Cause Of Gastric Outlet Obstruction Research Articles

Operative Procedures and Postoperative Complications in Patients with Gastric Outlet Obstruction

Background: Gastric outlet obstruction denotes complete or partial obstruction of the distal stomach, pylorus, or proximal duodenum. This can happen as a result of an obstructing lesion, external compression, or obstruction caused by acute edema, chronic scarring and fibrosis, or a combination of the two. The most common causes of gastric outlet obstruction are gastric cancer and pyloric stenosis secondary to peptic ulceration. We have very limited research-based information regarding postoperative complications in patients with gastric outlet obstruction. Aim of the study: This study was carried out to determine the operative procedures and postoperative complications in patients with gastric outlet obstruction. Methods: Between September 2012 to February 2013, this prospective observational study was carried out in the surgery department of Rangpur Medical College Hospital, Rangpur, Bangladesh. A total of 50 patients presenting with the features of gastric outlet obstruction were included in this study. A convenient purposive sampling technic was used in sample selection. In 27 patients, surgery was performed. Registration schedules, editing computerization, preparing dummy tables, and analyzing and matching data were all part of the data processing work. Results: In the cases of benign gastric outlet obstruction, bilateral truncal vagotomy and retro colic isoperistaltic gastrojejunostomy were preferred. Distal partial gastrectomy with lymph node dissection was done in resectable antral growth of the stomach. Palliative gastrojejunostomy was done in advanced gastric and pancreatic malignancy. Gastrojejunostomy with biopsy from the duodenum and lymph node was taken from one pre-operatively diagnosed case of duodenal tuberculosis, which was made by endoscopic biopsy. Complication occurred mostly in the malignant cases; 7 (43.75%) patients developed wound infection, of which 5 (31.25%) patients developed wound dehiscence. There was a duodenal stump-blow out in ...

EP23 - A rare case of “Gastric Outlet Obstruction (GOO) Secondary to Hydrops of Gallbladder” caused by recurrent acalculous cholecystitis: a variant of Bouveret’s Syndrome -a rare case and review of literature

Abstract We present an extremely rare case of gastric outlet obstruction (GOO) in a young male attributed to hydrops of the gallbladder resulting from recurrent episodes of acute acalculous cholecystitis. Remarkably, approximately one and half years prior to this presentation, the patient was diagnosed with confirmed acute acalculous cholecystitis and had tested positive for Covid 19, despite exhibiting no respiratory symptoms. While it is established that Patients with acute acalculous cholecystitis can develop gallbladder mucoceles due to the mechanism akin to mechanical cystic duct obstructions. This functional condition leads to a non-emptying, distended gallbladder where biliary mucus replaces bile salts (1). Conventionally, hydrops of the gallbladder is associated with prolonged blockage of the cystic duct, often caused by an impacted gallstone in neck / cystic duct or a stricture in cystic duct. Bouveret’s Syndrome, characterized by GOO results from the impaction of a large gallstone in the duodenum or pyloric channel, typically secondary to a cholecystoenteric fistula (2),is a recognized rare entity. However, our case stands apart as it elucidates an infrequently reported cause of GOO- hydrops of gall bladder inducing extrinsic compression of the duodenum / pylorus and this case also emphasizes the distinction from Bouveret’s syndrome. This case underscores the importance of considering unusual etiologies in the diagnosis of GOO and emphasizes the need for timely recognition and intervention in such rare instances to ensure optimal patient outcomes. Additionally, we provide a comprehensive review of existing literature, highlighting the scarcity of reported cases with such relevant presentations.

Endoscopic ultrasound-guided gastrojejunostomy for benign gastric outlet obstruction (GOO): a retrospective analysis of patients and outcomes.

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has been well utilized in treating malignant gastric outlet obstructions (GOO) given its efficacy and lower risk profile compared to surgery. However, its efficacy and potential for use in patients with benign GOO who are poor surgical candidates is not well documented. The aim of this study was to examine the role of EUS-GJ in treatment of benign GOO in select patients. This is a single-center, open-label, retrospective descriptive study that included all consecutive patients undergoing EUS-GJ to treat benign causes of GOO. Direct antegrade and direct retrograde methods were utilized. A total of 18 patients were included, 38.9% female with an average age of 63.3years. Extrinsic GOO was present in (10 of 18) 55.5% of patients and intrinsic etiology was present in (8 of 18) 45.5% of patients. Technical success was achieved in 100% (18 of 18) patients and clinical success was achieved in 94% (17 of 18) patients. In total, 13 patients had follow-up endoscopy, 2 patients were treated relatively recently in time, 1 patient was lost to follow-up, and 2 patients died of other chronic illnesses. Stents remained in place for a median of 286days (range 88-1444days). In patients whose stents were removed, 75% (3 of 4) had extrinsic etiologies of GOO. This study reports a favorable long-term patency with excellent technical and clinical success of EUS-GJ in patients with benign GOO. Despite the limitations of sample size and retrospective nature, it adds to the extremely limited literature of EUS-GJ in management of patients with benign GOO.

Challenges in managing duodenal intussusception: A rare cause of gastric outlet obstruction in adults

Challenges in managing duodenal intussusception: A rare cause of gastric outlet obstruction in adults

Gastric antral web presenting with esophageal stricture and severe malnutrition

Gastric antral web is a rare cause of gastric outlet obstruction in children. Common complaints include intermittent non-bilious vomiting, bloating, pain, loss of appetite, and weight loss. Herein, we report a case of gastric antral web presenting with esophageal stricture and malnutrition, which was followed for many years with a misdiagnosis. An 8-year-old African boy was referred to our pediatric gastroenterology clinic due to recurrent vomiting and severe malnutrition. According to his medical history, the patient began experiencing non-bilious vomiting at 40 days of age and a diagnosis of gastroesophageal reflux was made. He was hospitalized multiple times and received nasogastric tube feedings in the following 4 years. He was re-evaluated for growth retardation and malnutrition at 4 years of age. He had been diagnosed with gluten enteropathy and was fed a gluten-free diet. Recently, he developed difficulty swallowing solid food and was only able to consume liquid meals. Esophagography revealed segmental stenosis in the distal portion of the esophagus. After stricture excision with thoracotomy, upper gastrointestinal series with a radiopaque substance indicated normal esophageal passage; however, prolonged gastric emptying time was also noted. Upon examination during laparotomy, a congenital web was detected in the antral region and was excised. Esophageal and gastric pathologies were consistent with stricture caused by reflux esophagitis and gastric antral web. Today, gastric antral web is mostly diagnosed and treated in infancy. Near total obstruction is relatively easy to diagnose; however, many patients with partial obstruction are followed-up for years with an incorrect diagnosis. Therefore, it should be considered in such cases, persistent vomiting and gastroesophageal reflux may be associated with esophageal stricture.

Endoscopic removal of gossypiboma: a rare cause of gastric outlet obstruction

Endoscopic removal of gossypiboma: a rare cause of gastric outlet obstruction

Peptic Duodenal Stricture Causing Gastric Outlet Obstruction: A Case Report

Gastric outlet obstruction (GOO) is an uncommon but serious problem caused by benign causes. The incidence of GOO caused by peptic ulcer disease (PUD) is decreasing due to successful Helicobacter pylori treatment. Hence, these aggressive cases are rare. We present a case of a man who experienced intermittent abdominal pain and constipation for a week but acutely worsened in the last five days. He complained of intractable nausea and vomiting, leading to intolerable oral intake. Physical examination revealed abdominal distention, tenderness in epigastrium and right hypochondrium, and hypoactive bowel sounds. Laboratory results revealed leukocytosis with neutrophilia. Gastroscopy showed erosive esophagitis, pangastritis, and large duodenal ulcer causing stricture of duodenum pars I. An open distal gastrectomy, Roux-en-Y reconstruction, and fundoplication was then performed. The patient’s general condition improved after ninth day of care and was discharge on the eleventh day of care. PUD is a major cause of GOO, but incidence has decreased to 5% with the use of proton pump inhibitors. If the distal stomach or duodenum is significantly obstructed, GOO should be considered. The gold standard for diagnosis is endoscopy. Initially, conservative and supportive therapy should be done followed by endoscopic treatment in appropriate cases. If there is no improvement, surgical interventions should be done. This case demonstrated the need for definitive invasive procedures in the intervention of GOO caused by PUD. When conservative measures fail, this case also adds support to the direct anatomic treatment of duodenal strictures.

OGC P36 The role of self-expanding metallic stents and surgical gastric bypass for palliation of gastric outlet obstruction caused by gastric cancer

Abstract Background The treatment of inoperable gastric cancer, causing gastric outlet obstruction (GOO) is focused on palliation of symptoms. Self-expanding metallic stent (SEMS) or surgical gastric bypass (SGB) are used to relieve GOO. Available data on SEMS and SGB are often unreliable as studies usually include patients with different causes of GOO including pancreatic or duodenal cancers or extrinsic disease. Their utility for GOO due to gastric cancer remains uncertain as gastric motility and function could be affected by the pathology. We aim to review outcomes of SEMS and SGB for GOO from gastric cancer in our unit over a 5-year period. Methods Retrospective review of all patients who have had SEMS or SGB for palliation of GOO from gastric cancer between 01/01/2018 and 31/12/2022. Data was collected on the pathology of the tumour, pre-intervention symptoms scoring, post-intervention symptoms scoring, length of stay, complications and survival. Thirty-five patients were identified and included in the study. Results Thirty patients with SEMS and five patients with SGB were analysed. Median survival was 16 weeks. Median length of stay after SEMS was 5.5 days (IQR: 1.2-12.7, range 1-83) and after SGB was 10 days (IQR: 9-11, range 8-32). 2/30 in the SEMS group had early complication requiring re-stenting and 1/5 in SGB group had early complication requiring further surgery and subsequent SEMS. Complete palliation of obstruction was achieved in 17/21 (70%) of SEMS and 4/9 (40%) of SGB patients. Complete palliation with SEMS was more likely when stomach cancer was localised (81%) rather than widespread (44%). Conclusions Self-expanding metallic stents are safe and effective in the palliation of symptoms in patients with gastric outlet obstruction due to gastric cancer and perhaps function better than surgical bypass. They are more effective when the obstructing gastric cancer is localised disease. Longer hospital stay associated with surgical bypass may compromise the palliative process when the survival is often limited.

A Successful Pyloromyotomy In A Child With COVID-19 Infection

Infantile Hypertrophic Pyloric Stenosis (IHPS) is the most common cause of gastric outlet obstruction in children, usually manifesting between 2 and 6 weeks of age by non-bilious vomiting. Although the COVID-19 pandemic has dominated the world since the beginning of 2020 causing the restructuring of healthcare delivery, patients still require high-quality medical care concerning other diseases. We report a 6-week infant with confirmed COVID-19 infection, who developed mild symptoms after a successful pyloromyotomy. Our aim is to encourage other professionals not to delay the necessary treatment in asymptomatic COVID-19 patients, considering the proper use of personal protective equipment, as it may worsen the course of the underlying disease.

Prepyloric Diaphragm in Children: A Diagnosis Not to be Missed.

Background: Prepyloric diaphragm is a rare cause of gastric outlet obstruction (GOO). Accurate diagnosis is often difficult and is usually confirmed after surgery. To avoid delayed management, this entity, with its specific clinical and radiological features, should be kept in mind. Case presentation: We report a case of prepyloric diaphragm in a 7-month year old boy. He presented with non-bilious vomiting since birth. A first upper gastrointestinal series was initially misinterpreted as gastroesophageal reflux. After re-examination of the gastrointestinal series, a pyloric obstacle was suspected, and a second Contrast study evoked a pyloric obstacle which gave rise to the indication for surgical exploration after resuscitation. Endoscopy was suggestive of the diagnosis and the accurate diagnosis was done during surgery. Conclusion: This report illustrates the complexity of this diagnosis. Knowledge of this entity and a good, detailed analysis of contrast study in combination with ultrasound and endoscopy could lead to a rapid diagnosis and an adequate care with a good prognosis.

Brunner’s gland hyperplasia as a cause of gastric outlet obstruction in a seven year old boy

Link of Video Abstract: https://youtu.be/9-ynkRS_wo8 Introduction: Brunner’s glands are acinotubular glands which are located mostly in the deep mucosal or submocosal layers of the proximal duodenum. Hyperplasia of these glands is reported in almost 1 in 50 upper gastrointestinal endoscopies and accounts for approximately 5 to 10 percent of all benign duodenal tumors. Brunner’s gland hyperplasia is usually asymptomatic. It can take form of polypoid or mass lesions and precipitate pyloric obstruction, gastrointestinal hemorrhage, and intussusception in children. Due to its rarity in pediatric population, it tends to be misdiagnosed. Case Description: This case report presents a case of seven year old boy with Brunner’s gland hyperplasia presented with recurrent vomiting. A seven year-old boy was admitted to the hospital due to of worsening of intractable vomiting since five months prior to admission. He also felt abdominal discomfort, bloating, and early satiety since he was 3 years old. The patient had been treated with several medications without significant improvement. Epigastric pain was observed on abdominal palpation. Gastroscopy showed partial gastric outlet obstruction (pyloric obstruction), erosive gastritis, multiple ulcers, and erosive esophagitis. Histopatologic results from biopsy revealed chronic gastritis and positive for Helicobacter pylori. Abdominal CT scan showed protrusion solid lesion intraluminal with diameter 1.18 x 1 x 1.25 cm in part II duodenum. Patient was consulted to pediatric surgeon for laparotomy exploration and duodeno-duodenostomy. Excision of Brunner’s gland dan biopsy were performed. Surgical report showed gastric dilatation with duodenal wall hypertrophy on part I-II of duodenum. Histopathological from biopsy revealed Brunner’s gland hyperplasia with lymphoid tissue. Post surgery patient recovered well and eventually discharged without any complains. The prognosis was good. Conclusion: Generally, Brunner’s gland hypertrophy is benign and has a good prognosis. However, with the growth of benign proliferative lesions of Brunner’s glands, mucosal ulcers may develop, thereby leading to the repair of gastric foveolar metaplasia with papillary architecture and then malignant transformation.

The Confusing Tale of Foreign Body Gastric Outlet Obstruction

Background: Duplication cysts are rare congenital anomalies that can occur anywhere in the gastrointestinal tract from the mouth up to the anus. Acquired gastric outlet obstruction (GOO) during infancy beyond the neonatal period is a very rare condition and should be considered when other causes of GOO such as infantile hypertrophic pyloric stenosis, antral diaphragm, and pyloric atresia are excluded.Case Presentation: We report a one-year old female infant who presented with an acute onset of copious persistent vomiting that was initially diagnosed with a duplication cyst of the duodenum, but was found to have GOO after surgical exploration.Conclusion: Clinicians should be mindful of the common causes of GOO and have a high index of suspicion for acquired causes.

Rare presentation of gastric outlet obstruction with jejunal impaction of gall stones-the Bouveret’s syndrome

Gall stones related complications are very common in the world, Bouveret’s syndrome is one of the rare complications (1-3%). Bouveret’s syndrome presents a diagnostic and therapeutic challenge. We present a rare case of an 80-year-old lady diagnosed with gastric outlet obstruction with jejunal impaction of gallstones, because of a gallstone impacted in the jejunum 50 cm from duodenojejunal flexure. The patient was operated on with enterotomy and retrieval of gall stones impacted in the jejunum, with roux en y gastrojejunostomy drainage procedure, the gastro-duodenal fistula was left in situ, because of high risk and unstable general condition of our patient intra-operatively. The patient had multiple pre-existing pre and peri-operative comorbidities, fortunately, our patient recovered and our patient was discharged on 21st postoperative days. Identifying Rigler’s triad symptoms is synonymous with diagnosing Bouveret’s syndrome. However, classical Rigler’s triad is present in only 40% of cases, hence alertness and a high degree of suspicion are required to differentiate Bouveret’s syndrome from other mechanical causes of gastric outlet obstruction. The atypical cases of Bouveret’s syndrome present a challenge to the surgeon for early diagnosis and therapeutic surgical management.

Neuroendocrine carcinoma of stomach causing gastric outlet obstruction: a diagnostic dilemma

Gastric neuroendocrine tumour (GNET), also known as carcinoids, are a very rare cause of gastric outlet obstruction and arise from entero-chromaffin like cells of the mucosa. They account for 0.2/1000001 population and 8.7% of all Gastrointestinal carcinoids. They are four types based on the degree of differentiation, cell of origin and other pathologic features. Type 4 GNET are referred to as neuroendocrine carcinoma accounting for <1% of GNET. They are aggressive, poorly differentiated, locally invasive tumours with metastatic potential. Hence, they require an aggressive approach in terms of surgery and multimodality adjuvant treatment. Our patient is an elderly hypertensive who had complaints of projectile vomiting over ten days associated with weight loss over the last two years. A diagnosis of gastric outlet obstruction was made, and she underwent a contrast CT scan and endoscopy twice, both being suggestive of malignancy involving the antrum region however, the endoscopic biopsy showed unremarkable histology. Subsequently, she underwent emergency laparotomy in which there was a hard growth palpable in the antrum for which distal gastrectomy, D1 lymphadenectomy and gastrojejunostomy were done. Post-op HPE was suggestive of neuroendocrine carcinoma, thus, depicting our difficulty with diagnosis based on pre-op biopsy report given its rarity.

Acute acalculous cholecystitis as a rare cause of gastric outlet obstruction

Gastric outlet obstruction (GOO) is a condition that classically presents with upper abdominal pain and post-prandial vomiting due to mechanical obstruction secondary to luminal, intraluminal or extraluminal disease. Our case report, the first of its kind in the literature to our knowledge, describes GOO secondary to acalculous cholecystitis in a 58-year-old male who presented to the emergency department with abdominal pain and nausea. This unusual case highlights the need for clinicians to consider uncommon differentials in patients presenting with common symptoms such as abdominal pain and nausea.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

S3618 Gastric Outlet Obstruction as a Presenting Symptom of Duodenal Adenocarcinoma

Introduction: Gastric outlet obstruction (GOO) can be due to benign or malignant causes. Benign etiologies of GOO have been down-trending, resulting in 50-80% of cases of GOO attributable to malignancy. Of the malignant causes leading to GOO, pancreatic adenocarcinoma with extension to the duodenum or stomach is the most common cause, followed by distal gastric cancer. However, primary duodenal adenocarcinoma as the cause of GOO is relatively rare, and we present a case of moderate to poorly differentiated duodenal adenocarcinoma leading to GOO. Case Description/Methods: An 82-year-old man with no reported past medical history presented to the hospital with epigastric abdominal pain associated with worsening distention, nausea, multiple episodes of non-bloody projectile vomiting, and associated weight loss of 12 pounds in the past 2 months. The abdominal exam was unremarkable. Labs were nonsignificant. A computer tomography (CT) scan of the abdomen and pelvis revealed a massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction (Figure A). NGT was placed for decompression, with significant relief of symptoms. The patient underwent EGD, and no gross mass or obstructive etiology was noted in the entire stomach, including pylorus and antrum. There was inflammatory appearing mucosa characterized by extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions (Figure B). Biopsies were obtained and showed moderate to poorly differentiated adenocarcinoma (Figure C, D). Subsequently patient underwent palliative duodenal stent placement with symptomatic relief. Discussion: Clinical history is important in suspecting the diagnosis of GOO. Cross-sectional imaging aids in diagnosis but sometimes does not help differentiate benign vs. malignant etiologies. EGD is helpful when imaging is inconclusive and for definitive pathological diagnosis. Most patients achieve symptomatic relief with conservative measures like NPO and NGT decompression. The definitive treatment for GOO varies based on etiology. Most patients with malignant causes need surgery for a cure if suitable candidates. Until recently, surgical gastrojejunostomy was the primary approach for palliative purposes. However, duodenal stent placement has become the primary palliative option as it is a cost-effective, minimally invasive option with adequate symptom relief, shortened hospital stay, and faster resumption of oral intake.Figure 1.: A: CT abdomen/pelvis showed massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction. Circumferential thickening and narrowing of the descending duodenum. B: EGD revealing inflammatory appearing mucosa with extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions. C: Immunohistochemistry/histology of biopsies obtained during EGD revealing duodenal adenocarcinoma with tumor glands. D: Tumor emboli in the lymphatics of the duodenal villi.

S355 Presidential Poster Award Recurrent Obstruction After Surgical GJ in a Rare Case of Gastric Outlet Obstruction: EUS to the Rescue

Introduction: Eosinophilic enteritis is a rare cause of gastric outlet obstruction and if not recognized early can be very difficult to manage. Endoscopic ultrasound (EUS) guided gastrojejunostomy (GJ) is most often used for malignant disorders. However, it can act as a very effective temporary tool in benign disorders for effective medical therapy to take its course. Case Description/Methods: A 49-year-old man presented to us with features of recurrent vomiting and pain abdomen for 5 months. He had alcohol-related chronic calcific pancreatitis. Three years prior to current presentation he had features of gastric outlet obstruction for which he underwent oesophagogastroduodenoscopy (EGD) revealing a circumferential ulcer in antropyloric region with swelling. He underwent truncal vagotomy with antecolic gastrojejunostomy. Biopsy from the specimen had revealed eosinophilic gastroenteritis (EE). He again had some symptoms of obstruction 2 months after surgery which responded to proton pump inhibitors. He remained apparently well with regular follow up for chronic pancreatitis. Now he was symptomatic with progressive symptoms of gastric outlet obstruction since last 4 months. On endoscopy he was found to have both afferent and efferent loop strictures. He was also having a few geographic ulcers and psuedopolyps near stricture mouth. He underwent balloon dilatation twice upto 13.5 mm but symtoms did not improve. Repeat biopsies were taken from the ulcer and stricture site revealed EE with eosinophilic abscesses. Barium meal follow-through and Contrast enhanced CT was done for evaluation of stricture. A nasoduodenal (ND) tube of 10 french was negotiated over guidewire through the stricture using a cannula. It was used to continue enteral feeding. Surgical consultation was taken and poor surgical outcome was predicted in view of both loop involvement. He was started on oral budesonide and planned for an endoscopic bypass procedure. The ND tube was used to distend the normal jejunal loops beyond stricture and endoscopic ultrasound was used for gastrojejunostomy using a lumen apposing metal stent. Discussion: EUS-GJ is a viable option for gastric outlet obstruction even in benign cases for bridging for further surgical or medical therapy. Post-surgery complications may be difficult to manage and EUS-GJ appears more lucrative for the short time period. It requires a carefully selected patient with preset managment plan and a learning curve for successful implementation. Watch the video at https://tinyurl.com/ACGAbstractS355

S3496 You Shall Not Pass: Rare Duodenal Bulb Adenocarcinoma Causing Gastric Outlet Obstruction

Introduction: Duodenal carcinoma accounts for only 1-2% of diagnosed gastrointestinal cancers in the United States. Due to its insidious onset, advanced disease is often established at the time of diagnosis resulting in poor outcomes for patients. Although duodenal adenocarcinomas have been found to comprise around half of all small bowel adenocarcinomas, disease arising from within the duodenal bulb in the D1 segment is a vanishingly rare phenomenon. Case Description/Methods: A 52-year old female with a past medical history of morbid obesity with placement of laparoscopic adjustable gastric band 14 years prior presented with frequent emesis, inability to tolerate oral diet and a 22kg weight loss. Recent esophagogastroduodenoscopy during a previous admission revealed a cratered ulcer in the duodenal bulb. An upper GI series was obtained, showing a 2cm mass in the bulb apex which was confirmed by computed tomography. A repeat esophagogastroduodenoscopy was performed which identified a firm and friable ulcer with contact bleeding with complete obstruction of the duodenal bulb. Subsequent histopathology confirmed the presence of invasive, moderately differentiated adenocarcinoma. (Figure) Discussion: Small bowel tumors comprise about 2% of all GI tumors. Adenocarcinoma accounts for about 30% of all small bowel tumors. The duodenum comprises 53% of all small bowel neoplasms. Of duodenal tumors, about 57% occur in the D2 segment of the duodenum. One 2014 meta-analysis of small bowel cancers between 1990-2012 from an institutional registry (excluding ampullary cancers arising from the bile duct mucosa) identified only 30 cases of primary duodenal adenocarcinoma with none arising from D1. A previous 1991 literature review cites 47 cases of primary duodenal adenocarcinoma arising from D1, however, anatomic distinction between the duodenal bulb and the distal D1 segments was not made. Although small bowel tumors are the third leading cause of gastric outlet obstruction, lesions are typically asymptomatic. In a study of 217 primary duodenal adenocarcinoma, the median survival was 20 months with 35% presenting with metastatic disease (39% present with stage III disease). Although it is difficult to distinguish the prevalence of duodenal bulb neoplasms, it has been clearly demonstrated that neoplasms arising from the D1 segment of the duodenum are extremely rare. By presenting this case, we hope to increase the index of suspicion for small bowel neoplasms as part of the differential for gastric outlet obstruction.Figure 1.: CT demonstration of duodenal bulb mass causing gastric outlet obstruction; Figure 2: Endoscopic image of duodenal bulb tumor.

A Prospective Comparative Study to Assess the Management Outcomes of Patients with Infantile Hypertrophic Pyloric Stenosis Using Ramstedt’s Pyloromyotomy and Double ’Y’ Pyloromyotomy

Abstract Background: Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of gastric outlet obstruction in infancy in which the pyloric portion of the stomach becomes hypertrophied, leading to obstruction of gastric emptying. Various approaches have been tried for surgical management of IHPS. The first successful surgery was performed by Dufour and Fredet in which the hypertrophic pyloric muscle is longitudinally splitted and closed transversely. However, Ramstedt introduced extramucosal pyloromyotomy, introduced in 1912 which still remains the gold standard for surgical management of IHPS. Later on, in 2009, Alayet et al. introduced a new technique known as Alayet’s double-Y (DY) pyloromyotomy which he claimed to have a better functional outcome compared to Ramstedt’s pyloromyotomy (RP) while maintaining a safety profile similar. The objective of this study was to compare the outcome of surgical management of IHPS between DY pyloromyotomy and Ramstedt’s pyloromyotomy. Materials and Methods: It was a prospective study conducted in the Paediatric Surgery Department of SVPPGIP, SCB Medical College, Cuttack, from January 2019 to April 2022. All the IHPS cases were admitted and optimised thoroughly with regard to hydration, acid-base status and electrolyte imbalance. We have included 60 patients and were divided into two groups; every alternate patient was pooled into one group. Detailed and informed consent was taken from parents regarding the surgical procedure of their baby. The patients were selected alternatively, i.e., if one patient underwent Ramstedt’s pyloromyotomy then in the next patient Alayet’s DY pyloromyotomy procedure was done. The demographic characteristics of all patients, operative procedure performed, duration of surgery, intraoperative anaesthesia or surgical complication, post-operative vomiting patterns and weight gain data were collected and analysed in Microsoft Excel sheet and SPSS software. The student’s t-test was used to compare both groups. Results: We found that both groups were similar while considering the demographic characteristics as there were no significant statistical differences noticed in the patient population with regard to age (DY Group 42.73 ± 9.01 days vs. RP Group 40.63 ± 7.6 days; P = 0.8209), sex (DY 4F/26M vs. RP 6F/24 M), weight at presentation (DY 3.3 ± 0.33 kg vs. RP 3.2 ± 0.21 kg; P = 0.33449), symptoms and clinical condition. All patients were optimally resuscitated before proceeding to surgery with regard to hydration, electrolyte imbalance and acid-base status. While considering anaesthesia, both groups were equal in terms of it and no anaesthesia-related complications were recorded in our study. However, during the first post-operative week, a significant difference was noted between DY versus RP groups with regard to vomiting (DY 1.33 ± 0.59 days vs. RP 2.8 ± 0.76 days; P = < 0.0001) and weight gain (299.86 ± 41.90 g vs. 199.03 ± 21.72 g; P = 0.008), respectively. Patients were followed up for 6 months post-operatively. No long-term complications were noticed in both groups. Weight gain after 1 month DY 577.46 ± 169.96 g versus RP 574.70 ± 170.10 g, (P = 0.949969), after 2 months DY (758.43 ± 94.53 g vs. RP 758. 8 ± 94.68 g, P = 0.98699) and after 3 months DY (593 ± 20.01 g vs. RP 591.16 ± 20.89 g, P = 0.61136). Overall, the operative time duration was the same in both groups. We had not noticed any intraoperative complications, post-surgical site infections were encountered. There was no need to redo pyloromyotomies in our study. Conclusion: Our study demonstrated that the double-Y pyloromyotomy procedure provides a better functional outcome with regard to vomiting and weight gain in the early post-operative period. It seems to be due to the wider opening of the pyloric canal at both ends of pyloromyotomy incision with a wide angle compared to Ramstedt’s pyloromyotomy. Obviously, the chance of mucosal perforation is also less as the enforce of the mucosa is divided into two directions. The method is suitable for both conventional and laparoscopic surgery. The small sample size was a limiting factor in this study. However, more studies need to be done on this technique to prove its efficacy and establish it as a standard technique for the future.