Gastrostomy For Decompression Research Articles

The Impact of Palliative Decompressive Gastrostomy Tube Placement on Patients and Their Caregivers: A Mixed Methods Analysis.

Palliative decompressive gastrostomy tubes are intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life. The objective of this study was to assess the impact of palliative decompressive gastrostomy tube on patient and caregiver well-being. We prospectively enrolled patients with a malignant SBO and their caregivers at the time of informed consent for decompressive gastrostomy tube placement. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and at 2-week post-procedure follow-up. The Caregiver Burden Scale survey was administered to caregivers at baseline. Survey scores were compared using paired t-tests. We also conducted semistructured interviews with patients and their caregivers at two-week follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders. We enrolled 15 patient-caregiver dyads. Preprocedure, the median caregiver burden scale score was 37.5 (significant burden ≥ 21). Eight patients (53%) survived to 2 weeks; among these patients, median ESAS scores (51 versus 43.5, p < 0.001) and median FACIT-Pal-14 scores (22 versus 32, p = 0.015) were significantly improved at 2-week follow-up. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for better education and resources. Decompressive gastrostomy tubes effectively alleviated symptoms in patients with inoperable malignant SBOs. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors.

CT Fluoroscopy-Guided Percutaneous Gastrostomy in the Palliative Management of Advanced and Relapsed Ovarian Cancer: The Charité Experiences and a Review of the Literature.

Peritoneal carcinomatosis-associated malignant bowel obstruction is a common feature that merits more attention in advanced and recurrent ovarian cancer. Decompressive gastrostomy is one of the most preferred methods to palliate distressing symptoms and maintain patients' quality of life. We retrospectively identified 31 patients with ovarian cancer-associated MBO, who underwent decompressive CT fluoroscopy-guided percutaneous gastrostomy (CT-PG) between September 2015 and April 2023 at our institution. A systematic literature review was conducted for CT-guided gastrostomy in ovarian cancer. Prior to CT-PG, 27 (87%) patients underwent unsuccessful attempts at endoscopic gastrostomy or surgery due to bowel obstruction; a total of 55% had received ≥3 lines of chemotherapy. CT-PG could be successfully inserted in 25 of 31 (81%) patients without grade 4-5 complications. CT-PG insertion was feasible in 76% of patients with previous unsuccessful attempts of endoscopic gastrostomy. A total of 80% of patients with a successful insertion had considerable symptom relief and could tolerate fluid intake. Mean survival after the procedure was 44.4 days. Chemotherapy could be administered in 7 of 25 (28%) patients following the CT-PG insertion. CT-guided percutaneous gastrostomy is a safe procedure that effectively manages intractable symptoms of bowel obstruction in ovarian cancer. This minimally invasive technique should be emphasised as a routine instrument within the palliative management of MBO.

Readmission and Disposition in Patients With Malignant Bowel Obstructions Following Gastrostomy Tube.

Patients with peritoneal carcinomatosis (PC) can develop malignant bowel obstructions (MBOs) requiring inpatient admission and nasogastric tube decompression. Palliative decompressive gastrostomy tubes (G-tubes) may affect patient disposition, allowing for self-management and reduction in inpatient services. Therefore, we sought to assess disposition and inpatient readmission rates in patients admitted with PC and MBO following G-tube placement. The Vizient® Clinical Data Base was queried for inpatient admissions from October 2018 to May 2022 utilizing ICD-10 codes to identify patients admitted with PC and bowel obstruction, with or without G-tube placement. Demographics and hospital outcomes were recorded. Descriptive statistics and multivariate logistic regression analysis were performed. From 750 patients, 59 (7.9%) had a G-tube placed. Compared to patients without G-tubes, those with G-tubes had lower rates of disposition to home (32.2% vs 70.0%, P < .001) and higher rates of disposition to hospice (home: 30.5% vs 7.8%, P < .001, facility: 10.2% vs 3.9%, P = .02). There was no significant difference in the rate (17.3% vs 22.3%, P = .40) or risk (OR = 1.44, 95% CI .69-3.01) of 30-day readmissions with G-tubes. However, palliative care consultation (OR 33.77, 95% CI 19.16-59.52) and G-tube placement (OR 5.82, 95% CI 2.56-13.25) were independent predictors for hospice. Placement of G-tubes in patients with PC and MBO was associated with higher rates of disposition to hospice but there is no difference in 30-day readmission rates compared to those without G-tubes. Further prospective studies are needed to understand the role of G-tube placement in patients with MBO in relation to outcomes and disposition.

Enhanced gastric decompression for palliation of malignant bowel obstruction.

Malignant bowel obstruction (MBO) is a sequela of advanced intraabdominal cancer and has a profound impact on quality of life. Common therapy is endoscopic decompressive gastrostomy tube placement. Standard gastrostomy tubes are poorly designed to completely evacuate the dependent portions of the stomach due to their location on the anterior gastric wall. In our institution we have begun placing the ASPIRE Assist gastrostomy tube (ASPIRE Bariatrics, Exton, PA) which includes a 15cm long, 30Fr fenestrated gastric tube extension for enhanced gastric decompression. This tube is FDA indicated for gastric decompression and marketed for endoscopic weight loss. The purpose of this study is to review our experience managing MBO utilizing the ASPIRE Assist tube. This is a retrospective analysis of outcomes at a single institution. All decompressive endoscopic gastrostomy tubes placed by two surgeons between November 2019 and July 2021 were reviewed. Endoscopic placement was performed utilizing standard safe tract and Ponsky pull techniques. Fourteen patients were identified (10F:4M), mean age 70 (range 35-89). Primary cancer diagnoses included gynecologic (8), colorectal (3), bladder (1), small bowel (1), peritoneal serous (1). During the 12months before decompressive gastrostomy tube placement, mean number of hospital admissions for MBO was 1.6 (range 1-3). Following tube placement, twelve patients had no further hospital admissions for MBO over their lifespan of mean 270days (range 8-679days). One patient had 1 admission for MBO in the 12months before tube placement and 3 admissions in the 4months after placement. A second patient had 2 admissions in the 12months before tube placement and 1 admission in their 54-day lifespan after placement. There were no major complications. Endoscopic placement of the ASPIRE Assist gastrostomy tube is safe for palliation of MBO and may improve gastric decompression compared with standard endoscopic gastrostomy tubes. Enhanced gastric decompression can better manage symptoms, reduce hospital encounters, and improve quality of life. Further study is needed, however, our initial data appears promising.

Esophageal perforation due to acute esophageal necrosis: A case report and a comprehensive literature review

Background. Acute esophageal necrosis is a rare and potentially lethal entity. The pathogenesis is multifactorial, generally presenting with symptoms of upper gastrointestinal bleeding. We present a case that presents atypically with initial esophageal perforation. Case presentation. A 46-year-old man with a history of alcoholism and cocaine use, an active smoker, and a ruptured celiac trunk aneurysm treated by embolization, who, after acute chest and epigastric pain, is diagnosed with a Stanford B thoracoabdominal aortic dissection, being repaired endovascularly by placing an aortic endoprosthesis. Due to clinical suspicion of mesenteric ischemia complicated with esophageal/gastric perforation, a postoperative tomography was performed, revealing perforation of the esophagus distal to the left pleura and ischemic cholecystitis. Transhiatal esophagectomy, cervical esophagostomy, Witzel-type decompressive gastrostomy, Witzel-type feeding jejunostomy, classic cholecystectomy, and mediastinum drainage were performed. During the postoperative period, the patient remained in critical condition, dying as a result of hypoxic encephalopathy. The histopathological study reported acute transmural esophageal ischemia. Discussion. Tissue hypoperfusion plays a dominant role in the pathogenesis of acute esophageal necrosis. Esophageal perforation is a serious complication and can occur in the early stages, with esophagectomy and deferred digestive reconstruction being the appropriate treatment. Conclusion. Ischemia is a fundamental mechanism of acute esophageal necrosis; its diagnosis must always be established in the various complications that may occur in patients with hemodynamic compromise, in order to obtain a timely treatment.

70-Year-Old Man With Chronic Nausea and Vomiting

70-Year-Old Man With Chronic Nausea and Vomiting

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.

Laparoscopic-Percutaneous Combined Gastrostomy: Initial Experience and Description of a Technique.

Background: Gastrostomy is a widely used procedure that aims to obtain access to the stomach. Its purpose may be feeding or gastric decompression. Currently, the most common techniques are endoscopic and radiologic. Sometimes, these accesses are not available due to technical or patient-specific factors. In these cases, laparoscopic and percutaneous approaches combined could be an option. The aim of this study was to describe a laparoscopic-percutaneous combined gastrostomy procedure, feasibility, and complications. Materials and Methods: Retrospective descriptive observational study. All patients underwent laparoscopic-percutaneous combined gastrostomy required for feeding or decompressive gastrostomy. We analyzed variables: demographics, surgical indication, operation time, hospitalization stay, success, and morbidity/mortality associated to the procedure. Results: A total of n = 17 patients were recruited (58.8% women and 41.2% men), with mean age of 53. Regarding the indications of laparoscopic-percutaneous combined gastrostomy, 47% were due to upper gastrointestinal/head and neck tumor, 29.4% stomach location in a retrocostal position, 17.7% colonic interposition, and 5.9% acute gastric dilation of remnant after Roux-en-Y gastric bypass. The mean time of the procedure was 25 minutes, and mean hospitalization stay was 1.2 days. The success of the procedure was 100%. No complications and mortality associated with the procedure were reported. Conclusion: Laparoscopic-percutaneous combined gastrostomy is fast, feasible, safe, and cost effective. It is an option in patients where it is not possible to perform standard minimally invasive approaches.

Safety and efficacy of percutaneous transabdominal and transesophageal decompression gastric catheters for palliation of malignant bowel obstruction.

To evaluate the safety and primary technical success rate of gastric decompression via percutaneous transabdominal gastrostomy (PTAG) or percutaneous transesophageal gastric (PTEG) catheter placement for management of malignant bowel obstruction (MBO). A secondary purpose was to evaluate the safety and success rate for PTAG catheter placement in patients with both MBO and ascites. A single-institution retrospective review of 385 patients who underwent attempted decompression gastric catheter placement from March 2013 to August 2018 was performed. Medical records and imaging studies were reviewed. A subgroup of patients with concomitant MBO and ascites were identified. The primary outcome measures were procedural technical success and procedural complications. 394 decompression gastrostomy catheters were attempted from 2013 to 2018, n = 353 PTAG and n = 41 PTEG. The success rate was 95.5% (n = 337 of 353) for PTAG and 97.6% (n = 40 of 41) for PTEG. There were 63 total complications involving 47 (13.9%) patients following PTAG and 13 total complications involving 9 (22.5%) patients following PTEG, P = 0.16. For the subgroup of patients with MBO and ascites, the success rate was 94.8% (n = 182 of 192 patients), and there were 20 complications involving 17 (12.9%) of 132 patients. Gastric decompression for patients with MBO via PTAG or PTEG catheter placement is associated with high success rates and low complications.

Acute Mediastinitis Following Esophageal Perforation with Swallowing of Duck Bone: A Case Report

<i>Background</i>: Acute mediastinitis is still associated with a high morbidity and mortality. Mediastinitis secondary to esophageal perforation is a rare but potentially life-threatening condition. <i>Case presentation</i>: This report aims to present an acute mediastinitis case, in a 54-year-old healthy female patient, which originated from an intrathoracic esophageal perforation with swallowing of duck bone that confirmed by computed tomography of the chest. The patient was successfully treated by an emergency left thoracotomy, effective surgical drainage and aggressive debridement of the affected mediastinal compartments, primitive repair of perforated esophagus with intercostal muscle flap, decompressive gastrostomy and jejunostomy for feeding. Post-operatively, the patient was benefited from broad-spectrum antibiotics, intensive care and resuscitation associated with a close follow-up consequence. <i>Results</i>: Mediastinitis was well-controlled. Post interventional computed tomography scan with hydro-soluble contrast ingestion showed no extraluminal leak and good integrity of esophagus. The patient restored normally oral feeding without any complications and was discharged after 24 days of hospitalization without any sequelae. <i>Conclusions</i>: Early diagnosis is critical for expediting the choice of an optimal treatment strategy and plays an important role in improving mortality from acute mediastinitis following perforated esophagus. Besides intensive care and resuscitation, we advocate an emergency thoracic surgery for cases with established mediastinitis following intrathoracic esophageal perforation.

S2048 Awareness of Early Diagnosis and Surgical Management of Pediatric Intestinal Pseudo-Obstruction

INTRODUCTION: Gastrointestinal motility is produced by two types of smooths of muscles in the gastrointestinal tract which are circular muscles and longitudinal muscles. These muscles are stimulated by a complex multifaceted connection between intrinsic enteric nervous system and central nervous system. The enteric nervous system is composed of Interstitial cells of Cajal, submucosal plexus, myenteric plexus, migratory motor complex and gut neuromodulators. Gut motility disorders are derived from numerous etiologies that arise from the muscular, nervous, cellular, molecular components. Pediatric intestinal pseudo obstruction is a disorder that needs early diagnosis and prompt treatment to avoid associated life-threatening complications. CASE DESCRIPTION/METHODS: A 27 weeks gestational age baby girl born to a 25 year G1P0 mother with history of abruptio placenta and chorioamnionitis was admitted to the neonatal intensive care unit due to extreme low birth weight and prematurity. Patients developed disseminated Herpes Simplex Virus infection complicated with left grade 2 intraventricular hemorrhage. Afterwards, patient developed persistent total parenteral nutrition dependence, enteral food intolerance, marked intestinal dilation and constipation for 4 months since birth. Rectal biopsies rule out Hirschsprung disease. Multiple abdominal x-rays showed marked diffuse intestinal dilation. Water soluble enema study revealed inflammatory changes suggestive necrotizing enterocolitis. Patient was taken to the operation room since no clinical improvement. Intraoperative findings included viable intestinal tissue without ischemic change and no mechanical obstruction. After negative exploratory laparotomy we decided to perform a rigorous review of literature regarding intestinal dysmotility disorders. DISCUSSION: Our patient was diagnosed with pediatric intestinal pseudo obstruction based in our review of literature which is a intestinal motility disorder. Our plan was to perform multiple full thickness intestinal biopsies to confirmed diagnosis and surgical management with decompressive gastrostomy and ileostomy. Unfortunately, patient developed acute-clinical deterioration due to septic shock, catheter-related bacteremia and multiple organ failure. Functional motility disorders should be included as a differential diagnosis once mechanical obstruction rule out. Our aim is to provide awareness of early identification of PIPO and management since life-threatening complications may develop.

Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer.

The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.

Percutaneous Gastrostomy Placement for Decompression of the Excluded Gastric Remnant following Roux-en-Y Gastric Bypass Surgery

Abstract Purpose To evaluate the feasibility and safety of percutaneous gastrostomy for decompression of the excluded stomach in patients’ status post Roux-en-Y gastric bypass (RYGB). Materials and Methods Between January 2001 and August 2017, 10 consecutive RYGB patients who underwent placement of a decompressive gastrostomy of the excluded stomach were identified in an institutional database. Technical success was defined as successful gastrostomy catheter placement in the bypassed stomach using fluoroscopy and/or ultrasound guidance. Clinical success was established if dilation of the excluded stomach improved after gastrostomy with resolution of associated symptoms. Charts were reviewed for treatment-related adverse events post-procedure. Results The cohort was predominantly female (9/10), with an average age of 54 ± 14 years. Median follow-up was 35.2 months (range: 0.6–115). Indications for decompressive gastrostomy placement included small bowel obstruction (6/10) or afferent limb obstruction at the jejunojejunal anastomosis (4/10). The most common presenting symptoms were abdominal pain, distension, and vomiting. All patients had successful gastrostomy placement in the excluded remnant, using ultrasound and fluoroscopic guidance, with no procedural complications. The 12 to 16F Cope loop catheters was used in this cohort, and gastropexy sutures were used in two cases. All 10 patients demonstrated clinical resolution of symptoms after gastrostomy placement. Two patients developed minor complications of tube site leakage and poor tube function requiring gastrostomy exchange within 1 week of the procedure. Conclusion Fluoroscopic and ultrasound-guided percutaneous gastrostomy catheter placement is a safe, effective, and feasible approach to treating dilation of the excluded gastric remnant in RYGB patients.

Abstract No. 568 Percutaneous gastrostomy for treating dilatation of the excluded stomach after Roux-en-Y gastric bypass surgery

To describe the use of percutaneous gastrostomy for decompression of the excluded stomach in patients with roux-en-Y gastric bypass (RYGB) and assess feasibility and safety of this approach. Between Jan 2001-Aug 2017, 10 consecutive RYGB patients who underwent decompressive gastrostomy of the excluded stomach were identified in an institutional database. Technical success was defined as successful gastrostomy tube placement in the bypassed stomach using fluoroscopy or ultrasound guidance. Clinical success was established if dilation of the excluded stomach improved after gastrostomy with resolution of associated symptoms. Charts were interrogated for treatment-related adverse events postprocedure. The cohort was predominantly female (9/10), with an average age of 54 ± 14 years. Median follow-up was 35.2 months (range, 0.6-115). Indications for decompressive gastrostomy included small bowel obstruction (6/10) or obstruction of the afferent limb at the jejunojejunal anastomosis (4/10). The most common presenting symptoms were abdominal pain, distension, and vomiting. All patients had successful gastrostomy placement in the excluded remnant using only ultrasound and fluoroscopy guidance, with no procedural complications. In 2 patients, a 12 Fr locking pigtail catheter was used. In 7 cases, a 14 Fr pigtail catheter was used; one of these tubes was later upsized to 18 Fr. In one case, a 16 Fr pigtail catheter was used. Only 2 patients had gastropexy sutures placed during procedure. All patients demonstrated improvement in gastric dilation after gastrostomy. 2 patients developed complications of tube site leakage and poor tube function within 1 week of procedure, which resolved with tube exchange. In 4 patients, tubes were removed after 8 weeks with symptom resolution and no further intervention. In 4 patients, tubes remained in place, with successful decompression and symptom improvement, until subsequent surgical revision. In 2 patients, tubes remained in place with transfer to hospice. Fluoroscopic and ultrasound-guided percutaneous gastrostomy is a safe, effective, and feasible approach to treating dilation of the excluded stomach in RYGB patients.

Benefits and risks of a percutaneous endoscopic gastrostomy (PEG) for decompression in patients with malignant gastrointestinal obstruction.

Gastrointestinal obstruction presents many burdens for patients with end-stage abdominal cancer, such as nausea and vomiting. Few detailed data on the efficacy of a percutaneous endoscopic gastrostomy (PEG) for decompression exists. This retrospective cohort study investigates the quantity of symptom relief realized with PEG and the corresponding complications. Chart reviews of 75 patients with malignant gastrointestinal obstruction, who received a PEG for decompression, were performed. Abstracted data includes symptoms (vomiting, nausea, abdominal pain) and medication up to 7days before and after the intervention, complications, demographics, potential influencing factors and survival. Generalized estimating equations (GEE) models determined symptom reduction. PEG decreased the mean frequency of vomiting per day from 2.2 (95% confidence interval (CI) 1.7-2.7) to 0.4 (95% CI 0.3-0.6) (p<0.001). The probability of the occurrence of nausea on a given day was 80% (95% CI 74-85%) prior to the PEG placement and 40% (95% CI 34-47%) afterwards (p<0.001). One hundred twelve complications were reported in 56 patients (none 19/75 patients (25%), minor 52/75 (69%), major 18/75 (24%)). Stomal leakage (18/75 patients), mild wound pain (17/75) and tube occlusion (13/75) occurred most frequently. The failure of the first attempt of the PEG placement (7/75) presented as the leading major complication. The PEG for decompression significantly reduces vomiting and nausea in patients with malignant gastrointestinal obstruction (p<0.001). Minor complications are common and should be discussed prior to the intervention. Nevertheless, the PEG appears to demonstrate prevailing benefits in comparison to the risks.

Temporary percutaneous T-fastener gastropexy and continuous decompressive gastrostomy in dogs with experimentally induced gastric dilatation.

OBJECTIVE To evaluate a percutaneous, continuous gastric decompression technique for dogs involving a temporary T-fastener gastropexy and self-retaining decompression catheter. ANIMALS 6 healthy male large-breed dogs. PROCEDURES Dogs were anesthetized and positioned in dorsal recumbency with slight left-lateral obliquity. The gastric lumen was insufflated endoscopically until tympany was evident. Three T-fasteners were placed percutaneously into the gastric lumen via the right lateral aspect of the abdomen, caudal to the 13th rib and lateral to the rectus abdominis muscle. Through the center of the T-fasteners, a 5F locking pigtail catheter was inserted into the gastric lumen and attached to a device measuring gas outflow and intragastric pressure. The stomach was insufflated to 23 mm Hg, air was allowed to passively drain from the catheter until intraluminal pressure reached 5 mm Hg for 3 cycles, and the catheter was removed. Dogs were hospitalized and monitored for 72 hours. RESULTS Mean ± SD catheter placement time was 3.3 ± 0.5 minutes. Mean intervals from catheter placement to a ≥ 50% decrease in intragastric pressure and to ≤ 6 mm Hg were 2.1 ± 1.3 minutes and 8.4 ± 5.1 minutes, respectively. After catheter removal, no gas or fluid leakage at the catheter site was visible laparoscopically or endoscopically. All dogs were clinically normal 72 hours after surgery. CONCLUSIONS AND CLINICAL RELEVANCE The described technique was performed rapidly and provided continuous gastric decompression with no evidence of postoperative leakage in healthy dogs. Investigation is warranted to evaluate its effectiveness in dogs with gastric dilatation-volvulus.

A Successful Strategy for Surgical Treatment of Boerhaave’s Syndrome Sans Thoracotomy

Boerhaave's syndrome is a rare life threatening condition that is often misdiagnosed and fatal if not treated promptly. While the gold standard is early surgical intervention, recent studies have showed success with conservative management. We report a case of Boerhaave's syndrome that was managed conservatively by decompressive gastrostomy, feeding jejunostomy, bilateral intercostal drainage tubes with added proximal diverting cervical esophagostomy. The patient recovered completely and stoma closure was done two months later.

Gastrojejunal Anastomosis Perforation after Gastric Bypass on a Patient with Underlying Pancreatic Cancer: A Case Report and Review of the Literature.

Introduction. We describe a case of gastrojejunal anastomosis perforation after gastric bypass on a patient with underlying pancreatic cancer. Case Description. A 54-year-old female with past surgical history of gastric bypass for morbid obesity and recent diagnosis of unresectable pancreatic cancer presents with abdominal pain, peritonitis, and sepsis. Computerized axial tomography scan shows large amount of intraperitoneal free air. The gastric remnant is markedly distended and a large pancreatic head mass is seen. Intraoperative findings were consistent with a perforated ulcer located at the gastrojejunal anastomosis and a distended gastric remnant caused by a pancreatic mass invading and obstructing the second portion of the duodenum. The gastrojejunal perforation was repaired using an omental patch. A gastrostomy for decompression of the remnant was also performed. The patient had a satisfactory postoperative period and was discharged on day 7. Discussion. Perforation of the gastrojejunal anastomosis after Roux-en-Y gastric bypass is an unusual complication. There is no correlation between the perforation and the presence of pancreatic cancer. They represent two different conditions that coexisted. The presence of a gastrojejunal perforation made the surgeon aware of the advanced stage of the pancreatic cancer.

Outcomes Following Percutaneous Gastrostomy for Gastrointestinal Decompression at a Tertiary Care Center

Outcomes Following Percutaneous Gastrostomy for Gastrointestinal Decompression at a Tertiary Care Center

A Rare Case of Concurrent SMA Syndrome and Portal Vein Thrombosis

Purpose: This is a case of a 62-year-old man who presented with complaints of periumbilical abdominal pain and vomiting of 2 days' duration. He noted a 4-month history of watery, non-mucoid diarrhea with a 15lb unintentional weight loss. Prior workup for chronic diarrhea included stool studies, colonoscopy, and CT scan abdomen, all of which were normal. The patient appeared cachectic with a diffusely tender abdomen and voluntary guarding. Initial labwork was pertinent only a mild leukocytosis. Liver function tests, amylase, lipase, and lactate levels were all normal. A CT scan abdomen revealed changes consistent with portal vein thrombosis and SMA syndrome (Figures 1 and 2). An abdominal ultrasound was obtained, revealing changes confirming SMA syndrome. An EGD revealed a dilated stomach with large amounts of gastric contents. A decompressive gastrostomy tube with a feeding jejunal extension was placed radiographically. The patient was started on heparin and broad-spectrum antibiotics. The patient was managed medically with improvement in his clinical status. He was discharged to a rehabilitation facility in stable condition. This case highlights the effects of SMA syndrome on the portal vasculature. Review of the literature reveals a paucity of similar cases, most involving the pediatric population with SMA syndrome, complicated by gastric wall pneumatosis and portal venous gas. In our case, local compression on the SMV well may very well have been the single most important contributing factor. Special attention should also be paid to pressure effects of a dilated proximal duodenum and/or dilated stomach. We should remain alert to the possible association of SMA syndrome with the portal vasculature and rule it out on imaging.Figure 1: Axial contrast CT image obtained during the portal venous phase demonstrates a non-occlusive thrombus within the right portal vein (arrow).Figure 2: Image demonstrates narrowing of the distance between the SMA (arrow) and the aorta (A) at the level of the 3rd portion of the duodenum (arrowhead).