Aetiology and clinical spectrum of gastric outlet obstruction in North West India.

Our study to evaluate the aetiological and clinical spectrum of gastric outlet obstruction (GOO) in North-west India showed malignant cause (54.9%) was more common than benign (45.1%). Common causes of malignancy were gall bladder (37.5%), gastric (31.8%) and pancreatic carcinoma (19.6%); commonest benign causes were opioid abuse (29%), peptic ulcer disease (21.6%), ingestion of corrosives (20.2%) and chronic pancreatitis (12.3%).

Patient-generated subjective global assessment versus nutritional risk screening 2002 for gastric cancer in Chinese patients.

Aim: Patient-Generated Subjective Global Assessment (PG-SGA) and Nutritional Risk Screening 2002 (NRS2002) are used to evaluate patients' nutritional status. Materials & methods: The data of 114 gastric cancer patients with pyloric obstruction treated between July 2016 and July 2017 were assessed retrospectively. Results: Based on clinical evaluation, 70.1% had malnutrition, with 61.4% at nutritional risk by NRS2002 and 66.7% by PG-SGA. The area under the receiver operating characteristic curve was 0.858 for PG-SGA and 0.706 for NRS2002. Sensitivity and specificity were 89 and 85% for PG-SGA and 78 and 76% for NRS2002. In both assessments, patients at risk showed more postoperative complications. Conclusion: PG-SGA was more suitable for evaluating the preoperative nutritional status of gastric cancer patients with pyloric obstruction, with higher diagnostic efficacy.

Delayed gastric emptying following pancreatoduodenectomy: a Roux-en-Y gastrojejunostomy vs Billroth II gastrojejunostomy randomized study

Introduction: delayed gastric emptying (DGE) is the most common complication after pancreaticoduodenectomy (PD) and it occurs in 50% of cases. Objectives: the endpoint was to determine if there were any differences in the incidence of DGE between Roux-en-Y gastrojejunostomy (ReY) and Billroth II gastrojejunostomy (BII) in PD with pancreaticogastrostomy (PG). Methods: this was a case-control prospective randomized study of all PD cases between 2013 and 2016. Sixty-four patients were included, 32 in each group. An intention-to-treat statistical analysis was performed. Results: no significant differences were found with regard to morbidity and mortality or hospital stay. DGE was present in 25% of the patients in the BII group in comparison to 15.6% in the ReY group, which was not statistically significant (p = 0.35). There was a higher percentage of patients with primary DGE in the BII group, 12.5% versus 6.2%, but this was not statistically significant (p = 0.53). No difference in DGE severity was observed. Male gender (OR 8.38 [1.1; 129]), abdominal complications (OR 15 [1.7; 396.9]), pre-operative malnutrition (OR 99.7 [3.3, 11,126]) and hemorrhage (OR 9.4 [1.37, 107.94]) were the main risk factors for DGE according to the multivariate analysis. Conclusions: there were no significant differences in the incidence or severity of DGE between BII or ReY after PD with PG

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Manejo nutricional en la rehabilitación multimodal precoz en cirugía pancreática / Nutrition management in enhanced recovery after abdominal pancreatic surgery

Los programas de rehabilitación multimodal precoz son estrategias estandarizadas perioperatorias con el objetivo de mejorar la recuperación del paciente, disminuir las complicaciones, la estancia hospitalaria y el coste sanitario. El aspecto nutricional es un componente esencial de la rehabilitación multimodal precoz, recomendándose realizar un cribado nutricional previo al ingreso hospitalario, evitar el ayuno prequirúrgico mediante una sobrecarga oral de hidratos de carbono, e iniciar de manera precoz la ingesta oral posquirúrgica. Sin embargo, no existen protocolos estandarizados de progresión de dieta en cirugía pancreática. Se realiza una revisión de las diferentes estrategias nutricionales publicadas desde 2006 hasta 2016 en la rehabilitación multimodal precoz de este tipo de cirugía y sus posibles implicaciones en la evolución postoperatoria. Los estudios evaluados son muy heterogéneos por lo que no se pueden extraer resultados concluyentes sobre el protocolo de dieta a implementar, su influencia en variables clínicas ni la necesidad o no de nutrición artificial concomitante (AU)

Multimodal rehabilitation programs are perioperative standardized strategies with the objective of improving patient recovery, and decreasing morbidity, hospital stay and health cost. The nutritional aspect is an essential component of multimodal rehabilitation programs and therefore nutritional screening is recommended prior to hospital admission, avoiding pre-surgical fasting, with oral carbohydrate overload and early initiation of oral intake after surgery. However, there are no standardized protocols of diet progression after pancreatic surgery. A systematic review was been performed of papers published between 2006 and 2016, describing different nutritional strategies after pancreatic surgery and its possible implications in postoperative outcome. The studies evaluated are very heterogeneous, so conclusive results could not be drawn on the diet protocol to be implemented, its influence on clinical variables, or the need for concomitant artificial nutrition (AU)

Peptic Ulcer Disease in Bangladesh: A Multi-centre Study.

The incidence of peptic ulcer has steadily declined through out the world. This decreasing trend is also noticeable in this subcontinent. The point prevalence of peptic ulcer (PUD) in Bangladesh was around 15% in eighties. The aim of this study was to see the present prevalence of peptic ulcer at endoscopy and to identify changing trends in the occurrence of peptic ulcer in Bangladesh. This retrospective analysis of the endoscopic records of multiple tertiary referral centres of Dhaka city were done from January 2012 to July 2013. A total of 5608 subjects were the study samples. We included those patients having peptic ulcer in the form of duodenal ulcer, benign gastric ulcer including pre-pyloric ulcer and gastric outlet obstruction due to peptic ulcer. Duodenal ulcer and benign gastric ulcer were found in 415(7.4%) and 184(3.28%) patients respectively and gastric outlet obstruction due to peptic ulcer was found in 23(0.40%) patients.

Predictive factors of Gastrointestinal motility Dysfunction after gastrojejunostomy for peptic ulcer stenosis.

BACKGROUND: Despite the establishment of effective medical therapies in peptic ulcer disease, gastric outlet obstruction remains one of the most common health problem in Tunisia. Various operations have been attempted, which may lead to postoperative morbidity. Gastrointestinal (GI) motility dysfunction is the most common complications. AIM: to determine the predictive factor of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis. METHODS: We carried out a retrospective study to evaluate the postoperative recovery of the motility of the upper gastrointestinal tract after gastrojejunostomy for peptic ulcer stenosis. During the 9- year study, 138 patients underwent operations for ulcer peptic stenosis. Among the patients, 116 (84,1%) were treated with gastrojejunostomy. Descriptive statistics, univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 47.85 years (range: 19- 92years) and most. Were male (84, 5 %). Ninety two (79.3%) patients had a documented history of peptic ulcer disease. The duration of symptoms ranged from 10 to 372 days (mean: 135.86 days). Eighty two (71%) patients were operated on through laparotomy. Laparoscopic procedure was performed in 29% of the patients. There was no operative mortality. Perioperative morbidity occurred in 12.4% (14 patients). Gastrointestinal motility dysfunction occurred in 12 patients (10.3%). It was treated by nasogastric aspiration and prokinetics. By univariate analysis; diabetes (0,010), cachexia (0,049), ASA class (0.05) were all statistically associated with gastrointestinal motility dysfunction in this series. Multivariate logistic regression analysis (table 2) showed that the cachexia (0,009), ASA class (0.02) were the main predictors of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis in the followed patients. CONCLUSION: Gastrointestinal motility dysfunction is the most common complications after gastrojejunostomy for pyloric adult stenosis. Surgery must be preceded by careful medical preparation. It is more likely to occur in patients with an ASA class 2 or greater. Those patients should be considered for other treatment options, such as endoscopic balloon dilation.

Gastric hairballs in rabbits: significance in developmental toxicity study.

We surveyed 1053 pregnant rabbits of the Kbl:NZW strain collected from 27 developmental toxicity studies to reveal the prevalence and significance of gastric hairballs. The incidence of hairballs was 2/525 (0.4%) in the control group and 17/528 (3.2%) in the high dose group. In the high dose group, 16 dams resulted in abortion or death. In addition, decreases in body weight and food consumption were more severe in dams with hairballs than in their group-mates without hairballs.

Gastric cancer: biology and clinical manifestations in Israel.

BACKGROUND: Gastric cancer (GC) in Israel remains incompletely characterized. The aim of this study was to define the clinical and pathological characteristics of GC in Israel and to compare them to the general Western population. PATIENTS AND METHODS: This is a retrospective analysis of 461 consecutive GC patients treated at a single institution between 1995 and 2007. Epidemiological and clinical-pathological data were retrieved from the patients' medical files and the institutional electronic database and analyzed using standard statistical methods. RESULTS: Epidemiology, clinical manifestations, histopathological findings, clinical course, and prognostic factors for disease outcome were all similar to those reported in the Western literature. Findings unique to the Israeli population included: (1) rarity of GC-associated risk factors; (2) increased GC incidence in Ashkenazi Jews; (3) high incidence of second primary malignancy and family history of cancer; and (4) no dominancy of proximal GCs. CONCLUSION: There do not appear to be any major differences in the biology or clinical manifestations of GC in Israel. Western recommendations for diagnosis and treatment of GC may therefore be applied to the Israeli patient population.

Laparoscopic gastrojejunostomy for the treatment of gastric outlet obstruction.

BACKGROUND AND OBJECTIVES: Laparoscopic gastrojejunostomy (LGJ) has been proposed as the technique preferred over open gastrojejunostomy for relieving gastric outlet obstruction (GOO) due to malignant and benign disease. This study investigates the feasibility and safety of LGJ for GOO. METHODS: A retrospective review was performed of patients who underwent LGJ at Mount Sinai Medical Center from 2004 to 2008. Patient's operative course and longterm outcomes were collected. RESULTS: Twenty-eight patients were reviewed (16 had malignancy, 7 had PUD, 3 had Crohn's disease, and one had obstruction of unclear cause). Average operative time was 170 minutes, and estimated blood loss was 80cc. One case was converted to open; another had stapler misfiring. Patients regained bowel function at a median of 3 days and remained in the hospital for a median of 8 days. There were 4 major postoperative complications (14%): 1 anastomotic leak and 1 trocar-site hemorrhage requiring reoperation and 2 gastrointestinal bleeds requiring endoscopic intervention. There were 5 minor complications (18%), including a partial small bowel obstruction, 1 patient developed bacteremia, and 3 patients had delayed gastric emptying. One patient had persistent GOO requiring reoperation 3 months later. CONCLUSION: LGJ can be performed for GOO with improved outcome and an acceptable complication rate compared to the open GJ reported in the literature.

Delayed presentation of hypertrophic pyloric stenosis: a rare case.

Hypertrophic pyloric stenosis (HPS) is the most common cause of gastric outlet obstruction in infants, with an incidence of 1.5 to 3 per 1000 live births, and classically presents at 3 to 4 weeks of age. Delayed presentation of HPS is an extremely rare occurrence after early infancy. With the exclusion of congenital HPS, gastric outlet obstruction in childhood is a rare condition (1:100,000). We report a case of delayed presentation of HPS in a 4 1/2-year-old child in whom the pylorus was hypertrophied and appeared like an "olive," and for which pyloromyotomy was curative.

The clinical presentations of ectopic biliary drainage into duodenal bulbus and stomach with a thorough review of the current literature.

BACKGROUND: Ectopic biliary drainage is a rare congenital anomaly on which we have scarce data in the current literature. METHODS: The data were collected from the records of 400 endoscopic retrograde cholangio-pancreatography (ERCP). In this report, we present 10 cases (male/female: 9/1, mean age 54 years, range 38-74) with ectopic biliary openings into the duodenum and/or stomach diagnosed by endoscopic retrograde cholangio-pancreatography (ERCP). RESULTS: In our series, the frequency of ectopic biliary drainage is 2% (10 out of 400 ERCPs). Recurrent attacks of cholangitis and complicated ulcer formation in the distal stomach and bulbar duodenum were the most common signs in the present series. The sites of ectopic biliary drainage were the stomach in 1 case, the duodenum bulbus in 7 cases and the postbulbar duodenum in 2 cases. Bulbar ulcer, deformed pylorus and bulbus were present in 7 cases, apical bulbar stricture in 2, gastric ulcer in 1, pyloroplasty and/or gastroenterostomy in 3 cases. One case had had previous bleeding episode. Some of them had undergone previous surgeries for gall-stone disease (cholecystectomy in 5 cases, bile duct operation in 3 cases) and ulcer complications (pyloroplasty/gastroenterostomy in 3 cases). ERCP revealed dilatation of the biliary tree and hook shaped distal choledochus in all cases, choledocholithiasis in 7 and Mirizzi syndrome in 1. Endoscopic balloon dilatations for gastric outlet obstruction, extraction of bile stones after balloon dilating the ectopic site, surgery for difficult cases with large bile duct stones or with gastric outlet obstruction were preferred methods in this series of patients. CONCLUSION: With this report, we have to remind that ectopic biliary drainage must be considered in the differential diagnosis when the clinician faces cases with gastric outlet obstruction due to peptic ulcer formation accompanied by cholangitis/cholestasis.

Gastrostomy tube-related complaints in the pediatric emergency department: identifying opportunities for improvement.

OBJECTIVE: To describe the pediatric emergency medicine management of patients who present with gastrostomy tube (G-tube)-related complaints and identify opportunities for improving care and preventing G-tube complications. METHODS: Retrospective cross-sectional descriptive study of patients (aged <18 years) who received care at an urban children's hospital (110 beds) emergency department (ED) for G-tube-related complaints. RESULTS: Over a 23-month period, there were 181 ED patient visits by 77 patients for G-tube-related complaints. The mean number of visits per patient was 2.4. There were 159 (88%) G-tube and 22 (12%) gastrojejunostomy tube (GJ-tube) patient visits. The standard type of G-tube used at the study site ED was an adjustable-length tube. The most common complaint for G-tubes was dislodgement (99, 62%); and for GJ-tubes, malfunction (11, 50%). There were 119 patient visits (75%) needing G-tube replacement. Of these, 115 (97%) were successfully replaced in the ED, 85 (74%) by the pediatric emergency medicine attending physician, and 30 (26%) by the pediatric surgery service. The method of securing or documenting the intragastric depth of the adjustable-length tubes was documented in 15 (10%) of the 157 patients who had G-tubes or foley catheters at the time of ED disposition. The most common major G-tube complication was gastric outlet obstruction (3), and the most common major GJ-tube complication was aspiration pneumonia (3) secondary to gastric malposition (2) or dislodgement (1) of the GJ-tube. Only 9 patient visits (5%) resulted in hospitalization, and there were no deaths. CONCLUSIONS: Patients with G-tubes had approximately 1.25 mean ED visits per year for G-tube complaints. The most common G-tube complaint was dislodgement. Most dislodged G-tubes were replaced by ED physicians without the assistance of surgeons, but documentation of management and methods of securing the tubes was often incomplete. There were few major complications or hospitalizations. Treatment guidelines are presented that emphasize documentation of confirming G-tube location at the time of disposition from the ED.

Risk factors for morbidity and mortality following gastroenterostomy.

BACKGROUND: Morbidity and mortality following traditional surgical treatment of gastric outlet obstruction is high. The aim of this work was to identify risk factors predictive of postoperative complications and mortality following gastroenterostomy. METHODS: One-hundred sixty-five consecutive patients subjected to open gastroenterostomy from January 1996 through July 2003 were included. Data on vital signs and operative variables were retrieved from medical records and recorded retrospectively. Risk factors for postoperative complications and mortality within 30 days after operation were analyzed with multiple logistic regression. RESULTS: The 30-day complication and death rates were higher after emergency operations (80% and 60%) than after elective operations (32% and 25%). A multivariate analysis disclosed that hypoalbuminemia (< or = 32 g/l), comorbidity, high age, and hyponatremia (< 135 micromol/l) were significantly associated with postoperative death, whereas hypoalbuminemia, comorbidity, high age, and emergency operation were predictors of postoperative complications. CONCLUSIONS: Complications and mortality after gastroenterostomy due to gastric outlet obstruction are associated with modifiable and non-modifiable risk factors. Prior to surgery means should be taken to correct low albumin and sodium levels to prevent complications. In addition, the surgeon should consider alternative treatment modalities including laparoscopic gastroenterostomy, self-expanding metallic stents, or tube gastrostomy to relieve or palliate gastric outlet obstruction.

Does pyloroplasty following esophagectomy improve early clinical outcomes?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether pyloroplasty following elective esophagectomy improves clinical outcomes. Altogether 170 relevant papers were identified using the below-mentioned search. One meta-analysis and six randomised controlled trials from the nine that were summarised in the meta-analysis represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that pyloroplasty seems to reduce the incidence of gastric outlet obstruction and speed up gastric emptying. In addition, the incidence of complications from this procedure seems low. However, other significant improvements to outcomes such as mortality, nutrition, anastomotic leakage, gastric symptoms and aspiration are yet to be established.

Stent collapse as a delayed complication of placement of a covered gastroduodenal stent.

OBJECTIVE: The purpose of this study was retrospective evaluation of the incidence, predictive factors, and interventional management of stent collapse after placement of a covered metallic stent in patients with obstruction of the gastric outlet or duodenum due to malignant disease. MATERIALS AND METHODS: Among 259 patients with symptomatic malignant gastroduodenal obstruction successfully treated with stent placement, stent collapse occurred in 12 (4.6%) of the patients 34-270 days (mean, 101.8 days) after stent placement. Multivariate analysis was performed to evaluate factors predictive of stent collapse. Interventional management of stent collapse also was evaluated. RESULTS: Multivariate analysis showed that presence of the stent in the peripyloric region (odds ratio, 27.745; p = 0.036), longer survival time (odds ratio, 1.016; p < 0.001), and absence of chemotherapy after stent placement (odds ratio, 31.661; p = 0.048) were independent predictors of stent collapse. Eleven patients with stent collapse were successfully treated with placement of a second bare stent. The twelfth patient refused further treatment. CONCLUSION: Stent collapse is an uncommon delayed complication of placement of covered metallic stents in patients with malignant gastroduodenal obstruction. Collapse occurs most commonly in the peripyloric region, in patients with longer survival times, and in patients who do not undergo chemotherapy after stent placement. Stent collapse can be managed by coaxial placement of a second bare stent into the collapsed stent.

Critical extreme anterior slippage (paragastric Richter's hernia) of the stomach after laparoscopic adjustable gastric banding: early recognition and prevention of gastric strangulation.

BACKGROUND: We report an unusual complication after Lap-Band placement characterized by herniation of the anterior stomach through the band. METHODS: Group 1 - 105 patients: Operated elsewhere (prior to US FDA approval) and followed by us; perigastric technique was used in 74 and pars flaccida in 31. Group 2 - 218 patients: Operated by us since August 2001 using the pars flaccida approach only. 4 patients with this unusual problem were identified. RESULTS: Patients were all female, with age 37.5 (3343) yr, weight 143.7 (123-167) kg, and BMI 54 (45-65). Onset occurred at 9 (5-16) months, with weight loss: 38.5 (27-53) kg and %EWL 47.3 (31-54)%. All had sudden nausea, vomiting and epigastric abdominal pain that persisted despite emptying the band. None of these symptoms were related to a recent band adjustment. CT scan showed a paragastric Richter's hernia of the stomach underneath the band. At exploration, the band was in the normal location. 3 patients from Group 2 had Richter's hernia of the anterior stomach through the band; reduction of the stomach with closure of the defect was performed. One patient from group 1 had gangrene of the entrapped stomach, resulting in band removal and gastrectomy. CONCLUSION: Lap-Band patients with sudden nausea, vomiting and abdominal pain, when not relieved by emptying the band, should undergo a CT scan. If a traditional slippage is not confirmed, paragastric Richter's hernia of the stomach through the band should be suspected. Immediate exploration with reduction of the stomach and closure of the defect can salvage the stomach and the band. Gastro-gastric sutures must completely close the space underneath the band to prevent this complication.

Gastric outlet obstruction in Maiduguri.

In a review of sixty-four (64) cases of gastric outlet obstruction (G.O.O.) seen at the University of Maiduguri Teaching Hospital between 1991 and 1996, cicatrising chronic duodenal ulcer accounted for 65.7% of cases, followed by antral carcinoma of the stomach 15%, congenital hypertrophic pyloric stenosis 9.4%, carcinoma of the head of pancreas 6% and congenital bands 3%. The usual presentations were forceful vomiting in a patient with background history of dyspepsia of varying duration depending on cause, visible persistalsis, weight loss, abdominal masses and electrolyte imbalances. Diagnoses was easy clinically and confirmed by barium studies and/or gastroduodenoscopy. Treatment offered depended on the cause of gastric outlet obstruction.

Helicobacter pylori infection in duodenal ulcer with gastric outlet obstruction.

One hundred and three patients were included in the study. Thirty seven had duodenal ulcer (DU) (Group I), 35 DU with gastric outlet obstruction (GOO) with presence of an active ulcer in the duodenum (Group II). Thirty one had DU with GOO but no active ulcer (Group III). Presence of H. pylori infection was determined by urease test, serology and/or histology. The prevalence of H. pylori in these groups was compared. Levels of Anti-H. pylori IgG antibody titres were also compared. The patients with duodenal ulcer (DU) were significantly younger (38 +/- 2 years) compared to those with established gastric outlet obstruction without ulcer (45 +/- 2 years) (P = 0.02). The prevalence of H. pylori infection in DU (95%), DU with GOO with ulcer (91%) and DU with GOO but no ulcer (90%) was not significantly different (p > 0.05). Anti-H. pylori IgG antibody titre levels were 72 +/- 6 EU/ml in Group III. The titre levels between Group I and Group III were significantly different (P < 0.05). The prevalence of H. pylori infection is high is patients with DU and is unaltered by gastric outlet obstruction. The presence or absence of an active ulcer with gastric outlet obstruction does not affect its association with H. pylori infection.