Endoscopic submucosal dissection for the treatment of a large inflammatory fibroid polyp in the gastric antrum prolapsing into the duodenum: A case report.

RATIONALE: Inflammatory fibroid polyp (IFP), also known as Vanek tumor, is a rare, benign gastrointestinal lesion characterized by its inflammatory and fibroid histological features. IFP is often discovered incidentally during endoscopic examinations. It is exceedingly rare for an IFP to prolapse into the duodenum and results in incomplete obstruction of the pylorus. PATIENT CONCERNS: A 64-year-old male patient was admitted to the hospital with recurrent episodes of melena over a 6-month period, along with complaints of dizziness and fatigue in the past 10 days. DIAGNOSES: Gastroscopy showed a giant polypoid mass on the posterior wall of the gastric antrum, prolapsing into the duodenum. Abdominal computer tomography (CT) confirmed the tumor protruding into the duodenum. Pathologic examination of the resected specimen confirmed the IFP diagnosis. INTERVENTIONS: The giant tumor was completely and successfully excised using endoscopic submucosal dissection (ESD). After the surgery, the patient underwent acid suppression and fluid replenishment therapy. OUTCOMES: The patient responded well to ESD and was discharged in stable condition. As of the submission of the case report, there has been no recurrence of the tumor after a 5-month follow-up, and the patient is still under follow-up. LESSONS: While IFPs have traditionally been managed surgically, ESD demonstrates promising treatment outcomes, avoiding the need for surgical distal gastrectomy, and emerges as a safe and effective treatment option.

Endoscopic Removal of an Embedded Fishbone in the Gastric Antrum.

This report showed the clinical manifestations of a 26-year-old patient who was admitted to our hospital with epigastric discomfort. Computed tomography (CT) showed a hyper-density linear object Esophagogastroduodenoscopy (EGD) revealed a submucosal bulge in the gastric antrum. And endoscopic ultrasonography (EUS) demonstrated a hyperechoic lesion with a posterior shadowing in the anechoic area. Based on the above results, a diagnosis of fishbone invasion into the antral submucosa was considered. Then endoscopic submucosal dissection (ESD) was performed and a 3-cm-long fishbone was extracted with the forceps. As a rare case, the imaging findings of the fishbone under the endoscopy and the computed tomography were described.

Endoluminal Leiomyoma of the Gastric Antrum: a Report of a Rare Case.

Endoluminal gastric leiomyoma (GL) of the antrum is a rare benign tumor. In this paper, we report a case of a 72-year-old patient that presented for a 1-month episode of epigastric pain. Imaging found a well-limited tumor in the antrum with extrinsic compression on ulcerated congestive mucosa. A surgical resection based on Finsterer's antrectomy with end-to-side trans-mesocolic gastro-jejunal anastomosis was performed. The histopathological examination in combination with immunohistochemistry diagnosed GL and found a diffuse and marked staining of smooth muscle actin (SMA) and h-caldesmon (h-CD) and negative expression of CD117 and DOG1. The patient was discharged without post-surgical complications and is still alive at the time of this case report writing.

Antrum Preservation Versus Antrum Resection in Laparoscopic Sleeve Gastrectomy With Effects on Gastric Emptying, Body Mass Index, and Type II Diabetes Remission in Diabetic Patients With Body Mass Index 30-40 kg/m2: a Randomized Controlled Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a widely performed procedure nowadays. There is a controversy on whether antrum resection (AR) or antrum preservation (AP) should be done and if this has an effect on BMI, gastric emptying, and associated medical conditions such as diabetes mellitus (DM). STUDY DESIGN: This randomized controlled trial included 56 patients in the AP group and 53 patients in the AR group with BMI 30-40 kg/m2. Weight, BMI, fasting and postprandial blood glucose (FBS and PPBS), HbA1C, oral hypoglycemic drug use, and % gastric emptying by gastric scintigraphy at 30, 60, 90, and 120 min were recorded preoperatively and postoperatively at 3, 6, and 12 months. Postoperative % of total weight loss (TWL) and symptoms of de novo GERD were observed at 3, 6, and 12 months. RESULTS: The AR group had significantly lower BMI and HbA1C and higher %TWL than the AP group. There was a significant difference between the two groups regarding % of gastric emptying with the AP group showing higher values at 30, 60, 90, and 120 min. There were no significant differences regarding FBS, PPBS, and oral hypoglycemic use. The AR group had more incidence of GERD symptoms postoperatively yet with no significant difference. CONCLUSION: LSG with antrum resection (2 cm from the pylorus) had significantly less postoperative BMI, higher %TWL, better control of type II DM, and more retention of gastric contents in patients with BMI 30-40 kg/m2 in comparison with LSG with antral preservation with non-significant increase in incidence of GERD symptoms.

Pyloric gland adenoma with low-grade intraepithelial neoplasia: A case report and literature review.

RATIONALE: Pyloric gland adenoma (PGA) is often associated with pyloric gland metaplasia. It has high malignant potential but a low clinical diagnosis rate. Therefore, we reported a case of PGA and reviewed the literature to summarize the clinicopathological features of pyloric adenoma. PATIENT CONCERNS: A 62-year-old female underwent gastroscopy due to intermittent acid regurgitation and heartburn, which revealed a 4×6 mm flat, elevated lesion in the greater curvature of the upper gastric body, with depression in the central region and blood scab attachment. DIAGNOSIS AND INTERVENTION: Biopsy revealed gastric adenoma with low-grade intraepithelial neoplasia. The patient was treated with ESD, and pathology showed gastric pyloric gland adenoma with low-grade dysplasia. The cells were positive for MUC6 and MUC5AC immunohistochemically. OUTCOMES: The patient received proton pump inhibitors and gastric mucosal protective agents for one month after ESD. She occasionally presented acid regurgitation and heartburn, with no abdominal pain, abdominal distension, melena, or hematochezia. Follow-up gastroscopy will be reexamined 1 year later. LESSONS: PGA has nonspecific performance under endoscopy, and its diagnosis mainly depends on pathology. Clinicians need to increase their ability to recognize such lesions and treat them in time to improve the prognosis.

Complete resection of the gastric antrum decreased incidence and severity of delayed gastric emptying after pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) is the main complication after pancreaticoduodenectomy (PD), but the mechanism is still unclear. The aim of this study was to elucidate the role of complete resection of the gastric antrum in decreasing incidence and severity of DGE after PD. METHODS: Sprague-Dawley rats were divided into three groups: expanded resection (ER group), complete resection (CR group), and incomplete resection (IR group) of the gastric antrum. The tension (g) of remnant stomach contraction was observed. We analyzed the histological morphology of the gastric wall by different excisional methods after distal gastrectomy. Moreover, patients underwent PD at our department between January 2012 and May 2016 were included in the study. These cases were divided into IR group and CR group of the gastric antrum, and the clinical data were retrospectively analyzed. RESULTS: The ex vivo remnant stomachs of CR group exhibited much greater contraction tension than others (P < 0.05). The contraction tension of the remnant stomach increased with increasing acetylcholine concentration, while remained stable at the concentration of 10 × 10-5 mol/L. Furthermore, 174 consecutive patients were included and retrospectively analyzed in the study. The incidence of DGE was significantly lower (3.5% vs. 21.3%, P < 0.01) in CR group than in IR group. In addition, hematoxylin-eosin staining analyses of the gastric wall confirmed that the number of transected circular smooth muscle bundles were higher in IR group than in CR group (8.24 ± 0.65 vs. 3.76 ± 0.70, P < 0.05). CONCLUSIONS: The complete resection of the gastric antrum is associated with decreased incidence and severity of DGE after PD. Gastric electrophysiological and physiopathological disorders caused by damage to gastric smooth muscles might be the mechanism underlying DGE.

[Two unusual causes of peptic anastomotic ulcer]. / Dve neobychnye prichiny pepticheskoi yazvy anastomoza.

Two unusual cases of anastomotic ulcer complicated by bleeding after gastric resection are reported. There were retained antrum in one patient and long 'dry' intestinal loop after laparoscopic Roux resection in another one. Emergency gastric stump resection with Haberer procedure were successfully performed in both cases.

Effects of Proton Pump Inhibitor on the Distribution of Helicobacter pylori and Associated Gastritis in Patients with Gastric Atrophy.

BACKGROUND/AIMS: Acid suppression therapy is thought to be associated with the topography of Helicobacter pylori and associated gastritis, leading to corpus-predominant gastritis. This study was aimed to investigate the influence of proton pump inhibitor (PPI) treatment on the distribution of H. pylori and associated gastritis in patients with atrophic change. METHODS: Patients who underwent endoscopic resection for gastric neoplasms and received PPI for 2 months were prospectively analyzed. Biopsy specimens were obtained from 5 areas in the stomach before, during, and after the treatment with PPI. Histological examination was -performed using the updated Sydney system, and -bacterial density of H. pylori was further graded by immunohistochemistry (ClinicalTrials.gov registration number NCT02449941). RESULTS: A total of 15 patients were analyzed, of whom 7 had H. pylori infection. The degree of activity and inflammation were greater in patients with H. pylori infection than in those without H. pylori infection. During the PPI treatment, the density of H. pylori decreased not only in the antrum but also in the corpus. The degree of activity and inflammation improved significantly in the antrum, particularly in the presence of H. pylori infection, while the corpus gastritis was not affected by PPI use. Atrophy and intestinal metaplasia remained unchanged in both regions of the stomach. The observed changes reverted following the discontinuation of PPI treatment. CONCLUSION: PPI treatment decreased H. pylori both in the antrum and the corpus in patients with atrophic gastritis. Antral gastritis improved during PPI treatment, whereas no changes were found in the corpus.

Comparison of Weight Loss in Sleeve Gastrectomy Patients With and Without Antrectomy: a Prospective Randomized Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) restricts gastric volume to achieve weight loss. We aimed to compare the efficacy of LSG with and without antrectomy for achieving weight loss. METHODS: The prospective randomized study comprised 127 obese patients that underwent either LSG with antrectomy (2 cm to pylorus) (group 1) or LSG without antrectomy (6 cm to pylorus) (group 2), using 36 Fr and 32 Fr bougies, respectively. Patients were examined at 3-, 6-, 12-, and 24-month intervals for body mass index (BMI) measurements. RESULTS: Overall, 66 (51%) and 57 (49%) of patients were assigned to groups 1 and 2, respectively. The mean BMI of group 1 patients were 49.5 ± 8.01, 35.8 ± 5.40, 31.3 ± 4.9, 26.7 ± 4.02, and 22.9 ± 4.01 at the baseline, 3rd, 6th, 12th, and 24th month, respectively. The decreases in BMI were statistically significant. The mean BMI of group 2 patients were 46.7 ± 7.06, 39.3 ± 6.04, 32.4 ± 5.01, 26.6 ± 3.76, and 21.6 ± 3.70 at baseline, 3rd, 6th, 12th, and 24th month, respectively. The differences were also statistically significant. When compared with group 2, group 1 patients showed significantly lower BMI values on the 3rd month. Other differences were not statistically significant. CONCLUSION: LSG with or without antrectomy is safe and effective for weight loss. Larger studies are required to identify patients likely to benefit from LSG with antrectomy.

How does the extent of antral resection affect the residual gastric volume and excessive weight loss?

AIM: To identify the effect of the extent of antral resection on the residual gastric volume (RdGV) and excess weight loss (EWL) among patients who underwent laparoscopic sleeve gastrectomy(LSG) due to the obesity. MATERIAL AND METHODS: The demographical data, operative details, postoperative morbidity, mortality and the percentages of EWL in the postoperative 3, 6 and 12 months of the patients who underwent LSG between January 2014 and August 2015 were analyzed. These patients were divided into three groups regarding the antral resection margin (ARM): Group 1(n=80): ARM≤3cm; Group2 (n=35): 3 6cm from pylorus) resulted in reduced operating cost and decelerated reach to optimal EWL% with similar postoperative outcomes. KEY WORDS: Antral resection margin, Excess weight loss, Laparoscopic sleeve gastrectomy, Residual gastric volume, Surgical technique.

[Surgical treatment of ulcerative pyloroduodenal stenosis]. / Khirurgicheskoe lechenie iazvennogo piloroduodenal'nogo stenoza.

AIM: To obtain the most reliable information about surgical treatment of ulcerative pyloroduodenal stenosis based on the methodology of evidence-based medicine. MATERIAL AND METHODS: Searching platforms were elibrary, Cochrane Library and PubMed database. The probability of major systematic errors in randomized controlled trials (RCTs) was evaluated. RESULTS: Systematic review included 20 RCTs for the period 1968-2009 with overall sample of 1794 patients. Evaluation of external validity allows to generalize the results of these studies to the entire population of patients with ulcerative pyloroduodenal stenosis. Assessment of internal validity based on the number of systematic errors showed that 7 (35%) of 20 of RCTs corresponded to the highest level of evidence (level 1), 13 (65%) of 20 had systematic errors and were downgraded in the rating (level 1-). Significant heterogeneity of RCTs impedes metaanalysis. Conclusions and practical recommendations for the treatment of ulcerative pyloroduodenal stenosis are formed according to the results of individual RCTs. CONCLUSION: Selective vagotomy may be performed for functional stenosis. In case of organic stenosis, truncal vagotomy should be combined with drainage surgery (pyloroplasty, gastroenterostomy) or Roux/Billroth-1 antrectomy. Treatment of decompensated stenosis within evidence-based medicine is unclear. We have not identified target researches with evidence level 1 for this form of stenosis.

Treatment of Congenital Gastric Outlet Obstruction due to a Web: A Retrospective Single-center Review.

BACKGROUND: Congenital gastric antral web and congenital pyloric atresia are rare reasons of congenital gastric outlet obstruction (CGOO). Depending on the different forms, the symptoms vary from unspecific epigastric pain to nonbilious "projectile" vomiting, ileus and failure to thrive. Throughout the years, many different treatment options are described, like simple surgical dilatation, incision or excision of the membrane, possibly combined with a pyloroplasty. PATIENTS AND METHODS: In this retrospective single-center observation study, we present 9 cases with different kinds of webs leading to CGOO. In a time period of 45 years (1970 to 2015) different treatment strategies and limitations of minimal invasive endoscopic treatment on the basis of complications and outcome are discussed. RESULTS: Six patients had an incomplete antrum web. One patient suffered from a complete antrum web. In addition, in 2 patients a complete pyloric web, as well as an incomplete pyloric web was found. During the past 45 years, the treatment options for CGOO due to webs changed, and with the development of smaller and more flexible video endoscopes an endoscopic treatment has become feasible. The treatment strategy and follow-up examination was specific to every patient. CONCLUSION: On the basis of our review, minimal endoscopic procedures in small newborns and toddlers require a high level of experience. They are technically challenging and need suitable equipment. Overall, endoscopists and pediatric surgeons should equally be prepared for all possible complications in every treatment step. The endoscopic approach to managing this unusual disease may require multiple interventions and is associated with a risk of perforation. Therefore, we are convinced that centers undertaking this treatment modality should be equipped with the proper instrumentation, prepared to perform multiple endoscopic interventions, and supported with an ability to emergently convert to surgery if required.

Uninodular Fibromyxomatous Gastric Tumor Resected by Endoscopic Submucosal Dissection.

Esophagogastroduodenoscopy of a 45-year-old woman revealed a submucosal tumor in the gastric antrum. Endoscopic submucosal dissection of the tumor was performed. The histological findings revealed a fibromyxomatous tumor composed of myofibroblastic cells with no evidence of malignancy. The growth pattern of the resected specimen was not multinodular or plexiform. We therefore tentatively referred to the present tumor descriptively as a gastric uninodular fibromyxomatous tumor, stressing its singular nodularity. It was initially roughly 10 mm in size but grew over a period of 4 years. A uninodular plexiform fibromyxoma might increase in size but might not become multinodular if it remains small.

Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection.

BACKGROUND: Among the controversial points in laparoscopic sleeve gastrectomy (LSG) is how much of the antrum to be resected. This study aimed to evaluate food tolerance after preservation or resection of the antrum during LSG. METHODS: Prospective randomized study included 50 patients scheduled for LSG. Participants were randomly allocated into one of two groups. In antral resection (AR-LSG) group (n = 25), resection started 2 cm from the pylorus. In antral sparing (AS-LSG) group (n = 25), it started 6 cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6 months. Quality of life (QOL) was evaluated by using the Bariatric Analysis and Reporting Outcome System (BAROS). Food tolerance was assessed using the Quality of Alimentation questionnaire. Primary outcome measure was food tolerance and %EWL. RESULTS: Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6 months. The two groups were comparable in %EWL and BMI change after 3 and 6 months. Six months after surgery, the majority of patients had a very good quality of life, with no significant difference between the two groups (p = 0.877). There was no significant difference between the two groups in operative time, intraoperative blood loss, and hospital stay. CONCLUSIONS: Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6 months postoperatively when compared with total antral resection.

[Comparison of clinicopathological features and prognosis between adenocarcinoma of esophagogastric junction and adenocarcinoma of gastric antrum].

OBJECTIVE: To compare the clinicopathological features and the prognosis between patients with adenocarcinoma of esophagogastric junction (AEG) and with adenocarcinoma of gastric antrum (AGA), and to investigate the prognostic factors of AEG and AGA. METHODS: A retrospective cohort study was performed on clinicopathological data of 239 AEG patients (AEG group) and 313 AGA patients selected simultaneously (AGA group) undergoing operation at Harbin Medical University Cancer Hospital from January 2001 to December 2012. INCLUSION CRITERIA: (1) receiving radical surgery (R0 resection); (2) AEG or AGA confirmed by pathological examination of postoperative tissue specimens; (3) without preoperative neoadjuvant radiotherapy or chemotherapy; (4) complete clinicopathological and follow-up data; (5) patients who died of non-tumor-related causes were excluded. Chi-square test and independent samples t-test were used to determine differences in clinicopathological factors between two groups. The overall survival (OS) of patients was compared by Kaplan-Meier method and Log-rank test. Multivariate prognosis analysis was performed using Cox proportional hazards regression model. RESULTS: As compared to AGA group, AEG group had higher proportion of male [82.0%(196/239) vs. 65.2%(204/313),χ²=19.243,P<0.001], older age [(60±10) years vs. (55±12) years, t=4.895, P<0.001], larger tumor diameter [(5.6±2.4) cm vs. (5.0±3.3) cm, t=2.480,P=0.013], more T4 stage[64.8%(155/239) vs. 55.6%(174/313),Z=-3.998, P<0.001], and more advanced tumor stage [stage III:60.7%(145/239) vs. 55.6%(174/313),Z=-2.564,P=0.010]. There were no statistically significant differences in serum albumin or hemoglobin between two groups (all P>0.05). The 5-year OS rate was 33.5% and 56.9% in AEG group and AGA group respectively and the median OS was 60.0(3.0-60.0) months and 33.6(3.0-60.0) months respectively; the difference was statistically significant (P<0.001). In AEG group, univariate analysis showed that differences of hemoglobin level (5-year OS rate: 24.0% for <130 g/L, 39.9% for ≥130 g/L, P=0.006), tumor diameter (5-year OS rate: 41.9% for <5 cm,28.8% for ≥5 cm, P=0.014), N stage (5-year OS rate: 42.2% for N0, 40.9% for N1, 31.7% for N2, 15.8% for N3a, 9.0% for N3b, P<0.001) and TNM stage (5-year OS rate: 56.2% for stage I, 38.5% for stage II, 28.3% for stage III,P=0.017) were statistically significant (all P<0.05); multivariate analysis revealed that the worse N stage was an independent risk factor of prognosis survival for AEG patients(HR=1.404,95%CI:1.164-1.693, P<0.001), and serum hemoglobin level ≥130 g/L was an independent protective factor of prognosis survival for AEG patients (HR=0.689,95%CI:0.501-0.946,P=0.021). In AGA group, univariate analysis showed that differences of serum albumin (5-year OS rate: 49.1% for <40 g/L, 61.1% for ≥ 40 g/L, P=0.021), tumor diameter (5-year OS rate: 74.2% for <5 cm, 39.9% for ≥ 5 cm, P<0.001), T stage (5-year OS rate: 98.3% for T1,83.3% for T2,50.0% for T3,36.8% for T4, P<0.001), N stage (5-year OS rate: 89.0% for N0, 62.3% for N1, 50.0% for N2, 33.9% for N3a, 10.3% for N3b, P<0.001) and TNM stage (5-year OS rate: 97.3% for stage I, 75.8% for stage II, 32.8% for stage III, P<0.001) were statistically significant (all P<0.05); multivariate analysis revealed that the worse T stage (HR=1.516,95%CI:1.060-2.167,P=0.023) and the worse N stage (HR=1.453,95%CI:1.209-1.747,P<0.001) were independent risk factors for prognosis of AGA patients. CONCLUSIONS: As compared to AGA, AEG presents have poorer prognosis,and is easier to present with later pathological stage and larger tumor diameter. N stage and hemoglobin level are independent factors associated with the OS of AEG patients. T stage and N stage are independent factors associated with the OS of AGA patients.