Diagnosis and management of surgical disease at Ethiopian health centres: cross-sectional survey of resources and barriers to care.

OBJECTIVES: The aim of this study was to characterise the resources and challenges for surgical care and referrals at health centres (HCs) in South Wollo Zone, Ethiopia. SETTING: Eight primary HCs in South Wollo Zone, Ethiopia. PARTICIPANTS: Eight health officers and nurses staffing eight HCs completed a survey. DESIGN: The study was a survey-based, cross-sectional assessment of HCs in South Wollo Zone, Ethiopia and data were collected over a 30-day period from November 2014 to January 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Survey assessed human and material resources, diagnostic capabilities and challenges and patient-reported barriers to care. RESULTS: Eight HCs had an average of 18 providers each, the majority of which were nurses (62.2%) and health officers (20.7%). HCs had intermittent availability of clean water, nasogastric tubes, rectal tubes and suturing materials, none of them had any form of imaging. A total of 168 surgical patients were seen at the 8 HCs; 58% were referred for surgery. Most common diagnoses were trauma/burns (42%) and need for caesarean section (9%). Of those who did not receive surgery, 32 patients reported specific barriers to obtaining care (91.4%). The most common specific barriers were patients not being decision makers to have surgery, lack of family/social support and inability to afford hospital fees. CONCLUSIONS: HCs in South Wollo Zone, Ethiopia are well-staffed with nurses and health officers, however they face a number of diagnostic and treatment challenges due to lack of material resources. Many patients requiring surgery receive initial diagnosis and care at HCs; sociocultural and financial factors commonly prohibit these patients from receiving surgery. Further study is needed to determine how such delays may impact patient outcomes. Improving material resources at HCs and exploring community and family perceptions of surgery may enable more streamlined access to surgical care and prevent delays.

Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers.

INTRODUCTION: Marginal ulcer is a common complication following Roux-en-Y gastric bypass with incidence rates between 1 and 16%. Most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. Revision of the gastrojejunal (GJ) anastomosis carries significant morbidity with complication rates ranging from 10 to 50%. Thoracoscopic truncal vagotomy (TTV) may be a safer alternative with decreased operative times. The purpose of this study is to evaluate the safety and effectiveness of TTV in comparison to GJ revision for treatment of recalcitrant marginal ulcers. METHODS: A retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from 1 September 2012 to 1 September 2017. All underwent medical therapy along with lifestyle changes prior to intervention and had preoperative EGD that demonstrated a recalcitrant marginal ulcer. Revision of the GJ anastomosis or TTV was performed. Data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. RESULTS: Twenty patients were identified who underwent either GJ revision (n = 13) or TTV (n = 7). There were no 30-day mortalities in either group. Mean operative time was significantly lower in the TTV group in comparison to GJ revision (95.7 ± 16 vs. 227.5 ± 89 min, respectively, p = 0.0022). Recurrence of ulcer was not significant between groups and occurred following two GJ revisions (15%) and one TTV (14%). Complication rates were not significantly different with 62% in the GJ revision group and 57% in the TTV group. Approximately 38% (5/13) of GJ revisions and 28% (2/7) of TTV patients experienced complications with Clavien-Dindo scores > 3. There was no difference in postoperative symptoms between both groups. CONCLUSIONS: Our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. However, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups.

Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy.

BACKGROUND: High dose intravenous proton pump inhibitor after endoscopic therapy for peptic ulcer bleeding has been recommended as adjuvant therapy. Whether oral proton pump inhibitor can replace intravenous proton pump inhibitor in this setting is unknown. This study aims to compare the clinical efficacy of oral and intravenous proton pump inhibitor after endoscopic therapy. METHODS: Patients with high-risk bleeding peptic ulcers after successful endoscopic therapy were randomly assigned as oral lansoprazole or intravenous esomeprazole group. Primary outcome of the study was re-bleeding rate within 14 days. Secondary outcome included hospital stay, volume of blood transfusion, surgical intervention and mortality within 1 month. RESULTS: From April 2010 to Feb 2011, 100 patients were enrolled in this study. The re-bleeding rates were 4% (2/50) in the intravenous group and 4% (2/50) in the oral group. There was no difference between the two groups with regards to the hospital stay, volume of blood transfusion, surgery or mortality rate. The mean duration of hospital stay was 1.8 days in the oral lansoprazole group and 3.9 days in the intravenous esomeprazole group (p > 0.01). CONCLUSION: Patients receiving oral proton pump inhibitor have a shorter hospital stay. There is no evidence of a difference in clinical outcomes between oral and intravenous PPI treatment. However, the study was not powered to prove equivalence or non-inferiority. Future studies are still needed. TRIAL REGISTRATION: NCT01123031.

Spinal cord stimulation as a novel approach to the treatment of refractory neuropathic mediastinal pain.

Spinal cord stimulation (SCS) offers new hope for patients with neuropathic pain. SCS "neuromodulates" the transmission and response to "painful" stimuli. The efficacy of SCS has been established in the treatment of a variety of neuropathic pain conditions and more recently in refractory angina pectoris, peripheral vascular disease, and failed back surgery syndrome. Recent publications suggest that visceral pain could be successfully treated with SCS. We report the first successful use of a spinal cord stimulator in the treatment of refractory neuropathic mediastinal, esophageal, and anterior neck pain following esophagogastrectomy.

Gastrocolic fistula as a complication after gastrojejunostomy.

Gastrocolic fistula formation is an extremely rare complication of gastric ulcer disease. We report a case of a 55-year-old man who presented with a two-month history of abdominal discomfort, postprandial diarrhea, nausea and faecal vomiting. Upper gastrointestinal endoscopy showed an ulcer in the greater curvature of the stomach. Barium enema examination revealed an obvious gastrocolic fistula between the greater curvature of the stomach and the transverse colon. The involved segment of the colon was excised and truncal vagotomy and antrectomy was performed. The patient was discharged on the 7th postoperative day. It is concluded that cases with postprandial diarrhea and nutritional disturbances after gastric surgery should remind us of the probability of gastrocolic fistula formation.

Avances en el síndrome aórtico agudo / Progress in the acute aortic syndrome

El síndrome aórtico agudo es un proceso agudo de la pared aórtica que afecta a la capa media; incluye la disección aórtica, el hematoma intramural y la úlcera penetrante. En los últimos años, las técnicas de imagen han ayudado a conocer la historia natural de estas entidades y a comprender mejor el importante dinamismo de esta enfermedad. A pesar de los importantes avances en el diagnóstico y el tratamiento quirúrgico, la mortalidad en la fase aguda sigue siendo alta. La sospecha clínica precoz y la mejoría de la experiencia quirúrgica parecen ser las únicas variables que podrían facilitar la reducción de la mortalidad. Una vez superada la fase aguda, en la mayoría de los pacientes permanece una afectación de la aorta descendente y un 30% presenta complicaciones a los 3-5 años. En esta fase es necesario instaurar un tratamiento médico óptimo y un seguimiento próximo con técnicas de imagen. La incorporación del tratamiento intravascular ha abierto nuevas perspectivas en el tratamiento de esta enfermedad y podría mejorar el pronóstico a largo plazo. En este artículo se revisan los avances en el diagnóstico y el tratamiento de este síndrome (AU)

Acute aortic syndrome is an acute lesion of the aortic wall involving the aortic media. The term covers aortic dissection, intramural hematoma, and penetrating ulcer. In the last few years, imaging techniques have increased our understanding of the natural history of these disease entities and of the dynamics of the disease processes. Despite significant advances in diagnosis and surgical treatment, the mortality rate in the acute phase remains high. Early clinical suspicion and greater surgical expertise appear to be the only factors that are able reduce mortality. Once the acute phase is past, the descending aorta continues to be involved in most patients, 30% of whom develop complications within 3-5 years. During this later phase, it is essential to optimize medical treatment and to use imaging techniques to follow-up the patient closely. The availability of endovascular treatment has provided new approaches to the management of the condition and could improve long-term prognosis. The aim of this article was to review recent progress in the diagnosis and therapeutic management of this syndrome (AU)

Gastrojejunocolic fistula following surgery for peptic ulcer complications: two case reports.

Two patients were admitted in the surgical unit--I of Mymensingh Medical College Hospital on January 2001 and March 2001 with the complaints of epigastric pain and discomfort, feculent eructation and fecal vomiting, diarrhoea with lienteric stools, weight loss and weakness. Both of them had previous history ulcer complications. The diagnoses of gastrojejunocolic fistula were made on the basis of history, barium enema examination and upper gastrointestinal endoscopy. Early resuscitation with correction of nutritional deficiencies, fluid and electrolyte imbalance was attempted along with blood transfusion, antibiotics and other supportive measures. But the first patient was too ill to cope up with the treatment and developed cardio-respiratory symptoms. A single stage procedure comprising of partial gastrectomy along with resection of the fistula and restoration of bowel continuity (by jejunojejunostomy, colocolostomy and closure of duodenal stump) was adopted in both patients. Early postoperative recovery was good in both but the first patient expired on 8th postoperative day from acute myocardial infarction, while the second one developed anastomotic leakage and wound infection, which were managed conservatively. On follow up the second patient was found in sound health till to date after his discharge from the hospital.

Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.

BACKGROUND: After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients. METHODS: We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy. RESULTS: We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P<0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13). CONCLUSIONS: After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.

Gastrojejunocolic fistula following surgery for peptic ulcer.

This article aims to emphasize that gastrojejunocolic fistula following peptic ulcer surgery, though uncommon in the post vagotomy era, still continues to occur. We stress the changing trends in its epidemiology, aetiopathogenesis and treatment. The case records of 12 patients with gastrojejunocolic fistula (seen over a 15 year period) were reviewed. Details regarding clinical presentation, investigations and treatment were analyzed and the results compared with previous published series. All the 12 patients in this study had a short loop posterior retrocolic gastrojejunostomy as part of the primary peptic ulcer surgery. Diarrhoea and profound weight loss was present in all of them. Incompleteness of vagotomy was proved in all the six patients investigated for the same. The fistula was demonstrated in all of them on barium enema, while it was seen on upper GI endoscopy in 4. Eight patients were treated by a one stage resection and repair of fistula. A three stage procedure was performed in two.

[The effect of alpha-glucosidase inhibitor on burning epigastralgia in dumping syndrome: a case report].

Dumping syndrome results from a rapid passage of carbohydrate in the small intestine after gastric surgery. A 50-year-old man developed the syndrome after surgery for peptic ulcer. He often complained of burning epigastralgia after meals. Various methods of treatment had only a limited effect. Acarbose, alpha-glucosidase inhibitor, suppresses the breakdown of carbohydrates in the small intestine and consequently reduced osmolarity. The patient had a dramatic improvement in the dumping syndrome including epigastralgia, diarrhea and perspiration with an administration of acarbose 50 mg. There was no intractable side effect. Preprandial administration of acarbose is a reasonable treatment in the case of dumping syndrome.

[Diagnosis, prevention and treatment of postoperative reflux gastritis]. / Diagnostika, profilaktika i lechenie posleoperatsionnogo refliuks-gastrita.

Postoperative reflux gastritis in persons who were operated on for peptic ulcer occurs much more frequently after resection of the stomach (68.6%) than after organ-preserving operations on the stomach (39.4%). The incidence of reflux gastritis after gastric resection depends on the type of gastroenteroanastomosis. It is encountered much less frequently after Roux' operation (9.2%). The pronounced character and frequency of reflux gastritis after organ-preserving operations on the stomach are determined by the type of stomach-draining operations, the localization of the ulcer before the operation, whether in the stomach or the duodenum, the existence of duodenogastric reflux (DGR) before the operation. Measures for the prevention of postoperative reflux gastritis in the management of peptic ulcer are as follows: (a) wide introduction of organ-preserving operations, preferably SPV by itself or in combination with duodenoplasty; (b) formation of Roux' gastroenteroanastomosis when resection of the stomach is indicated. Reflux gastritis must be treated by nonoperative methods, including medicinal, dietetic, and spa therapy. Surgery is indicated in reflux gastritis combined with other diseases of a stomach which had been operated on, for which an operation is necessary, and in occasional cases of erosive reflux gastritis.

Long-term consequences of surgical treatment of peptic ulcer.

Surgical treatment of peptic ulcer may lead to several late postoperative morphological and metabolic abnormalities. Forty two patients (16 females and 26 males) at mean age of 47 years after surgery for peptic ulcer (mean postoperative period of 9 years) were recruited in this study. Following methods have been used for evaluation of those patients: clinical and serum biochemical assessment, UGI tract endoscopy, histology of gastric or duodenal mucosa biopsies, test for H-pylori presence, Ca-P-Mg homeostasis and BMD using DXA-absorptiometry. No clinical and biochemical abnormalities were found. In 60% of examined pts gastritis or duodenitis with various degrees of the reflux were found endoscopicaly. In 64% of pts histology showed signs of mucosal inflammation. Recurrent ulcer was found in 3 pts. H-pylori was present in 16 pts (40%). The significant reduction of BMD, especially of the lumbar spine, in the pts after the PG resection in comparison to the pts with the vagotomy was found. Within several years after gastric operation the patient must be carefully evaluated and adequate supplementation of Ca and vitamin D is strongly recommended.

[The effect of HBO therapy in the early postoperative period on the late outcomes of "compelled" suturing in perforated gastroduodenal ulcers]. / Vliianie GBO-terapii v rannem posleoperatsionnom periode na otdalennye iskhody "vynuzhdennogo" ushivaniia probodnykh gastroduodenal'nykh iazv.

Under study were long-term results of forced suturing of perforated ulcers of the stomach and duodenum in 96 patients. It was shown that in patients who were subjected to hyperbaric oxygenation in addition to medicamentous treatment at the early postoperative period excellent and good results were obtained two times more often and there was 1.5 time less amount of bad outcomes as compared with patients who were not given HBO therapy. A conclusion is made that HBO therapy has a positive influence at the early postoperative period on restoration of the disturbed balance in the system "aggression-protection" in ulcer disease which results in greater number of patients who recovered after suturing perforated gastroduodenal ulcers.

[The effect of mud treatment on the function of the bile-secreting system]. / Vliianie griazelechenie na funktsional'noe sostoianie zhelchevydelitel'noi sistemy.

Ultrasonic scanning following a course of mud therapy found out a stimulatory effect of the treatment on gallbladder motility. The bile composition reflected an anti-inflammatory action of mud applications which also enhanced bile lithogenesis.

[The prevention and treatment of postoperative intestinal paralysis in peptic ulcer surgery]. / O profilaktike i lechenii posleoperatsionnogo pareza kishechnika v khirurgii iazvennoi bolezni.

Under analysis were results of using intraintestinal electrostimulation with autonomous electrostimulators of gastrointestinal tract and graded enteral probe nutrition under control of intraintestinal pressure in 68 patients after operation on the stomach and duodenum. The method gives more rapid recovery of the intestine mobility, is economically profitable, makes the risk of insufficiency of the duodenal stump after gastric resection considerably less. The method is recommended for clinical practice.

[Functional state of the stomach after vagotomy and the correction of various post-vagotomy complications]. / Funktsional'noe sostoianie zheludka posle vagotomii i korrektsiia nekotorykh post-vagotomicheskikh oslozhnenii.

The author studied the secretory and motor-emptying function and the endoscopic picture of the stomach after various types of vagotomy conducted for peptic ulcer in 84 patients. The effect of the motor-evacuative function on the secretion values is shown. It is pointed out that secretion must be studied after restoration of adequate motor-emptying function, which is normalized 3-6 months after the operation. The endoscopic picture of the stomach depends on the type of the auxiliary operation on the stomach and the lapse of time after the operation, and the existence of reflux. The author suggests a differentiated complex of rehabilitation therapy including endogenous intracavitary pneumomassage of the stomach, its percutaneous electrostimulation, and the intake of mildly-mineralized water; early application of these measures raises the efficacy of the surgical treatment.

Bile acids and the increased risk of colorectal tumours after truncal vagotomy.

An association between colorectal cancer and previous peptic ulcer surgery is reported. In a prospective screening study, 100 asymptomatic patients (80 men and 20 women) who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema, colonoscopy and gallbladder ultrasonography. Control data were obtained from forensic autopsy subjects. The incidence of neoplasms greater than or equal to 1.0 cm in the vagotomized group was 14 per cent (11 adenomas, 3 carcinomas) and 3 per cent in controls (P = 0.01). Duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography. The mean percentage of cholic (CA), chenodeoxycholic (CDCA), deoxycholic (DCA) and lithocholic (LCA) acids in the bile of vagotomized patients was 32.3, 45.6, 20.7 and 1.4 per cent respectively compared with 45.3, 36.2, 17.9 and 0.7 per cent respectively in controls. The increased proportions of CDCA and LCA and decreased proportions of CA in the duodenal bile of vagotomized patients were significant (P less than 0.001; P = 0.02; P = 0.007). Abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy.