Timing of pyloric stenosis and effectiveness of endoscopic balloon dilation after pyloric endoscopic submucosal dissection.

BACKGROUND AND AIM: There have been studies on risk factors for stenosis after pyloric endoscopic submucosal dissection (ESD). However, the most appropriate strategies for the management of cases with these risk factors have not been established. This study aimed to investigate post-ESD management by evaluating the timing of stenosis and the effectiveness of endoscopic balloon dilation (EBD) after pyloric ESD. METHODS: We retrospectively reviewed cases of pyloric ESD. We first reassessed risk factors for stenosis in multivariate analysis and receiver operating characteristic curve and defined patients with the identified risk factors as the risk group. The primary outcome was the timing of stenosis in the risk group assessed by the Kaplan-Meier method. RESULTS: We reviewed 159 cases with pyloric ESD and observed pyloric stenosis in 25 cases. Cases with circumferential mucosal defect ≥ 76% were identified as the risk group. The stenosis-free probability in the risk group was 97% (95% confidence interval [CI]: 79-100%), 94% (95% CI: 76-98%), and 85% (95% CI: 66-93%) on days 7, 14, and 21, respectively. It decreased every week thereafter and did not significantly change after day 56. Twenty-three stenosis cases, except for conservative improvement, including six whole circumferential pyloric ESD cases, were improved by EBD without complications. CONCLUSIONS: Post-ESD stenosis often developed from the third to the eighth week. In all pyloric ESD cases, including whole circumferential pyloric ESD cases, pyloric stenosis was improved following EBD without complications.

[A Case of Advanced Gastric Cancer with Umbilical Metastasis, Pyloric Stenosis, and Peritoneal Dissemination Underwent Palliative Surgery after Chemotherapy].

A 62-year-old woman was diagnosed with gastric cancer, Type 4, cT4b(LN, mesentery of transverse colon), N1 M1H0P1CY1, cStage ⅣB. S-1 and L-OHP(SOX)were administered for 4 courses and clinical response was SD. She interrupted the treatment because of practicing folk therapy. She had an emergency hospitalization due to pyloric stenosis, vomiting, and an umbilical tumor with pain. She was treated with 1 course of mFOLFOX6(5-FU, L-OHP, l-LV)followed by palliative surgery(laparoscopy assisted distal gastrectomy, Roux-en-Y reconstruction, resection of umbilical tumor, and bypass for transverse colon stenosis due to dissemination). The pathological diagnosis was L, Circ, Type 4, 126×89 mm, por> sig, pT4b(SI, mesentery of transverse colon), pN3a(12/13), H0P1CY1, pStageⅣ, and metastatic umbilical tumor. Following surgery, oral administration of mFOLFOX6 is continued. Umbilical metastasis(Sister Mary Joseph's nodule)is associated with poor prognosis, however, appropriate management including symptom control by palliative surgery and continuation of chemotherapy may lead a better prognosis.

Fitobezoar gástrico gigante secundario a estenosis pilórica tratado con Coca-Cola(R): a propósito de un caso / Giant gastric phytobezoar secondary to pyloric stenosis treated with Coca-Cola(R): A case report

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Retrospective Cohort Study on the Optimal Timing of Orogastric Tube/Nasogastric Tube Insertion in Infants With Pyloric Stenosis.

BACKGROUND: Hypertrophic pyloric stenosis in infants can cause a buildup of gastric contents. Orogastric tubes (OGTs) or nasogastric tubes (NGTs) are often placed in patients with pyloric stenosis before surgical management to prevent aspiration. However, exacerbation of gastric losses may lead to electrolyte abnormalities that can delay surgery, and placement has been associated with increased risk of postoperative emesis. Currently, there are no evidence-based guidelines regarding OGT/NGT placement in these patients. This study examines whether OGT/NGT placement before arrival in the operating room was associated with a longer time to readiness for surgery as defined by normalization of electrolytes. Secondary outcomes included time from surgery to discharge and ability to tolerate feeds by 6 hours postoperatively in patients with and without early OGT/NGT placement. METHODS: In this multicenter retrospective cohort study, data were extracted from the medical records of 481 patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis from March 2013 to June 2016. Multivariable linear regression and Cox proportional hazard models were constructed to evaluate the association between placement of an OGT/NGT at the time of admission with increased time to readiness for surgery (defined as the time from admission to the first set of normalized laboratory values) and increased time from surgery to discharge. Multivariable logistic regression was used to evaluate the association between early OGT/NGT placement and the ability to tolerate oral intake at 6 hours postsurgery. Analyses were adjusted for site differences. RESULTS: Among patients admitted with electrolyte abnormalities, those with an OGT/NGT placed on presentation required more time until their serum electrolytes were at acceptable levels for surgery by regression analysis (19.2 hours difference; 95% confidence interval, 10.05-28.41; P < .001), after adjusting for site. Overall, patients who had OGTs/NGTs placed before presentation in the operating room had a longer length of stay from surgery to discharge than those without (38.8 hours difference; 95% confidence interval, 25.35-52.31; P < .001), after adjusting for site. OGT/NGT placement before surgery was not associated with failure to tolerate oral intake within 6 hours of surgery after adjusting for site, corrected gestational age, and baseline serum electrolytes. CONCLUSIONS: OGT/NGT placement on admission for pyloric stenosis is associated with a longer time to electrolyte correction in infants with abnormal laboratory values on presentation and, subsequently, a longer time until they are ready for surgery. It is also associated with longer postoperative hospital stay but not an increased risk of feeding intolerance within 6 hours of surgical repair.

Current perioperative care of infants with pyloric stenosis: comparison of survey results.

BACKGROUND: Considerable variation in the perioperative management of infants with pyloric stenosis (PS) led the authors to undertake a survey of pediatric anesthesiologists to determine if consensus-based guidelines could be developed. MATERIALS AND METHODS: Physicians who are members of the Society for Pediatric Anesthesia or the Association of Pediatric Anaesthetists of Great Britain and Ireland completed an online questionnaire through SurveyMonkey regarding current management of patients with PS. RESULTS: There were significant differences in the use of anticholinergic premedication, the selection of induction technique, and the use of adjuvant regional analgesia between the members of both organizations. CONCLUSIONS: The authors recommend creating an international multiinstitutional registry to prospectively record and track perioperative management of patients with PS to facilitate the development of clinical practice guidelines.

The treatment of pyloric stenosis: Evolution in practice.

Over the last hundred years, idiopathic hypertrophic pyloric stenosis has undergone an evolution in treatment, with subsequent improvements in outcome. Initially, it was treated by physicians with antispasmodics and various alternative feeding and resuscitation modalities. The evolution of surgical approaches led to a revolution in outcome, from almost certain death to complete cure. The progression of surgical and medical treatments is reviewed in this article until, ultimately, Ramstedt's pyloromyotomy is reached. This distilled operation has remained the gold-standard procedure for over a century.

Utilidad de la determinación de cobre en periodo neonatal. Enfermedad de Menkes / Usefulness of Cu determination in the neonatal period. Menkes disease

Bajas concentraciones séricas de Cu en neonatos pueden ser la primera señal de una ingesta deficiente de este elemento o, alternativamente, de enfermedades genéticas que afectan su metabolismo. Desgraciadamente, es difícil la interpretación de las concentraciones de Cu en esta población, ya que están influenciadas por distintos factores, entre ellos la prematuridad, el tipo de alimentación y la presencia de un estado inflamatorio. Sin embargo, en el caso que aquí se describe fue la baja concentración sérica de Cu la primera pista para el diagnóstico de enfermedad de Menkes. Se demuestra así la utilidad de la determinación de Cu dentro de protocolos neurometabólicos y de retraso psicomotor en población neonatal y lactante (AU)

Low serum Cu concentrations in newborns can be the first indication of a severe Cu deficient intake or, alternatively, of genetic diseases affecting Cu metabolism. Unfortunately, interpretation of serum Cu concentrations in this population is difficult because they also influenced by several variables, such as, prematurity, type of feeding and inflammatory conditions. However, in the case described in this paper was a low serum Cu concentration the first clue for diagnosing Menkes disease. It is so demonstrated the usefulness of Cu determination within neurometabolic or psychomotor retardation protocols for newborn and infant populations (AU)

Risk factors and management for pyloric stenosis occurred after endoscopic submucosal dissection adjacent to pylorus.

Endoscopic submucosal dissection (ESD) has been widely accepted as a curative treatment for gastric neoplasm. Pyloric stenosis is a chronic complication that can be caused by ESD. The aim of this study is to clarify the risk factors and management for pyloric stenosis. From January 2004 to January 2014, a total of 126 patients who underwent ESD adjacent to pylorus were reviewed retrospectively. Pyloric mucosal defect was defined as when any resection margin of ESD was involved in the pyloric ring. Pyloric stenosis was defined as when a conventional endoscope could not be passed to the duodenum. Among the 126 patients, pyloric stenosis was identified in 9. In a univariate analysis, pyloric stenosis was more common in older patients (P < 0.05) and in lesions with resections over 75% of the pyloric ring circumference (P < 0.001). In a multivariate analysis, the factor that was associated with pyloric stenosis was the extent of the pyloric ring dissection (P < 0.001). Four of the 9 patients with pyloric stenosis had mild dyspepsia, and the others had gastric outlet obstruction symptoms. The 5 symptomatic patients underwent endoscopic balloon dilation (EBD), and the frequency of EBD was 1 to 8 times. The asymptomatic patients were treated conservatively. The incidence of pyloric stenosis was higher in lesions with resections over 75% of the pyloric ring circumference. Although EBD was an effective treatment for pyloric stenosis, conservative management was also helpful in patients who had mild symptoms.

NSAID-induced pyloric stenosis leading to oesophageal intramucosal dissection.

We describe a rare case of a 75-year-old woman with significant non-steroidal anti-inflammatory drug (NSAID) use who presented with haematemesis. Upper endoscopy revealed a large (9 cm) intramucosal dissection of the oesophagus without extension into the gastro-oesophageal junction and a severely narrowed pylorus. We postulate that she developed pyloric stenosis due to peptic ulcer disease from chronic NSAID use. This then led to gastro-oesophageal reflux. Undigested pills in the refluxate had contacted oesophageal mucosa, leading to pill-induced oesophageal injury. This, along with vomiting, is postulated to have led to the oesophageal intramucosal dissection. She improved with conservative medical management with a clear liquid diet and proton pump inhibitors, and a follow-up upper endoscopy 1 week later showed recovery of the previously seen intramucosal dissection.

[Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]. / Behandlung postoperativer Passagestörungen, Cholangitis und Pankreatitis.

Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction.

AIM: To evaluate the safety and efficacy of partially covered self-expandable metallic stents (SEMSs) in benign pyloric obstruction. METHODS: We retrospectively analyzed data from 10 consecutive patients with peptic ulcer-related pyloric obstructive symptoms (gastric outlet obstruction scoring system (GOOSS) score of 1) between March 2012 and September 2013. The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center. We assessed the technical success, symptom improvement, and adverse events after stenting. RESULTS: Early symptoms were improved just 3 d after SEMS placement in all 10 patients. The GOOSS score of all patients improved from 1 to 3. There were no serious immediate adverse events. The overall rate of being symptom free was 90% at a median of 11 mo of follow-up (range: 4-43 mo). Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation. Among them, four patients had sustained symptom improvement after the SEMS procedure. During the follow-up period, migration of the SEMS was observed in two patients (20.0%), both of whom had previous endoscopic balloon dilatation before SEMS insertion. CONCLUSION: Despite the small number in this study, partially covered SEMSs showed a favorable and safe outcome in the treatment of naïve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

[Gastroduodenal stent placement in gastric cancer patients with pyloric stenosis].

We examined 11 gastric cancer patients undergoing gastroduodenal stent placement for the treatment of gastric outlet obstruction at our hospital, and assessed the significance and problems associated with stenting. None of the patients exhibited any complications associated with stenting, and the median post-stenting fasting period was 3 days(range, 1-7 days). Oral intake improved significantly in all the patients; in patients with nasogastric tubes, the tubes were removed after stenting. However, in patients with peritoneal dissemination, oral intake alone was not sufficient, and additional parenteral nutrition was required. In conclusion, gastroduodenal stenting is believed to be useful for palliative care in gastric cancer patients with pyloric stenosis.

[A case of unresectable gastric cancer in a patient who maintained a good quality of life with multidisciplinary treatment].

Herein, we report the case of 57-year-old woman who visited our hospital for abdominal distention, difficulty in walking, and edema of the legs in January 2012. She underwent gastroendoscopy, resulting in a diagnosis of advanced gastric cancer of the pyloric antrum. A diagnosis of unresectable advanced gastric cancer was made because computed tomography (CT) showed the presence of ascites (suspected to indicate peritoneal dissemination), para-aortic lymph node metastases, and brain metastases. Stenting was performed for pyloric stenosis and cell-free and concentrated ascites reinfusion therapy (CART) was administered to facilitate oral intake. We administered two courses of chemotherapy with weekly paclitaxel. However, CT showed the presence of ascites and growth of the main tumor in the first month after the initiation of chemotherapy. We performed CART, and treatment was changed to S-1/paclitaxe(l 5 courses). Ascites decreased markedly and activities of daily living improved. However, 11 months after the initiation of therapy, the patient died.

Recanalization of severe gastric antral stricture after large endoscopic submucosal dissection: mucosal incision and local steroid injection.

Endoscopic submucosal dissection (ESD) of early gastric cancer is well-established in Japan. Although ESD enables en bloc resection of large lesions, it results in an extensive artificial ulcer that might lead to severe stricture, especially in case of large ESD in the pre-pylorus area. Here, we report two cases suffering from severe antral stenosis. The first case was refractory severe antral stenosis after a large ESD. Though we performed endoscopic balloon dilations, it remaind severe stricture. We made a mucosal incision on the opposite side of the ulcer scar and local triamcinolone acetonide (TA) injection into the incision site. In the second case there was considerable improvement of a pinhole stenosis using ESD counter-incision and local TA injection. Local steroid injection into the post-ESD artificial ulcer promotes the formation of granulation tissue of the healing process leading to regeneration of gastric mucosa without gastric deformity. Making a mucosal incision on the opposite side of post ESD ulcer and cutting the submucosal layer eases the mucosal tension, and the local injection of TA into a large artificial ulcer following ESD can prevent re-stenosis.

Atropine sulphate: rescue therapy for pyloric stenosis.

Infantile hypertrophic pyloric stenosis (IHPS) is a common condition which presents with non-bilious vomiting and failure to thrive secondary to gastric outlet obstruction. In the UK, management is by fluid resuscitation followed by pyloromyotomy. Incomplete myotomy complicates 0.3% of cases necessitating further surgery and exposing the patient to further risk. Medical management of IHPS with antimuscarinics to promote pyloric relaxation is a well-described treatment modality that is used as first-line therapy in some countries. The use of this technique is limited by the need for extended hospital admission with parenteral nutrition administration. We describe a case of IHPS complicated by incomplete pyloromyotomy and subsequently managed successfully by atropine sulphate therapy.