of rehabilitation being shown. Changes in EGG were studied in 92 patients with acute appendicitis. Efficiency of the above procedure was established with respect to obtaining supplementary objective data of informative value on the course of the pathological process in the abdominal cavity, which fact permits the prognostication of the different complications development. Transcutaneous electrostimulation of the stomach was shown to be helpful in gastroenterological patients as was intracavitary pneumomassage.

[2-Component silicone compounds in the emergency surgery of gastrointestinal hemorrhages]. / Dvukhkomponentnye silikonovye kompozitsii v neotlozhnoi khirurgii zheludochno-kishechnykh krovotechenii.

Based upon their clinico-experimental investigations the authors prove advantages of the two-component silicon compositions over oil preparations for the arrest of gastro-intestinal bleedings. Such compositions are recommended for patients whose treatment by traditional methods of hemostasis proved to be ineffective due to some causes which is often observed in elderly and senile patients.

[Effects of transcutaneous electrostimulation on motor function of the stomach after abdominal surgery]. / Vplyv cherezshkirnoï elektrostymuliatsiï na rukhovu funktsiiu shlunka pislia vykonannia abdominal'noï operatsiï.

While examining of 35 patients it was revealed that transcutaneous gastric electrostimulation application may influence the frequency and amplitude of gastric contractions, its tone and hydrogen ions secretion. Gastric electrostimulation efficacy was noted in 83.3% of patients after cholecystectomy conduction and in 58.3%--after laparotomy, conducted for peritonitis.

[The causes of incompetence of the duodenal stump and gastroenteric anastomosis and the means for its prevention in the surgery of duodenal ulcers]. / Prichiny nesostoiatel'nosti kul'ti dvenadtsatiperstnoi kishki i gastroénteroanastomoza i puti ee preduprezhdeniia v khirurgii duodenal'nykh iazv.

Causes of the incompetence of stump sutures in resection of the stomach observed in 90 out of 3479 patients with chronic duodenal ulcers were analyzed. Most patients were found to have a combination of general and local factors. Among the local factors the leading one was appearance of a large inflammatory infiltration around the "active" ulcers. The endoscopic autohemoapplication to the ulcer included in the complex of preoperative preparation of the patients reduced the frequency of incompetence of sutures from 2.58% to 1.33%.

[A study of subtotal gastrectomy under the acupuncture combined with epidural anesthesia of small dosage].

Forty-eight cases with benign gastric diseases were operated using acupuncture at Zusanli (ST 36) and Neiguan (PC 6) combined with epidural anesthesia of small dosage (group A, 39 cases), and simple epidural anesthesia of small dosage (group B, 9 cases). The results show that the effect in the group A is better than that in the group B. Namely, the analgesia is stronger, the tractive reaction of internal organs is lighter, the abdominal muscles are more relaxed, the dosage of anesthetic is much smaller and the physiological disturbance is less in the group A.

A new diagnostic test for incomplete vagotomy: experimental study in dogs.

Despite the decline in the number of operations for intractable duodenal ulcer disease, there are still many patients who suffer from the side effects of vagotomy. Incomplete vagotomy may be a significant cause of surgical treatment failure. Diagnosis of incomplete vagotomy is not easy since there is no reliable, safe, single test available for this purpose. We hypothesized that incomplete vagotomy can be made temporarily complete in response to a muscarinic blocking agent. A gastric cannula was inserted and vagotomy performed in 12 female dogs, which was incomplete in 6 and complete in 6 dogs. Gastric acid secretion was stimulated for 2 h with i.v. pentagastrin at a rate of 6 micrograms/kg per h. After the first hour 6 mg/kg pirenzepine (M1 muscarinic receptor antagonist which may block the effect of intact vagal fibers on postganglionic submucosal neurons) was added i.v. In the complete vagotomy dogs there was no significant decrease in gastric output rate: 12.28 +/- 4.06 mEq/h in the first hour, and 12.00 +/- 3.80 mEq/h in the second hour (mean +/- SE, P = 0.963, t = 0.048). In the incomplete vagotomy dogs a significant decrease in gastric acid output rate was observed: 10.19 +/- 1.10 mEq/h in the first hour, and 4.33 +/- 0.95 mEq/h in the second hour (mean +/- SE, P = 0.002, t = 4.029). We conclude that a pentagastrin/pirenzepine test may differentiate between complete and incomplete vagotomy in the dog.

[The rehabilitative treatment of patients following gastric resection at the hospital stage]. / Vosstanovitel'noe lechenie bol'nykh posle rezektsii zheludka na gospital'nom étape.

To diminish the frequency of postoperative pulmonary complications following gastric resection and stay in hospital, a complex of preventive and therapeutic measures has been designed and tested in 165 patients. The complex involves early exercise, aerosol therapy, vibratory massage, heparin electrophoresis of the chest. Clinicophysiological data on respiratory function, pulmonary circulation, hemocoagulation support the effectiveness of the rehabilitation in patients after gastric resection.

[The rehabilitative treatment of patients following stomach resection for peptic ulcer]. / Vosstanovitel'noe lechenie bol'nykh posle rezektsii zheludka po povodu iazvennoi bolezni.

The paper presents the results of the examination and treatment of 59 and 44 patients subjected to gastric resection for gastroduodenal ulcer early and late after the surgery, respectively. Special courses of aftertreatment are suggested. Electrophoresis of Karachi [correction of Karachinskaya] mud-water solution was explored as a component of the treatment.

[Gastrojejunocolic fistula. Report of 5 cases].

Gastrojejunocolic fistula is rare complication of recurrent peptic ulcer disease after gastrectomy and gastrojejunostomy. This paper reported five cases of gastrojejunocolic fistula. It's etiological, clinical, and surgical features were briefly discussed. The symptoms of gastrojejunocolic fistula are diarrhea, upper abdominal pain, gastrointestinal bleeding, fecal vomiting, anasarca, and weight loss. The physical examinations and laboratory studies revealed malnutrition. The diagnosis is most reliably and frequently made by barium enema and gastroscopy. Surgical treatment of gastrojejunocolic fistula includes one-stage resection, complete remove of antral mucosa; vagotomy; partial re-resection of the gastric stump; excision of the fistulous connection with the colon. TPN or TEN should be administered in patients suffering from malnutrition with TEN as the first choice in those when a nasoenteric tube could placed into the jejunum.