Altered Gastric Anatomy Research Articles

Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly increasing in the US, driven by its expanded approval for weight management in addition to hyperglycemia management in patients with type 2 diabetes. The perioperative safety of these medications, particularly with aspiration risk under anesthesia, is uncertain. To assess the association between GLP-1 RA use and prevalence of increased residual gastric content (RGC), a major risk factor for aspiration under anesthesia, using gastric ultrasonography. This cross-sectional study prospectively enrolled patients from a large, tertiary, university-affiliated hospital from June 6 through July 12, 2023. Participants followed preprocedural fasting guidelines before an elective procedure under anesthesia. Patients with altered gastric anatomy (eg, from previous gastric surgery), pregnancy, recent trauma (<1 month), or an inability to lie in the right lateral decubitus position for gastric ultrasonography were excluded. Use of a once-weekly GLP-1 RA. The primary outcome was the presence of increased RGC, defined by the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids on gastric ultrasonography. Analysis was adjusted for confounders using augmented inverse probability of treatment weighting, a propensity score-based technique. Secondarily, the association between the duration of drug interruption and the prevalence of increased RGC was explored. Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group). After adjustment for confounding, GLP-1 RA use was associated with a 30.5% (95% CI, 9.9%-51.2%) higher prevalence of increased RGC (adjusted prevalence ratio, 2.48; 95% CI, 1.23-4.97). There was no association between the duration of GLP-1 RA interruption and the prevalence of increased RGC (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14). Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.

Food and alcohol disturbance among people who have undergone bariatric surgery.

There have been numerous investigations of aberrant eating and substance abuse among patients who have undergone bariatric surgery, which affects the metabolism and the pharmacokinetics of alcohol. However, there is a dearth of literature considering the complex interplay between changes in post-surgery food and alcohol consumption. Furthermore, despite the increasing recognition of issues surrounding replacing food consumption with alcohol consumption (Food and Alcohol Disturbance [FAD]), most emerging research has focused on young adult populations. This perspective reviews and synthesizes the small but growing body of research on the interplay between food and alcohol consumption, particularly FAD, and considers its application to bariatric surgery in general. There are unique considerations for patients who have undergone bariatric surgery. Patients experience altered gastric anatomy, which affects food and alcohol metabolism, and are advised to abstain from drinking alcohol after surgery. After reviewing the available literature, this perspective highlights future directions for research and practice in bariatric surgery.

What to do When Decompressive Gastrostomies and Jejunostomies are not Options? A Scoping Review of Transesophageal Gastrostomy Tubes for Advanced Malignancies

In advanced malignant bowel obstruction, decompressive gastrostomy tubes (GTs) may not be feasible due to ascites, peritoneal carcinomatosis, and altered gastric anatomy. Whereas nasogastric tubes (NGTs) allow temporary decompression, percutaneous transesophageal gastrostomy tubes (PTEGs) are an alternative method for long-term palliative decompression. This study performed a scoping review to determine outcomes with PTEG in advanced malignancies. A systematic literature search was performed to include all studies that reported the clinical results of PTEGs for malignancy. No language, national, or publication status restrictions were used. The analysis included 14 relevant studies with a total of 340 patients. In 11 studies, standard PTEGs were inserted with a rupture-free balloon's placement into the mouth or nose and esophageal puncture under fluoroscopy or ultrasound, followed by a guidewire into the stomach with placement of a single-lumen tube. Of 340 patients, 65 (19.1%) had minor complications, and 5 (2.1%) had significant complications, including bleeding and severe aspiration pneumonia. Of 171 patients, 169 with PTEGs (98.8%) reported relief of nasal discomfort from NGT and alleviation of obstructive symptoms. The one randomized controlled trial reported a significantly higher quality of life with PTEGs than with NGTs. When decompression for advanced malignancy is technically not feasible with a gastrostomy tube, the PTEG is a viable, safe option for palliation. The PTEG is associated with lower significant complication rates than the gastrostomy tube and significantly higher patient-derived outcomes than the NGT.

Feasibility of resection and plication "RAP" technique for management of medically refractory GERD in patients with altered gastric anatomy.

Background and study aims Gastroesophageal reflux disease (GERD) is common, especially in patients after gastric surgery. Medical management of GERD is ineffective in up to 30 % patients and revisional gastric surgery for management of GERD is associated with higher morbidity. We aimed to assess the safety, feasibility, and efficacy of a novel endoscopic resection and plication (RAP) anti-reflux procedure for management of medically refractory GERD in patients with altered gastric anatomy. Patients and methods The RAP procedure involves endoscopic mucosal resection and full-thickness plication over the right posterior-medial axis extending 15 mm above and 20 to 30 mm below the squamocolumnar junction. Adverse events, technical feasibility, GERD health-related quality-of-life (GERD-HRQL) scores, and medication use were prospectively recorded. Results Twenty consecutive patients with previous gastric surgery underwent RAP between September 2018 and August 2020 with a median follow-up of 5.7 months. The median procedure duration was 66 minutes (IQR 53.8–89.5). RAP was technically successful in 19 patients. One patient developed gastric hemorrhage from suture dehiscence, which was managed endoscopically, and four patients developed esophageal stricture requiring endoscopic dilation. Following the RAP procedure, significant improvement in GERD-HRQL score was observed (mean 26.9, 95 %CI 23.36–30.55, P < 0.01). Fourteen of 19 patients reported > 50 % improvement in GERD-HRQL scores. Sixteen of 18 patients reported reduction in requirement for or cessation of antacid therapy. Conclusions Patients with refractory GERD after gastric surgery have limited therapeutic options. We have demonstrated that the RAP procedure is feasible, safe, and clinically effective at short-term follow-up. It provides a potential alternative to revisional surgery in patients with altered gastric anatomy.

ID: 3519521 FEASIBILITY AND DIAGNOSTIC YIELD OF SMALL BOWEL CAPSULE ENDOSCOPY IN PATIENTS WITH SURGICALLY ALTERED GASTRIC ANATOMY

Little is known about small bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and the diagnostic yield (DY) of orally ingested SB-CE in patients with altered gastric anatomy.

Tu1554 SMALL BOWEL CAPSULE ENDOSCOPY FOR DIAGNOSIS OF GASTRIC EMPTYING

Gastroparesis is defined as a delay in gastric emptying in the absence of mechanical obstruction. Currently the reference standard for diagnosis is a gastric emptying study (GES). This is a long procedure (up to 4 hours) that requires intake of radiolabeled food. Many patients are unable to tolerate intake of the standard meal due to their symptoms, others are concerned about intake of radioactive isotopes. Capsule endoscopy consists of a pill size camera that visualizes the esophagus, stomach and the small bowel. Our aim was to evaluate gastric transit using a small bowel capsule endoscope and to determine normal gastric transit time. This was a retrospective review of small bowel capsule endoscopy performed in 200 consecutive outpatients at our tertiary referral clinic between 2018 and 2019. All studies were read by a single senior staff attending. Only studies performed with PillCam SB version 3 (Medtronic, Minneapolis, MN) were included. Incomplete studies, patients with altered gastric anatomy or patients with endoscopic small bowel capsule placement were excluded from the study. A total of 200 consecutive patients above the age of 18 years were reviewed. 8 patients were excluded from the study. 192 patients were included in the study, 82 males and 110 females; mean age 57 years old (range 18-89). The most common reason for capsule placement was iron deficiency anemia (115 patients). All causes of capsule placement are summarized in table 1. There was no statistically significant difference between gastric transit times based on the reason for performing the capsule study. The mean capsule gastric emptying time (gastric transit time) was 40.1 minutes (95% CI 31-48) and median time was 16.9 minutes, range from 0.03 minutes to 352.50 minutes. To calculate the extreme values which may represent pathology, we calculated a range two standard deviations above and below the median. Thus, a gastric transit time ≥154 minutes and ≤1.6 minutes may represent pathologic outcomes of delayed and rapid gastric emptying. 175/192 (91%) of patients in our cohort were between two standard deviations. Of this cohort of consecutive patients, 11 patients underwent both capsule endoscopy and gastric emptying study. Using our model on this cohort, 63% (7/11) patients had a GTT within 2 SDs and were confirmed to have a normal GES. This is the first study per our knowledge to use capsule endoscopy to evaluate gastric transit time. Since capsule endoscopy is currently not approved for diagnosis of gastroparesis, this study is limited by a lack of direct comparison to the reference standard. However, it forms a basis for further research. In patients with gastric transit time <5th or >95th percentile providers should maintain a high index of suspicion for rapid gastric emptying and gastroparesis respectively.Table 1Reasons for Capsule placementView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Transgastric Endoscopic Cystogastrostomy in a Patient With Gastric Sleeve Anatomy

The endoscopic cystogastrostomy has become the standard for management of walled-off pancreatic fluid collections (PFC). However, altered gastric anatomy, such as the gastric sleeve, can present a challenge to endoscopists. As a result, patients with altered gastric anatomy may be referred for surgery, rather than endoscopic intervention. However, surgery is associated with increased costs and length of stay. Here, we report a successful transgastric necrosectomy/ PFC drainage. A 70 year old man with a history of sleeve gastrectomy in 2009 for obesity presented with necrotizing gallstone pancreatitis and subsequent peri- pancreatic fluid collection. After conservative management, the patient was discharged to home, only to present six weeks later with recurrent pancreatitis and poor oral intake. A CT of the abdomen showed an 8 cm pancreatic pseudocyst compressing the gastric sleeve. On upper endoscopy, gastric sleeve anatomy was noted without obstruction. Endoscopic ultrasound (EUS) showed a large 8 cm x 7 cm walled off necrosis adjacent to the stomach with approximately 50% necrosis. Using electrocautery, the hot Axios system (Boston Scientific) was used to access the necrotic collection from the antrum, approximately 3 cm proximal to the pylorus. This site was chosen to avoid intervening vessels seen more proximally and in surrounding areas. Cystogastrostomy was successfully performed with balloon dilation of the stent and placement of pigtail stents. Repeat EGD/EUS one month after Axios placement showed intact gastric anatomy and complete collapse of the prior necrotic fluid collection cavity. To our knowledge, no case reports have been published to date describing a transgastric approach to cystogastrostomy in patients with gastric sleeve anatomy. Endoscopists may shy away from this patient population due to concerns for decreased working space, increased intraluminal pressure and possible disruption of the suture line. One case report notes pseudocyst drainage via the duodenum in a gastric sleeve patient due to the above mentioned concerns. While concerns exist about the feasibility of necrosectomy in post gastric sleeve anatomy, this case shows that transgastric cystogastrostomy can be successfully and safely performed in patients with altered gastric anatomy, such as sleeve gastrectomy. Given the decreased maneuverability, more distal sites, such as the gastric antrum, may be most amenable to the procedure.1408_A.tif Figure 1: Axios stent in the distal gastric wall in post- sleeve gastrectomy anatomy.1408_B.tif Figure 2: 8 cm x 7 cm walled off necrosis adjacent to the stomach.

Stuck in the Gut. An Unusual Duodenal Bezoar Following Pyloric-exclusion Gastrojejunostomy

Introduction: Bezoars are foreign-bodies classified by their composition, with phytobezoars (indigested vegetable matter) being the most common. They are a rare entity usually found incidentally on imaging or routine endoscopy and tend to occur in patients with altered gastric anatomy such as following surgery. To our knowledge, no case reports exist of a small-intestinal phytobezoar following an unreversed pyloric-exlusion gastrojejunstomy. Case: A 19 year-old female with a history of blunt abdominal trauma at 18-months requiring pyloric-exclusion gastrojejunostomy presented with right-upper-quadrant (RUQ) abdominal pain, nausea, vomiting, and diarrhea associated with a 20-lb weight loss over the past few months. Her vital signs, complete blood count, and basic metabolic profile were unremarkable. Abdominal computed tomography with intravenous contrast revealed a large, ovoid, low-attenuation mass within the RUQ measuring 6.6 cm x 5.3 cm x 6.9 cm. Magnetic resonance imaging confirmed a mass in the duodenal bulb, most consistent with a bezoar (Panel A). Subsequent upper endoscopy exposed the yellow-colored bezoar extending from the 3rd portion of the duodenum into the proximal jejunum (Panel B). Additionally, it was noted on endoscopy that the patient's pyloric-exclusion was never reversed, suggesting the bezoar likely formed due to years of reflux from the jejunum into the duodenum. A schematic diagram of the location of the bezoar is provided (Panel C). Due to technical difficulty reaching the bezoar and insufficient pyloric dilatation endoscopically, she ultimately required surgical intervention with pyloroplasty to achieve complete removal of the bezoar. At follow-up, she reported resolution of symptoms and improvement in appetite with weight gain and regular bowel function.Figure: MRI showing mass in the duodenal bulb.Figure: EGD showing the yellow-colored bezoar extending from the 3rd portion of the duodenum into the proximal jejunum.Figure: Schematic diagram indicating the procedure (pyloric-exclusion gastrojejunostomy) and anatomic location of the bezoar.Discussion: Pyloric-exclusion gastrojejunostomy is performed as a temporizing measure when duodenal ischemia is suspected, as in our patient following blunt abdominal trauma. However, in unusual cases where patients do not have the pyloric exclusion reversed, reflux of food material into the duodenum can occur and result in a symptomatic bezoar formation.

EUS-guided Endoscopic Transduodenal Necrosectomy in a Patient With Sleeve Gastrectomy

Walled-off pancreatic fluid collections (PFC) occur after an acute attack of pancreatitis in approximately 10 percent of cases. Decompression of the collection is advocated when specific indications are met, such as pain, gastric outlet or biliary obstruction, fluid leakage, fistulization, weight loss and infection. Endoscopic drainage has been widely adopted as the primary approach for symptomatic walled-off PFC. Difficulty can arise in cases of altered gastric anatomy, as the procedure requires an adequate amount of space to maneuver. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). 40 year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 with intermittent post-prandial RUQ abdominal pain was found to have symptomatic gallstone disease. Patient's course was complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging at 8 weeks revealed 10.8 x 7.6 cm fluid collection with portions of solid components seen in the body and tail of the pancreas. The decision was made to attempt endoscopic necrosectomy. EGD revealed a tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. The patient underwent successful TDN with placement of three 10Fr pigtail stents. Patient had symptomatic improvement and was discharged to outpatient follow-up. Although the transgastric approach is preferred for walled-off PFC, usually due to more favorable location, as well as the comfort level of endoscopists, there is no definite evidence that transgastric drainage is superior to transduodenal drainage. The duodenal approach was used in our patient as sleeve gastrectomy involves removal of the stomach body and a large portion of the antrum producing a high pressure system inside the stomach which may lead to inadequate drainage. Additionally, intervention adjacent to the staple line may predispose to anastomotic leak and break down of the staple line. One prior case has been reported of a patient with sleeve gastrectomy undergoing laparoscopic cyst-gastrostomy after aborted endoscopic cyst-gastrostomy due to limited working space and the inability to visualize the posterior aspect of the stomach. Although laparoscopic cyst-gastrostomy is an acceptable approach for these patients, randomized trials have demonstrated equal efficacy between endoscopic and surgical luminal pancreatic pseudocyst drainage, with endoscopic treatment associated with shorter hospital stays and lower cost. This case illustrates the feasibility of endoscopic necrosectomy in patients with altered gastric anatomy.Figure 1Figure 2Figure 3

Efficacy of Endoscopic Submucosal Dissection for Cancer of the Operated Stomach

Cancer can develop in the operated stomach after partial gastrectomy and in the reconstructed gastric tube after surgery for esophageal cancer. It is considered that endoscopic therapy is more safe and suitable for the early gastric cancer developed in such stomach than operation. We investigated the efficacy of endoscopic submucosal dissection (ESD) for cancer of the operated stomach. Subjects were 669 gastric cancer patients who underwent ESD: 22 patients (23 lesions) had surgically altered gastric anatomy, whereas 647 patients (727 lesions) had normal gastric anatomy. In the altered gastric anatomy group, 13 patients, 6 patients, and 3 patients had previously undergone distal gastrectomy, gastric tube reconstruction, and proximal gastrectomy, respectively. Rates of complete en bloc resection and curative resection were compared between the two groups. Influence of an anastomotic site and/or a suture line on ESD outcomes was examined in the altered gastric anatomy group. The rate of complete en bloc resection by ESD was 82.6% (19/23 lesions) in the altered gastric anatomy group and 92.3% (671/727 lesions) in the normal gastric anatomy group. The rate of curative resection and incident rates of complications were not significantly different between the groups. In the altered gastric anatomy group, the rate of complete en bloc resection was significantly lower when a lesion had spread across an anastomotic site and/or a suture line (P = 0.0372). Furthermore, duration of ESD was significantly longer (P = 0.0276), and resection efficiency was significantly lower (13 mm(2)/min, P = 0.0283), when treating lesions with an anastomotic site and/or a suture line than when treating isolated lesions. Outcome of ESD for cancer of the operated stomach compares with that in normal stomach anatomy. Anastomotic site/suture line within a lesion influenced the ESD procedure.

The role of Endoscopic Ultrasound (EUS) in the management of patients with pancreatic cancer: now bigger than ever.

In this issue of the Journal of Gastrointestinal Oncology De Angelis et al. provide a comprehensive review of the role of endoscopic ultrasound (EUS) in the management of pancreatic cancer. At present the two main established roles of EUS are imaging and tissue acquisition. In addition some EUS-guided therapieshave gained limited but expanding role in pancreatic cancer patients. As correctly pointed by the authors, the role of standard EUS imaging for diagnosis and staging has decreased with the advent of dynamic contrast enhanced multi-detector row computed tomography (MDCT). Nevertheless, contrary to the prevailing perceptions both EUS and MDCT are operator dependent and significant variability of image quality and interpretations exist with MDCT. Furthermore, EUS remains superior imaging modality to detect small pancreatic lesions, mural nodules within a cyst, small lymph nodes and coexisting biliary pathology. We concur with the authors that inmost patients EUS and MDCT should be considered complimentary rather than competing imaging modalities for the evaluation of patients with suspected pancreatic lesions with MDCT been the initial test in most patients. Anotable exception is the screening of populations at high risk for pancreatic cancer where the recent International Cancer of the Pancreas Screening (CAPS) Consortium summit endorsed EUS as the initial test of choice (1,2). EUS is also preferably used for serial surveillance of premalignant pancreatic lesions [e.g., Intraductal papillary mucinous neoplasm (IPMN)] without the radiation exposure associated with MDCT (3). The addition of contrast-enhanced EUS and elastography may expand the utility of EUS imaging for solid pancreatic masses but their role is yet to be determined (4,5). Furthermore, early data on EUS-guided needle based confocal laser endomicroscopy (nCLE) have shown promising results in the evaluation of pancreatic cysts (6,7). On the contrary, EUS with fine needle aspiration (EUS-FNA) has refused to share the scene with other sampling modalities and has become the preferred method for tissue acquisition in patients with pancreatic lesions. EUS may not be necessary in all pancreatic cancer cases but pretreatment pathological diagnosis is essential in most patients with both resectable and advanced disease. Recently the role of EUS sampling has expanded further with the introduction of a new needle with core trap that can provide histologic samples also refereed as fine needle biopsy (EUS-FNB) (8). This is an exciting development because EUS-FNB can facilitate accurate tissue diagnosis in situations where FNA cytology has been known to be inadequate (e.g., autoimmune pancreatitis, lymphoma) but also can provide assessment for tumor vascular and lymphatic invasion. Furthermore, in the forceable future treatment decisions and patient prognosis most likely will be based on molecular markers and EUS appears to be the ideal tool to gather adequate tissue for analysis (9). EUS has also has expanded its role in selected patients with pancreatic cancer as a valuable therapeutic tool. At present, EUS-guided fiducial placement is now routinely done to facilitate image guided radiation therapy (10), EUS-guided celiac plexus neurolysis can greatly facilitate the management of pancreatic cancer pain (11), and EUS-guided biliary drainage is a viable alternative to percutaneous drainage in patient that had failed endoscopic retrograde cholangiopancreatography (ERCP) or in patients with altered gastric anatomy (12). Importantly, in the future EUS most likely will play an important role in delivering novel local antitumor therapy. Ethanol ablation for selected small mucinous cyst has shown promising results and EUS fine needle injection (EUS-FNI) of various viral and biologic therapies has undergone preliminary evaluation (13). In conclusion, despitestiff competition from other imaging modalities standard EUS imaging remains a valuable tool. Contrast-enhanced EUS, EUS elastography and needle based confocal endomicroscopy may further expand the utility of EUS imaging but their exact role is yet to be determined. EUS-FNA is currently the preferred modality for tissue acquisition in patients with pancreatic lesions and the advent of FNB may further solidify this essential role. The therapeutic role of EUS has expanded and ranges from primary in the case of fiducial deployment to fall back strategy in the case of EUS-guided biliary drainage. In the forceable future, EUS-FNI most likely will play a central role for delivery of novel targeted antitumor medications but for now its role is limited to palliative celiac plexus neurolysis.

Invited Commentary

Invited Commentary

Percutaneous transesophageal gastrostomy (PTEG): a safe and effective technique for gastrointestinal decompression in malignant obstruction and massive ascites

Enteral feeding and gastric decompression devices are common in critical, terminal, and chronically ill patients. Percutaneous transesophageal gastrostomy (PTEG) is a nonsurgical technique that creates an esophagostomy and allows enteral access in patients with a hostile abdomen, altered gastric anatomy, massive ascites, and carcinomatosis. We review our indications, technical experience, complications, and short- and long-term quality of life (QOL) in patients that underwent the PTEG procedure. Patients were terminally ill from advanced cancer requiring gastrointestinal decompression or had hostile abdomens needing long-term feeding access. The procedure is carried out by inserting a rupture-free balloon (RFB) into the cervical esophagus and utilizing transcutaneous ultrasound to puncture the balloon. A guide wire is passed through the needle into the balloon, followed by a dilator and sheath. The in-dwelling catheter is inserted through the sheath, which exits the esophagus, and resides in the stomach. Proper placement is confirmed by fluoroscopy. From December 2003 to January 2006, 17 patients were treated with PTEG. Except for two patients, all of the patients had advanced metastatic cancer. Presenting symptoms were nausea, vomiting, and dysphagia. Average age was 62.8 years, with nine men. Placement was successful in 16 patients (94%). There were no major complications and three minor complications (17.6%). Minor complications included two esophageal leaks at the catheter site and one catheter dislodgement. Seven patients (41.2%) died within 1 month after the procedure from their preexisting medical conditions. All patients were capable of being discharged from the hospital with adequate enteral access and gastrointestinal decompression. PTEG is a safe and effective method of enteral feeding and decompression in patients that have contraindications to standard enteral access. Appropriate patient selection and timing of PTEG placement is crucial for optimum benefit.

Necrotizing fasciitis after direct percutaneous endoscopic jejunostomy

Enteral jejunal feeding is indicated in patients who require enteral feeds but who are unable to tolerate intragastric feeding. These include patients with acute pancreatitis, patients with altered gastric anatomy after surgery, patients at high risk of aspiration pneumonia from gastric contents, and patients with gastroparesis. Enteral nutrition via a nasojejunal tube is suitable as a temporizing measure in these patients but not as a long-term option, because of patient discomfort and a propensity for accidental dislodgement. The 3 options for mediumto long-term jejunal feeding include a surgically placed jejunal tube, a percutaneous gastrostomy with jejunal extension (PEG/J), and a direct percutaneous endoscopic jejunostomy (DPEJ) tube. We describe a patient who underwent a DPEJ insertion complicated by necrotizing fasciitis.

Bezoars and Foreign Bodies of the Stomach

Bezoars are usually encountered in patients with altered gastric anatomy or function. Symptomatic, large phytobezoars or trichobezoars may require endoscopic fragmentation or surgical removal. Foreign bodies of the stomach are usually a self-limited problem, because at least 90% pass without symptoms, in patients with normal gastrointestinal anatomy. Endoscopic removal should be considered for sharp, pointed, or long objects, or in patients with altered anatomy, such as intestinal stricture.

Enteric alimentation: a radiologic approach.

A new guide wire-directed enteric feeding tube is described. Clinical trials have shown the tube can be rapidly placed in the small bowel in patients with altered gastric anatomy or decreased peristalsis. Fluoroscopically guided feeding tube placement has proved to be a valuable adjunct in the therapy of patients requiring long-term enteric alimentation.

Endoscopy of the partitioned stomach.

Fiberoptic endoscopy is an important diagnostic modality for evaluation of the patient with upper gastrointestinal (GI) tract symptoms following gastric bypass and gastroplasty. During a 3-year period, 182 patients underwent gastric partitioning procedures and 22 patients (12%) developed upper GI symptoms requiring endoscopic evaluation. Eight patients had undergone Mason vertical banded gastroplasty, 12 patients had undergone Gomez gastroplasty, and two patients had undergone Roux-en-Y gastric bypass. In four of five patients with abdominal pain, gastritis of the proximal pouch was observed. Of the two patients with symptoms of obstruction of the proximal gastric outlet, one patient was found to have a cherry pit occluding the channel. Intraoperative endoscopy was performed in one patient who developed upper GI bleeding after Roux-en-Y gastric bypass, the pylorus was scarred and stenotic and multiple superficial ulcerations were seen in the excluded distal stomach. In eight patients with symptoms suggestive of channel stenosis, four were found to have a stenotic channel and underwent endoscopic dilation of the channel. Upper GI endoscopy was performed in eight patients with Gomez gastroplasty to confirm suspected dilatation of the channel between the upper and lower gastric pouches. Upper GI contrast studies did not estimate accurately the diameter of the channel as determined during endoscopy. No complications were observed following any of the endoscopic procedures. As the collective experience with gastric partitioning procedures increases, the need for endoscopic examinations of the upper GI tract will also increase. Endoscopists should be familiar with the altered gastric anatomy and with the spectrum of upper GI lesions that develop following these operations.