Post-Gastrectomy Complications - An Overview.

Post-gastrectomy complications have been the associated sequelae after curative gastrectomy for long time. They include a conundrum of symptoms ranging from serious metabolic alterations to disorders attributed to mechanical and neural factors after reconstruction of the digestive continuity. Though, with the advancement in the surgical expertise and techniques and shift towards medical and endoscopic management for benign gastro-duodenal ulcer disease, there has been a decline in the incidence of these complications; they continue to raise "red flags" after major oncologic gastric resections. Identification of these symptoms and protocol based management of the same is of utmost importance in the surgical armamentarium of trainees and practicing physicians and surgeons.

Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) can result in de novo and worsen preexisting gastroesophageal reflux disease (GERD). Post-LSG patients with GERD refractory to proton pump inhibitors (PPI) usually undergo more invasive, anatomy-altering Roux-en-Y gastric bypass surgery. Lower esophageal sphincter (LES) electrical stimulation (ES) preserves the anatomy and has been shown to improve outcomes in GERD patients. OBJECTIVE: To evaluate the safety and efficacy of LES-ES in post-LSG patients with GERD not controlled with maximal PPI therapy. SETTING: Prospective, international, multicenter registry. METHODS: Patients with LSG-associated GERD partially responsive to PPI underwent LES-ES. GERD outcomes pre- and poststimulation were evaluated based on quality of life, esophageal acid exposure (after 6-12 mo), and PPI use. RESULTS: Seventeen patients (11 female, 65%), treated at 6 centers between May 2014 and October, 2016 with a median follow-up of 12 months (range 6-24), received LES-ES. Median age was 48.6 years (interquartile range, 40.5-56), median body mass index 31.7 kg/m2 (27.9-39.3). All patients were on at least daily PPI preoperatively; at last follow-up, 7 (41%) were completely off PPI, 5 (29%) took PPI on an intermittent basis, and 5 (29%) were on single-dose PPI. Median GERD-health-related quality of life scores improved from 34 (on-PPI, 25-41) at baseline to 9 (6-13) at last follow-up (off-PPI, P<.001). Percentage of time with esophageal pH<4 improved from 13.2% (3.7-30.7) to 5.8% (1.1-54.4), P = .01. CONCLUSION: LES-ES in post-LSG patients suffering from symptomatic, PPI-refractory GERD resulted in significant improvement of GERD-symptoms, esophageal acid exposure, and need for PPI. Preserving the post-LSG anatomy, it offers a valid option for patients unable or unwilling to undergo Roux-en-Y gastric bypass surgery.

Role of the gastroenterologist in the management of the obese patient. / Papel del digestólogo en el manejo del paciente obeso.

Obesity is a highly prevalent disease worldwide, and one in which gastroenterologists can play an important role. Some digestive diseases are more common in obese patients, and preoperative evaluation may be required in some cases. Additionally, bariatric surgery can lead to digestive complications in the short and long term that require intervention, and endoscopic treatment can be an important factor in weight loss. The aim of this review is to highlight the role of the gastroenterologist in the management of obese patients who are either scheduled for or have undergone surgical or endoscopic treatment for obesity.

[Acute pancreatitis and afferent loop syndrome. Case report]. / Pancreatitis aguda y síndrome de asa aferente. Reporte de caso.

BACKGROUND: The afferent syndrome loop is a mechanic obstruction of the afferent limb before a Billroth II or Roux-Y reconstruction, secondary in most of case to distal or subtotal gastrectomy. Clinical case: Male 76 years old, with antecedent of cholecystectomy, gastric adenocarcinoma six years ago, with subtotal gastrectomy and Roux-Y reconstruction. Beginning a several abdominal pain, nausea and vomiting, abdominal distension, without peritoneal irritation sings. Amylase 1246 U/L, lipase 3381 U/L. Computed Tomography with thickness wall and dilatation of afferent loop, pancreas with diffuse enlargement diagnostic of acute pancreatitis secondary an afferent loop syndrome. CONCLUSION: The afferent loop syndrome is presented in 0.3%-1% in all cases with Billroth II reconstruction, with a mortality of up to 57%, the obstruction lead accumulation of bile, pancreatic and intestinal secretions, increasing the pressure and resulting in afferent limb, bile conduct and Wirsung conduct dilatation, triggering an inflammatory response that culminates in pancreatic inflammation. The severity of the presentation is related to the degree and duration of the blockage.

Antecedentes: el síndrome de asa aferente se caracteriza por la obstrucción mecánica del asa aferente luego de la reconstrucción tipo Billroth II o en Y de Roux, en la mayoría de los casos secundaria a gastrectomía distal o subtotal. Caso clínico: paciente masculino de 76 años de edad, con antecedentes de: colecistectomía, adenocarcinoma gástrico seis años previos, gastrectomía subtotal y reconstrucción en Y de Roux. Inició con dolor abdominal, náusea y vómito; abdomen distendido, sin datos de irritación peritoneal. Amilasa 1246 U/L, lipasa 3381 U/L. La tomografía computada abdominal mostró dilatación y engrosamiento de la pared del asa aferente y el páncreas con incremento de tamaño. Se le diagnosticó pancreatitis aguda, originada por síndrome de asa aferente. Conclusiones: el síndrome de asa aferente aparece en 0.3 a 1% de los casos de pacientes con reconstrucción Billroth II, a consecuencia de la obstrucción mecánica del asa aferente, con mortalidad incluso de 57%. La obstrucción del intestino aferente por acumulación de secreción biliar, pancreática e intestinal incrementa la presión, que resulta en dilatación del asa aferente de la vía biliar y del conducto de Wirsung, lo que desencadena una respuesta inflamatoria que finaliza en un cuadro de pancreatitis. Su manifestación severa se relaciona con el grado y duración de la obstrucción.

The postoperative radiological features of laparoscopic sleeve gastrectomy.

Obesity is rapidly becoming one of the major challenges for health care systems. Surgery has proved to be one of the most effective methods of helping patients to achieve sustainable weight loss. Laparoscopic sleeve gastrectomy is a relatively new bariatric surgical technique. A staple line is placed in a line parallel to the lesser curve of the stomach, excluding up to 85% of the volume of the stomach. The excluded stomach is then resected leaving a 'tube' of residual stomach. Radiologists may be asked to perform and interpret imaging studies in the postoperative period and should be familiar with the normal appearances and common complications. Postoperative radiological investigations will typically be for suspected leak or obstruction. A water soluble contrast upper gastrointestinal (UGI) series should be performed in both suspected leak and obstruction if the patient is conscious and able to swallow. A normal postoperative UGI series will show free flow of contrast into the gastric remnant, which will be tubular with no spillage of contrast beyond the staple line, which is located on the caudal aspect of the gastric remnant. Stenosis or obstruction of the stomach may occur if the stomach remnant is too tight or torsion of the stomach. Stenosis is usually treated endoscopically with dilation and torsion is treated surgically. Leaks are often treated with covered stents which may be placed with endoscopic or radiological guidance. Collections may be drained under fluoroscopic, ultrasound or computed tomography guidance.

Complications of laparoscopic adjustable gastric banding: our local experience.

Obesity is a major medical problem both within Australia as well as throughout the developed world. Achievement of weight loss for any individual patient brings an additional desirable benefit of improvement or resolution of a wide range of comorbid conditions. Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and allied diseases. The term bariatrics was created around 1965, from the Greek root baro ('weight' as in barometer), suffix-iatr (relating to medical treatment) and suffix -ic ('pertaining to'). Besides the pharmacotherapy of obesity, it is concerned with obesity surgery. Bariatric surgery refers to surgical procedures of the gastrointestinal tract that are designed to induce weight loss. The treatment of obesity traditionally relied on non-surgical techniques to modify behaviour in regard to diet and exercise. This has variable and limited success. More recently, bariatric surgery has become the most rapidly growing form of treatment for obesity in recent years. In fact, it is the only current therapy that has been shown to achieve major and durable weight loss. It is important for the radiologist to be familiar with the normal anatomical appearance of the more common bariatric operations and to be able to recognise their potential complications on imaging. The aim of this pictorial essay is to give an insight into some of the more common complications of laparoscopic adjustable gastric banding surgery encountered in our centre during the period of 2001-2007.

[Improving the quality of life after gastrectomy is the next issue after saving the lives of patients with gastric cancer].

Gastrectomy saves the lives of many patients with gastric cancer. However, this surgical treatment is associated with clinical problems called postgastrectomy syndrome (PGS) which affect the quality of life (QOL) of such patients. For surgeons, improving the QOL after gastrectomy is an important goal after performing curative surgery. In the clinical setting, various surgical procedures such as limited resection, function-preserving procedures, and reconstruction using gastric substitutes have been advocated to reduce the severity of PGS. However, the actual conditions and pathophysiology of PGS have not been fully investigated. Various clinical studies and basic research have partially clarified the features and pathophysiology of PGS, although the strategies developed to treat PGS have been limited. The development of standardized, reliable instruments for understanding PGS and performing large-scale collaborative studies are required to improve the diagnosis and treatment of PGS. In Japan, such a project called the PGSAS has recently been completed. The results are being analyzed and will be reported in the near future.

[Functional syndromes after surgery of the upper gastrointestinal tract]. / Funktionelle Syndrome nach Oberbaucheingriffen.

Functional and metabolic syndromes after surgery of the upper gastrointestinal tract (including the pancreas) are frequent. Resections of organs mandate the reconstruction with a change of anatomy. Predominantly, the reconstruction using a Y-en-Roux jejunal loop is used. The surgical alteration of the anatomy may lead to a different physiology. Patients after esophagectomy or gastrectomy may suffer from dysphagia, dumping syndromes, reflux and anaemia. Pancreatic resections or drainage operations may cause an exocrine or endocrine insufficiency. Patients after surgery for gastroesophageal reflux or achalasia may have gas-related symptoms such as bloating and flatulence. The treatment options of these syndromes include physical measures, drugs, interventional procedures and even revisional surgery. Detailed preoperative information of the procedure and multidisciplinary postoperative treatment (general practitioner, surgeon, gastroenterologist etc.) of evolving functional syndromes is mandatory to achieve a high standard of care.

[Postgastrectomy syndromes in therapeutic practice ].

AIM: To specify policy of nutritive support late after radical gastric resection. MATERIAL AND METHODS: Patients with postgastroresectional dystrophy were examined using standard techniques and estimation of intestinal electric activity (registration of body surface biopotentials on Conan-M myngograph). RESULTS: Frequency-amplitude parameters of the intestine serve the basis for choice of mixtures for enteral correction. Nutritive support provided for on demand pharmaconutrients--microbiotic correctors. CONCLUSION: Myography gives additional information for decisions on the policy of nutritive support.

Postgastrectomy syndromes--diagnosis and treatment.

The stomach has a variety of functions that are lost with gastrectomy. Since nowadays a significant number of patients are long-term survivors, consequences of this loss need to be considered by gastroenterologists and surgeons alike. Abnormal transit, disturbed general nutrition and micronutrient deficiencies are the most common problems. The main resulting symptoms are early and late dumping, reflux esophagitis, weight loss, anemia, and osteopathy. It is not definitively clear if pouch reconstruction can really improve the situation. Dietary measures, rarely re-operation, and in particular adequate follow-up of metabolic and nutrition parameters with consequent substitution are the main therapeutic necessities.

[Longitudinal study on quality of life after gastrectomy for gastric cancer and starting points for intensified care]. / Longitudinaluntersuchung zur Befindlichkeit von Magenkarzinompatienten mit Gastrektomie: Ansatzpunkte zur Intensivierung der Betreuung?

UNLABELLED: This prospective longitudinal study on gastric carcinoma patients with gastrectomy was designed to answer the question about changes in several determinants of the quality of life (QL) at various times before and after surgery and to obtain evidence for specific approaches of therapeutic intervention. METHODS AND PATIENTS: 36 patients were given a questionnaire structured according to Eypasch et al. (self- assessment) before surgery, at discharge from the hospital, and after 3 and 6 months. The dual structure of the questions makes it possible to determine whether a single item is present at all (prevalence) and to what extent it impairs the quality of life (no impairment/some/moderate/strong impairment--corresponding to 0-3). The data were evaluated per domain of QL as well as item-related. RESULTS: Postoperatively, 14 patients had to be excluded from the study because of non-radical surgery, complications, recurrences, etc. After 6 months the items of all QL-determinants showed the lowest prevalence with the exception, however, of the somatic determinants, the items of which showed a prevalence of 27 % preoperatively, 64 % at discharge from the hospital, 58 % after 3 months, and 46 % after 6 months. The average degree of QL-impairment increased continuously from 1.17 preoperatively to 1.61 after 6 months. Preoperatively the psychic domain was predominantly impaired, postoperatively the somatic domain. CONCLUSION: Analysis of the subjective quality of life can reveal care deficits. Gastrectomy-associated symptoms seem to influence the quality of life considerably in the first 6 months after surgery. More attention has to be paid to the sequelae of surgery. The high pre- and postoperative frequency of psychic impairment makes it desirable to provide special psychooncological offers of care.

Segmental gastrectomy for early cancer in the mid-stomach.

BACKGROUND/AIMS: We modified the surgical procedure for segmental gastrectomy, which is normally used for peptic ulcers, to treat early gastric cancer of the mid-stomach. In this paper, we describe the surgical technique and its results. METHODOLOGY: The location of the tumor was confirmed by intra-operative endoscopic examination. An area 2 cm proximal and distal to the tumor was marked with sutures. Firstly, the lymph nodes were dissected from around the perigastric and along the left gastric and common hepatic arteries. Then, a segmental gastrectomy was performed. The greater omentum, omental sac, and vagal nerve, including the hepatic, pyloric and celiac rami, were left intact. An end-to-end gastrogastrostomy was performed using Gambee's sutures and 4-0 monofilament polydioxanone. Gastric drainage was not necessary. RESULTS: We performed segmental gastrectomies on 30 patients. Tumors less than 1 cm in diameter were found in 4 patients; 1.1-2 cm in 14, 2.1-5 cm in 11, and a tumor exceeding 5.1 cm in one patient. The cancer was confined to the mucosa in 23 patients; in the other 7, it had penetrated the submucosa. No lymph node metastases were found but 2 patients had microscopic invasion or permeation of the lymphatic vessels. One patient required post-operative balloon dilation of the pyloric sphincter for delayed gastric emptying. The remaining patients had no post-operative complications. To date, 29 patients, excluding one who died in a traffic accident, have survived disease-free for a mean of 30 months (range: 7-51). Their body weight and dietary volume returned to pre-operative levels within 12 months of surgery. CONCLUSIONS: Patients who underwent segmental gastrectomy have had a reasonably good quality of life in the post-operative follow-up to date.