Conventional Gastrojejunostomy Research Articles

Investigating biomechanical alterations and emptying patterns after various gastrojejunostomy strategy

Gastrojejunostomy is a prominent approach in managing distal gastric cancer that is unresectable due to gastric outlet obstruction (GOO). Research has demonstrated that stomach-partitioning gastrojejunostomy (SPGJ) exhibits superior clinical efficacy compared to conventional gastrojejunostomy (CGJ), however, the underlying mechanism of this phenomenon remains elusive. This study constructed 3D models of the SPGJ and CGJ based on the computed tomography (CT) images obtained from a patient diagnosed with distal gastric cancer. The biomechanical patterns of these procedures in the digestive system were subsequently compared through numerical simulations and in vitro experiments. The results of the numerical simulation demonstrated that the model following SPGJ promoted the discharge of food through the anastomotic orifice and into the lower jejunum. Furthermore, a decrease in passage size after partitioning, the low-level velocity of esophageal, and an increase in contents viscosity effectively inhibited the flow through the passage to the pylorus, ultimately reducing stimulation to tumor. The study also revealed that favorable gastric emptying is associated with a smaller passage and faster inlet velocity, and that lower contents viscosity. ​The experimental findings conducted in vitro demonstrated that SPGJ exhibited superior efficacy in obstructing the flow near the pylorus in comparison to CGJ. Moreover, a decrease in passage size correlates with a reduction in fluid flow towards the pylorus. These results provide the foundation of theory and practice for the surgical management of patients with GOO resulting from unresectable distal gastric cancer, and have potential implications for clinical interventions.

Stomach-partitioning versus conventional gastrojejunostomy for unresectable gastric cancer with gastric outlet obstruction: A propensity score matched cohort study

BackgroundStomach partitioning gastrojejunostomy (SPGJ) was introduced to deal with delayed gastric emptying (DGE). This study aimed to compare the short- and long-term outcomes of SPGJ versus conventional gastrojejunostomy (CGJ). MethodThis cohort study analyzed 108 patients who underwent gastrojejunostomy for unresectable gastric cancer: 70 patients underwent SPGJ, and 38 patients underwent CGJ between 2018 and 2022. Propensity score-matched (PSM) analysis was used to balance the baseline characteristics. ResultsAfter PSM, there were 26 patients in each group. SPGJ group had significantly lower incidence of DGE (3.8% vs. 34.6%), vomiting (3.8% vs. 42.3%), and prokinetics requirement (11.5% vs. 46.2%). SPGJ group had significantly shorter time to solid diet tolerance (4.1 days vs. 5.7 days) and postoperative hospital stay (7.7 days vs. 9.3 days). There was no significant difference in relapse reinterventions, gastric outlet obstruction (GOO) recurrence, conversion surgery, and survival outcomes. ConclusionsSGPJ was associated with lower rate of DGE, prokinetics requirement, and shorter time of solid diet tolerance compared to CGJ in the treatment of unresectable gastric cancer patients with GOO.

Exploring the safety and efficacy of stomach-partitioning gastrojejunostomy with distal selective vagotomy versus conventional gastrojejunostomy with highly selective vagotomy for treating benign gastric outlet obstruction: study protocol for a randomised controlled trial

IntroductionBenign gastric outlet obstruction (BGOO) severely impacts the quality of life of patients. The main treatment methods for BGOO include surgery and endoscopy, but both have significant drawbacks. Therefore, this...

Gastric emptying performance of stomach-partitioning gastrojejunostomy versus conventional gastrojejunostomy for treating gastric outlet obstruction: A retrospective clinical and numerical simulation study.

Purpose: This study evaluated the gastric emptying performance of stomach-partitioning gastrojejunostomy (SPGJ) versus conventional gastrojejunostomy (CGJ) for treating gastric outlet obstruction (GOO). Methods: First, 73 patients who underwent SPGJ (n = 48) or CGJ (n = 25) were involved. Surgical outcomes, postoperative recovery of gastrointestinal function, delayed gastric emptying, and nutritional status of both groups were compared. Second, a three-dimensional stomach model was constructed based on the gastric filling CT images from a GOO patient with a standard stature. The present study evaluated SPGJ numerically by comparing it with CGJ in terms of local flow parameters such as flow velocity, pressure, particle retention time, and particle retention velocity. Results: Clinical data found that SPGJ had significant advantages over CGJ in terms of time to pass gas (3 versus 4days, p < 0.001), time to oral intake (3 versus 4days, p = 0.001), postoperative hospitalization (7 versus 9days, p < 0.001), the incidence of delay gastric emptying (DGE) (2.1% versus 36%, p < 0.001), DGE grading (p < 0.001), and complications (p < 0.001) for GOO patients. Moreover, numerical simulation revealed that the SPGJ model would induce contents in stomach discharge to the anastomosis at a higher speed, and only 5% of that flowed to the pylorus. SPGJ model also had a low-pressure drop as the flow from the lower esophagus to the jejunum, reducing the resistance to food discharge. Besides, the average retention time of particles in the CGJ model is 1.5 times longer than that in the SPGJ models, and the average instantaneous velocity in CGJ and SPGJ models are 22mm/s and 29mm/s, respectively. Conclusion: Compared with CGJ, patients after SPGJ had better gastric emptying performance and better postoperative clinical efficacy. Therefore, we think that SPGJ may be a better option for treating GOO.

Partial stomach-partitioning gastrojejunostomy for gastric outlet obstruction: A cohort study based on consecutive case series from a single center

Gastric outlet obstruction can have a large impact on quality of life for patients with upper gastrointestinal cancer or benign obstruction. Partial stomach-partitioning gastrojejunostomy has previously shown promising outcomes compared to conventional gastrojejunostomy in terms of reduced delayed gastric emptying. The objective of the current study was to present outcomes of partial stomach-partitioning gastrojejunostomy in a single high-volume center for upper gastrointestinal cancer. A retrospective cohort study including all consecutive patients who underwent partial stomach-partitioning gastrojejunostomy from 2013 to 2020. The primary outcome was oral intake tolerance. A subgroup analysis was performed in all patients with manifest gastric outlet obstruction comparing partial stomach-partitioning gastrojejunostomy to conventional gastrojejunostomy. Partial stomach-partitioning gastrojejunostomy was performed in 32 patients and laparoscopic technique was used in 19 patients (59%). The procedure improved oral intake tolerance defined by gastric outlet obstruction scoring system by 0.63 points on average (P=0.041). No postoperative complications related to the procedure were observed. Recurrence of gastric outlet obstruction developed in six patients (19%), four patients (13%) required endoscopic reintervention but no patient required surgical reintervention. A comparison between partial stomach-partitioning gastrojejunostomy and conventional gastrojejunostomy showed no statistically significant differences regarding postoperative nutritional status, length of hospital stay, recurrence or reintervention. The results of the study show that partial stomach-partitioning gastrojejunostomy can be an effective surgical treatment for patients suffering from gastric outlet obstruction and that the procedure can be safely performed with laparoscopic technique.

Efficacy of stomach-partitioning on gastric emptying in patients undergoing palliative gastrojejunostomy for malign gastric outlet obstruction.

Palliative efficacy of conventional gastrojejunostomy in palliation of malignant gastric outlet obstruction is debatable. This study aims to compare the outcomes of conventional gastrojejunostomy and stomach-partitioning gastrojejunostomy and to explore the factors influencing the delayed gastric emptying after surgery in patients with malignant gastric outlet obstruction. The study subjects were divided into the following two groups based on whether the stomach was partitioned or not: Conventional gastrojejunostomy and stomach-partitioning gastrojejunostomy. All demographic data, patient characteristics, postoperative outcomes, including delayed gastric emptying grade and 30-day complications were collected. Following the comparison of the clinical outcomes, risk factors for delayed gastric emptying were determined by regression models. Fifty-three patients were included in this study. Of these, 37 patients underwent conventional gastrojejunostomy, whereas 16 patients underwent stomach-partitioning gastrojejunostomy. Patient demographics and baseline characteristics were comparable between groups. Although 10 (27%) patients in the conventional gastrojejunostomy group had delayed gastric emptying grade B-C, no patient in the stomach-partitioning gastrojejunostomy group experienced this condition. There was no difference between the groups concerning hospital stay and complications. In multivariate regression analysis, having distant metastasis (OR=0.156, 95%CI 0.034-0.720, p=0.017) and stomach-partitioning (OR=0.127, 95%CI 0.025-0.653, p=0.014) were found as independent factors for the delayed gastric emptying. In patients with malignant gastric outlet obstruction, compared with conventional gastrojejunostomy, stomach-partitioning may provide favorable clinical outcomes by improving gastric emptying.

Gastric partitioning for the treatment of malignant gastric outlet obstruction.

BACKGROUNDGastric outlet obstruction (GOO) is one of the main complications in stage IV gastric cancer patients. This condition is usually managed by gastrojejunostomy (GJ). However, gastric partitioning (GP) has been described as an alternative to overcoming possible drawbacks of GJ, such as delayed gastric emptying and tumor bleeding.AIMTo compare the outcomes of patients who underwent GP and GJ for malignant GOO.METHODSWe retrospectively analyzed 60 patients who underwent palliative gastric bypass for unresectable distal gastric cancer with GOO from 2009 to 2018. Baseline clinicopathological characteristics including age, nutritional status, body mass index, and performance status were evaluated. Obstructive symptoms were graded according to GOO score (GOOS). Surgical outcomes evaluated included duration of the procedure, surgical complications, mortality, and length of hospital stay. Acceptance of oral diet after the procedure, weight gain, and overall survival were the long-term outcomes evaluated.RESULTSGP was performed in 30 patients and conventional GJ in the other 30 patients. The mean follow-up was 9.2 mo. Forty-nine (81.6%) patients died during that period. All variables were similar between groups, with the exception of worse performance status in GP patients. The mean operative time was higher in the GP group (161.2 vs 85.2 min, P < 0.001). There were no differences in postoperative complications and surgical mortality between groups. The median overall survival was 7 and 8.4 mo for the GP and GJ groups, respectively (P = 0.610). The oral acceptance of soft solids (GOOS 2) and low residue or full diet (GOOS 3) were reached by 28 (93.3%) GP patients and 22 (75.9%) GJ patients (P = 0.080). Multivariate analysis demonstrated that GOOS 2 and GOOS 3 were the main prognostic factors for survival (hazard ratio: 8.90, 95% confidence interval: 3.38-23.43, P < 0.001).CONCLUSIONGP is a safe and effective procedure to treat GOO. Compared to GJ, it provides similar surgical outcomes with a trend to better solid diet acceptance by patients.

Stomach-partitioning gastrojejunostomy is better than conventional gastrojejunostomy in palliative care of gastric outlet obstruction for gastric or pancreatic cancer: a meta-analysis.

Unresectable gastric or pancreatic malignancies are the most common cause of gastric outlet obstruction (GOO). Although several authors reported better outcomes in patients submitted to gastric partitioning gastrojejunostomy (GPGJ) compared to conventional gastrojejunostomy (CGJ), clinical experience with GPGJ is poor, studies comparing the two techniques are few and no randomized trials were performed. Our systematic review aimed at comparing GPGJ (partial or complete) with CGJ in patients operated for GOO for gastric or pancreatic cancer. A computerized literature search was performed on Medline until January 2017. The studies included were 8 with a total of 226 patients. Study outcomes included delayed gastric emptying (DGE), nutrition by oral intake, length of hospital stay and survival time. The pooled effects were estimated using a fixed effect model or random effect model based on the heterogeneity test. Results were expressed as odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, the mean of the measures of central tendency was calculated. The GPGJ group had lower rates of DGE (OR =4.997, 95% CI: 2.310-10.810) and length of hospital stay (19.7 versus 23.3 days) and higher rates of nutrition by oral intake (OR =0.156, 95% CI: 0.055-0.442) and survival time (189.2 versus 115.2 days). GPGJ is associated with lower rates of DGE and higher rates of normal oral intake compared to CGJ with a tendency towards better survival in the GPGJ group. Multicenter randomized controlled trials would be required to confirm these results.

A systematic review and meta-analysis comparing partial stomach partitioning gastrojejunostomy versus conventional gastrojejunostomy for malignant gastroduodenal obstruction.

Partial stomach partitioning gastrojejunostomy (PSPGJ) was introduced as a palliative treatment for malignant gastric outlet obstruction (MGO) caused by unresectable gastric or periampullary cancers and suggested to offer advantages over conventional gastrojejunostomy (CGJ) in reducing the risk for delayed gastric emptying (DGE). However, insufficient evidence is available to allow a comprehensive view of the true value of PSPGJ. The present study aimed to show the advantages of PSPGJ in terms of alleviating DGE and improving postoperative recovery compared to CGJ. A systematic literature search was performed, and studies comparing DGE and other perioperative and postoperative data including operation time, blood loss, total postoperative complications, anastomotic leak, postoperative period before oral intake, and/or hospital stay between PSPGJ and CGJ for MGO were incorporated. Risk ratio (RR) for binary variables and weighted mean difference (WMD) for continuous variables were calculated, and meta-analyses were performed. Seven studies containing 207 patients were included. The risk for DGE was significantly lower after PSPGJ (RR 0.32; 95%CI 0.17 to 0.60; P < 0.001). PSPGJ significantly reduced the postoperative hospital stay (WMD -6.1days; 95%CI -8.9 to -3.3days; P < 0.001). No significant differences were observed in the other variables between the groups. PSPGJ for MGO seems to offer significant advantages in terms of alleviating DGE and improving postoperative recovery compared to CGJ.

Partial stomach partitioning gastrojejunostomy in the treatment of the malignantgastric outlet obstruction

Abstract Background In patients with unresectable gastric cancer and outlet obstruction syndrome, gastric partitioning gastrojejunostomy is an alternative, which could avoid the drawbacks of the standard techniques. Objective Comparison of antroduodenal stent, conventional gastrojejunostomy and gastric partitioning gastrojejunostomy. Material and methods A retrospective, cross-sectional study was conducted on patients with unresectable distal gastric cancer and gastric outlet obstruction, treated with the three different techniques over the last 12 years, comparing results based on oral tolerance and complications. An analysis was performed on the results using the Student's t test for independent variables. Results The 22 patients were divided in 3 groups: group I (6 cases) stent, group II (9 cases) conventional gastrojejunostomy, and group III (7 cases) gastric partitioning gastrojejunostomy, respectively. The stent allows a shorter “postoperative” stay and early onset of oral tolerance ( p p Conclusions The gastric partitioning gastrojejunostomy for treatment of gastric outlet obstruction in unresectable advanced gastric cancer is a safe technique, allowing a more complete diet with lower morbidity and improved survival.

Gastro yeyuno anastomosis con separación gástrica parcial en el tratamiento de la obstrucción gastroduodenal secundaria a cáncer gástrico avanzado

BackgroundIn patients with unresectable gastric cancer and outlet obstruction syndrome, gastric partitioning gastrojejunostomy is an alternative, which could avoid the drawbacks of the standard techniques. ObjectiveComparison of antroduodenal stent, conventional gastrojejunostomy and gastric partitioning gastrojejunostomy. Material and methodsA retrospective, cross-sectional study was conducted on patients with unresectable distal gastric cancer and gastric outlet obstruction, treated with the three different techniques over the last 12 years, comparing results based on oral tolerance and complications. An analysis was performed on the results using the Student-t test for independent variables. ResultsThe 22 patients were divided in 3 groups: group I (6 cases) stent, group II (9 cases) conventional gastrojejunostomy, and group III (7 cases) gastric partitioning gastrojejunostomy, respectively.The stent allows a shorter “postoperative” stay and early onset of oral tolerance (P<0.05), however, the gastric partitioning gastrojejunostomy achieve normal diet at 15th day (P<0.05). The mortality rate was higher in the stent group (33%) compared with surgical techniques, with a morbidity of 4/6 (66.7%) in Group I, 6/9 (66.7%) Group II, and 3/7 (42%) Group III. Re-interventions: 2/6 Group I, 3/9 Group II, and 0/7 Group III. The median survival was superior in the gastric partitioning gastrojejunostomy, achieving an overall survival of 6.5 months. ConclusionsThe gastric partitioning gastrojejunostomy for treatment of gastric outlet obstruction in unresectable advanced gastric cancer is a safe technique, allowing a more complete diet with lower morbidity and improved survival.

The Added Value of Partial Stomach-partitioning to a Conventional Gastrojejunostomy in the Treatment of Gastric Outlet Obstruction

IntroductionPoor results have been reported after conventional gastrojejunostomy (CGJ) as palliative surgical bypass treatment of gastric outlet obstruction (GOO). Partial stomach-partitioning gastrojejunostomy (PSPGJ) has been introduced as an alternative surgical treatment of GOO to reduce the risk of postoperative delayed gastric emptying (DGE). AimThe aim was to study PSPGJ as an alternative to CGJ in the treatment of GOO, with respect to DGE. Patients and MethodsA retrospective cohort study was completed in all patients who underwent a bypass of the duodenum via PSPGJ or CGJ due to GOO. Cases where concomitant biliary or bariatric procedures were performed were excluded. ResultsTwenty-four patients met the inclusion criteria for the study; ten cases underwent PSPGJ and 14 CGJ. The incidence of DGE grade B-C was significantly lower in the PSPGJ group (0 %) compared with the CGJ group (42.9 %, p = 0.024). Oral nutrition only was recorded more often at follow-up in the PSPGJ group (9/9, 100 %) than in the CGJ group (4/13, 30.8 %) (p = 0.002). ConclusionPSPGJ seems to be followed by a lower rate of DGE compared to CGJ.

Is modified devine exclusion necessary for gastrojejunostomy in patients with unresectable pancreatobiliary cancer?

Gastrojejunostomy is often performed as palliative surgery for unresectable pancreatobiliary cancer. Modified Devine exclusion (MDE) is a technical variation of gastrojejunostomy, which partially separates the mid-portion of the stomach. We conducted this study to assess whether MDE is necessary for gastrojejunostomy in patients with unresectable pancreatobiliary cancer. We compared the postoperative results of MDE (n = 26) with those of conventional gastrojejunostomy (CGJ; n = 20) performed palliatively for unresectable pancreatobiliary cancers. The morbidity rates were 38% after MDE and 50% after CGJ, with 23% and 40% of patients suffering delayed gastric emptying, respectively. Two of the CGJ group patients could never eat again. Modified Devine exclusion slowed the progression of anemia in all of the patients with duodenal bleeding. Modified Devine exclusion may be effective for patients with unresectable pancreatobiliary cancer.

Laparoscopic-assisted Stomach-partitioning Gastrojejunostomy for the Palliation of Gastric Outlet Obstruction From Antral Gastric Cancer

Conventional gastrojejunostomy is performed for gastric outlet obstruction; however, we have experience of some patients for whom oral intake was not adequately restored. Open stomach-partitioning gastrojejunostomy is a useful technique for the relief of unresectable and obstructing antral gastric cancers. We herein report the successful laparoscopic application of this technique in 2 patients: a 62-year-old male and a 65-year-old female with obstructing antral gastric cancer. There were no operative complications, and blood loss was minimal. Oral fluid intake was resumed 3 and 4 days postoperatively. Chemotherapy by oral administration was possible for each patient. There was no recurrence of the gastric outlet obstruction in either patient up until they died 6 and 10 months after surgery. Laparoscopic stomach-partitioning gastrojejunostomy is a safe and useful technique for treating unresectable and obstructing antral gastric cancer, allowing the possibility of adequate oral intake and permitting the administration of anticancer drugs.

Modified Devine Exclusion with Vertical Stomach Reconstruction for Gastric Outlet Obstruction: A Novel Technique

BackgroundA gastroenterostomy is the most commonly performed palliative procedure in patients with gastroduodenal outflow obstruction (GOO) caused by unresectable advanced gastric and pancreatic cancer. We developed a new technique—modified Devine exclusion with vertical stomach reconstruction—and evaluated the efficacy of this procedure. MethodsWe retrospectively studied 60 patients who underwent gastrojejunostomy for GOO caused by unresectable advanced gastric and pancreatic cancer. These patients were divided into two groups, the conventional gastrojejunostomy group (CGJ group) and the modified Devine exclusion with vertical stomach reconstruction group (MDVSR group). ResultsThe mean duration of the required nasogastric suction, the number of days after which diet could be initiated and after which oral ingestion of solid food could by safely resumed, and the duration of hospitalization after the surgery were significantly shorter in the MDVSR group. The patients in the MDVSR group had a significantly longer duration of stay at home and survival after the surgery. Moreover, in the MDVSR group, GOO did not recur in any of the patients until the time of death. ConclusionWe consider that our procedure of modified Devine exclusion with vertical stomach reconstruction is an easy and feasible technique for GOO.

Endoscopic Stenting Versus Surgical Gastrojejunostomy for Palliation of Malignat Gastroduodenal Obstruction

Objective: Palliative treatment of malignant gastroduodenal obstruction has been performed traditionally with gastrojejunostomy. Palliation with autoexpandable metal prostheses has also shown to be effective and to improve the quality of life of patients. We compared the effectiveness of conventional gastrojejunostomy with the application of an autoexpandable metal stent developed locally, for palliation of malignant gastroduodenal obstruction by evaluating clinical success, morbidity, mortality and length of hospital stay. Materials and Methods: Medical records from 80 patients with malignant gastroduodenal obstruction were reviewed: 40 patients had received treatment with the autoexpandable metal stent and 40 with gastrojejunostomy. Patients who underwent prophylactic gastrojejunostomy were excluded. Results: Gastroduodenal stents were successfully placed in 39 of 40 (97%) patients (21 males) and gastrojejunostomy was performed in 40 patients (23 men) with obstructive tumors of the gastroduodenal tract. The gastroduodenal obstruction was secondary to gastric, gallbladder or biliary tract, pancreatic and ampullary tumors or metastatic disease. These malignancies were considered unresectable in all patients. There were no statistical differences in the origin of the obstruction, hospital mortality or survival between the treatment groups. However, time to resume oral feeding (1.6 vs 7 days) and length of hospital stay (3 vs 14 days) were significantly shorter in the group receiving the stents (p < 0.01). Furthermore, morbidity was significantly lower in the stent group (15% vs 38%, p < 0,01). There was a trend in a higher activity index in the stent group (p = 0.08). Conclusions: The placement of autoexpandable metal stents was more beneficial in terms of length of hospital stay, time to resume oral feeding and morbidity than open gastrojejunostomy for the palliation of malignant gastroduodenal obstruction.

EMBRYOLOGIC AND ANATOMIC BASIS OF DUODENAL SURGERY

The following points should be remembered by surgeons (Table 1). In writing about the head of the pancreas, the common bile duct, and the duodenum in 1979, the authors stated that Embryologically, anatomically and surgically these three entities form an inseparable unit. Their relations and blood supply make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply. The authors had several conversations with Child, one of the pioneers of this procedure, whose constant message was to always be careful with the blood supply of the duodenum (personal communication, 1970). Beger et al popularized duodenum-preserving resection of the pancreatic head, emphasizing preservation of endocrine pancreatic function. They reported that ampullectomy (removal of the papilla and ampulla of Vater) carries a mortality rate of less than 0.4% and a morbidity rate of less than 10.0%. Surgeons should not ligate the superior and inferior pancreaticoduodenal arteries because such ligation may cause necrosis of the head of the pancreas and of much of the duodenum. The accessory pancreatic duct of Santorini passes under the gastrointestinal artery. For safety, surgeons should ligate the artery away from the anterior medial duodenal wall, where the papilla is located, thereby avoiding injury to or ligation of the duct. "Water under the bridge" applies not only to the relationship of the uterine artery and ureter but also to the gastroduodenal artery and the accessory pancreatic duct. In 10% of cases, the duct of Santorini is the only duct draining the pancreas, so ligation of the gastroduodenal artery with accidental inclusion of the duct is catastrophic. With the Kocher maneuver, surgeons reconstruct the primitive mesoduodenum and achieve mobilization of the duodenum, which is useful for some surgical procedures. Surgeons should not skeletonize more than 2 cm of the first part of the duodenum. If more than 2 cm of skeletonization is done, a duodenostomy using a Foley catheter may be necessary to avoid blow-up of the stump secondary to poor blood supply. Proximal duodenojejunostomy is advised for the safe management of patients with difficult duodenal stumps. Roux-en-Y choledochojejunostomy and duodenojejunostomy divert bile and food in the treatment of the complicated duodenal diverticulum. The suspensory ligament may be transected with impunity. It should be ligated before being sectioned so that bleeding from small vessels contained within can be avoided. Failure to sever the suspensory muscle completely, which is possible if the insertion is multiple, fails to relieve the symptoms of vascular compression of the duodenum (Fig. 18). Mobilization, resection, and end-to-end anastomosis of the duodenal flexure have been performed as a uniform surgical procedure, avoiding the conventional gastrojejunostomy. With a large, penetrating posterior duodenal or pyloric ulcer, surgeons should remember that The proximal duodenum shortens because of the inflammatory process (duodenal shortening) The anatomic topography of the distal common bile duct and the opening of the duct of Santorini and the ampulla of Vater is distorted Leaving the ulcer in situ is wise Careful palpation for or visualization of the location of the ampulla of Vater or common bile duct exploration with a catheter insertion into the common bile duct and the duodenum are useful procedures In most cases, the common bile duct is located to the right of the gastroduodenal artery at the posterior wall of the first part of the duodenum. (ABSTRACT TRUNCATED)

Stomach-partitioning gastrojejunostomy for unresectable gastric carcinoma.

To analyze the results of a new type of bypass procedure, stomach-partitioning gastrojejunostomy (SPGJ), for unresectable gastric carcinoma and to compare these results with those of conventional gastrojejunostomy (GJ). Retrospective review. A university hospital in Japan. Eight patients underwent SPGJ in 1 group, and 13 underwent conventional GJ in the other group. Staging was determined using preoperative diagnostic imagings and intraoperative findings. Assessment of food intake and mean survival rates. There were no significant differences between the 2 groups regarding male-female ratio, mean age, and histological type of carcinoma. All patients had stage IV cancers according to the classification of the Union Internationale Contre le Cancer. The rates of taking a regular meal at 2 weeks after an operation were 88% in the SPGJ group and 31% in the GJ group (P < .05). The mean 1-year survival rates for SPGJ and GJ groups were 42.9% and 7.7%, respectively (P < .05). The mean survival times were 13.4 months in the SPGJ group and 5.8 months in the GJ group (P < .05). Stomach-partitioning gastrojejunostomy achieved an improved quality of life and a better prognosis for patients, and it is the preferred bypass procedure for unresectable gastric carcinoma.

Experimental endobrachyesophagus in dogs: a model without mucosectomy

An experimental study is made to demonstrate the participation of biliopancreatic plus gastric acid reflux in the etiopathogenesis of endo-brachyesophagus. A jejunoesophagogastrostomy was performed in Beagle dogs according to the method described by Pera in rats. This operation, as well as Wendel’s plasty and a conventional gastrojejunostomy were not tolerated. Wendel’s operation using a transgastric GIA stapler plus a Jaboulay antroduodenostomy without mucosectomy was finally tolerated by the animals. Two groups were established: 10 controls (subjected to Wendel’s operation only); 16 dogs subjected to both the Wendel and Jaboulay procedures. Pre- and post-operative (1–12 months) evaluation comprised endoscopy-biopsy, 24-h pHmetry and manometry. Three dogs were sacrificed after 2–3 months, and a further three after 9–12 months. Manometry revealed the almost total disappearance of the lower esophageal sphincter. pHmetry showed a significantly longer period of time at pH>7 in the second group. Endoscopically, no changes were noted among the controls, while the second group showed Grade II-III esophagitis, with possibly metaplastic rivulets. In all specimens, and at over 3 cm from the esophagogastric junction, extensive cylindrical metaplasia was seen extending outwards from the glands. Alcian-blue stained goblet cells were observed, along with peptic ulcerations and even occasional dysplastic foci. This model demonstrates the pathogenic effect of the combined influence of the two refluxes; once standardized, it may prove useful in future therapeutic evaluations.