Incidence Of Gastric Outlet Obstruction Research Articles

Alarming Incidence of Gastric Outlet Obstruction Related to NSAIDS and Synthetic Opioid in North West India.

In recent years, there has been an alarming increase in cases of gastric outlet obstruction (GOO) at our center due to drug abuse. So, we conducted this study to know the incidence of nonsteroidal anti-inflammatory drugs (NSAIDs) and synthetic opioid abuse in cases of GOO. This was an observational study involving consecutive cases of GOO diagnosed from September 2017 to February 2019. A detailed history, including drug addiction history and clinical examination, was done. Investigations included routine biochemical and hematological tests, upper gastrointestinal endoscopy (UGIE), ultrasonography, rapid urease test (RUT), and histopathology of the diseased area. Among the 102 cases diagnosed with GOO, 62 (60.78%) cases had a history of drug addiction. The drug addiction history was as follows: NSAIDs and opioids in 56, opioids alone in four, and NSAIDs alone in two cases. The most common site of stricture was the second part of the duodenum. The features on histopathology were ulcerations of the mucosa infiltrated by eosinophils, plasma cells, and lymphocytes. There is an alarming increase in the incidence of GOO due to NSAIDs and opioid abuse at our center. Efforts should be made to control the indiscriminate use of these over-the-counter drugs to prevent dreaded complications.

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.

Single vs double bypass anastomosis for locally advanced periampullary tumors

Background data Pancreatic adenocarcinoma is one of the most serious malignancies in the world. Endoscopic retrograde cholangiopancreatography is limited to cases of bile duct obstruction owing to its association with severe adverse effects and low efficacy. Surgical resection offers the greatest chance of long-term recovery by a procedure called pancreaticoduodenectomy. Palliative surgical options involve an open or laparoscopic loop over a Roux-en-Y gastrojejunostomy (GJ). Various studies have looked at the idea of prophylactic GJ. Patients and methods This is a comparative retrospective study, designed for patients having locally advanced periampullary tumors who were treated by palliative bypass (single or double bypass) between January 2011 and December 2016 at Gastrointestinal Surgery Center of Mansoura University. This study aims to evaluate and compare the results of single vs double bypass procedure. Full preoperative assessment was done. Results There was no statistically significant factor between the single and double bypass groups with respect to demographic data. With respect to postoperative data, the single bypass group showed its upper hand regarding the day of starting oral fluids. The amount discharge from the nasogastric tube was significantly higher for the double bypass group. The overall complications were more or less similar between the two groups. Conclusion This study showed that prophylactic GJ substantially reduces the incidence of gastric outlet obstruction and thus, decreases the rate of readmission and the need for another surgery after the single bypass. The overall complications as well as the short-term survival did not differ between single and double bypass operations.

2695 Pedunculated Polyp at the Pyloric Channel Causing Intermittent Gastric Outlet Obstruction

INTRODUCTION: Gastric outlet obstruction (GOO) is the intrinsic or extrinsic obstruction of the pyloric channel or duodenum. The most common cause remains to be peptic ulcer disease which results in inflammation, edema or fibrosis. GOO typically presents with epigastric abdominal pain and postprandial vomiting. While the incidence of GOO is unclear, it has declined since the identification of Helicobacter pylori, H2-receptor antagonists and endoscopic therapy. We present a case of a benign polyp obstructing the pyloric channel. CASE DESCRIPTION/METHODS: 39 year-old female with a history of pulmonary embolism on Eliquis, Diabetes mellitus type 2 who presents for several months of epigastric pain, nausea and intractable vomiting. Prior to arrival, she had endoscopic evaluation at an outside hospital showing evidence of 1.5 cm gastric polyp in the pyloric channel. At the time, the polyp was not excised due to the patient being on anticoagulation. On admission, she underwent CT angiography showing no evidence of clot. She subsequently underwent repeat endoscopic evaluation demonstrating a 15 mm non-bleeding, pedunculated polyp at the pyloric channel obstructing the pyloric opening. The polyp was resected with hot snare. Biopsy showed a hyperplastic gastric polyp negative for malignancy. To prevent bleeding post-intervention, two hemostatic clips were placed. The patients abdominal pain, nausea and vomiting nearly resolved one day after her procedure. DISCUSSION: While the incidence of GOO has declined, it should continue to be considered in patient’s presenting with recurrent epigastric abdominal pain. Recent reviews estimate that, contrary to earlier years, 50 to 80% of cases have been attributable to malignancy such as pancreatic adenocarcinoma and distal gastric cancer. CT scan may show gastric distension or retained material within the gastric lumen. However, identifying the obstruction with upper endoscopy establishes the diagnosis. Treatment should be aimed at the underlying cause.

Gastric outlet obstruction, a clinical study in tertiary care hospital South India

Background: Gastric Outlet Obstruction implies complete or incomplete obstruction of the distal stomach, pylorus or proximal duodenum. Gastric outlet obstruction is not a single entity; it is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying. Now in the era of H2 blockers and proton pump inhibitors, incidence of duodenal ulcer producing gastric outlet obstruction has been decreasing as symptomatic ulcer begin to respond to medical treatment, and at the same time the incidence of antral carcinoma of stomach producing gastric outlet obstruction has comparatively increased, which may be due to increased early diagnosis of the condition with the help of flexible fibre optic endoscope.Methods: An elaborate study of these cases with regard to the history, clinical features, routine and special investigations, pre-operative treatment, operative findings, post-operative management and complications in post-operative period is done.Results: Of the 50 cases of gastric outlet obstruction 26 had carcinoma antrum (52%), 23 had cicatrized duodenal ulcer (46%) and 1 had gastric outlet obstruction secondary to corrosive ingestion. The age incidence of the patients in this study ranged from 22 – 84 years with a mean of 53.62 years. In case of obstruction secondary to duodenal ulcer the maximum age incidence is between 31-40 years. The maximum age incidence of gastric outlet obstruction due to carcinoma antrum is 61-70 years.In this series, 42 patients (84%) were males and 8 patients (16%) were female. Male to female ratio (M:F) is 5.25:1. M: F ratio in cicatrized duodenal ulcer is 10.5:1 and in carcinoma antrum is 3.33:1. 52% of the patients were manual labourers who gave a history of irregular diet habits. 68% of patients had history of smoking and 66% had history of alcohol intake. Post – prandial vomiting and epigastria pain are the main symptoms (96%) in this series. Other symptoms included anorexia (84%), weight loss (72%), post prandial Epigastric fullness (68%), haematemesis (24%), melena (64%) and constipation (48%). Pallor was present in 56% and dehydration in 62%. Blood group ‘O’ was common in cicatrized duodenal ulcer patients (52.18%) whereas blood group ‘A’ was common in malignant cases (50%).Conclusions: Number of cases with cicatrized duodenal ulcer as the chief etiological factor for gastric outlet obstruction is diminishing and the number of cases of antral carcinoma of stomach as the cause of gastric outlet obstruction is increasing. Upper Gastro intestinal endoscopy should be mandatory in all suspected cases of gastric outlet obstruction. It can diagnose the cause of obstruction very effectively than any other investigative modality. Effective treatment in carcinoma stomach depends on early diagnosis.

Acute Perforated Duodenal Ulcer in Maiduguri: Experience with Simple Closure and <i>Helicobacter pylori</i> Eradication

Effective medical management of peptic ulcer disease (PUD) has reduced the incidence of gastric outlet obstruction (GOO) as a complication, but perforation especially in the elderly remains unchanged and is in fact on the increase. There is a changing trend in emergency surgery for perforated duodenal ulcer (PDU) from definitive anti ulcer surgery to simple closure followed by Helicobacter pylori eradication. To present our experience in managing PDU with simple closure followed by Helicobacter pylori eradication. This was a chart review of patients managed for PDU over a nine year period (Jan 1999 to Dec 2007) using information obtained from ward admission registers, theatre operation registers, and patients case files from the medical records department. The patients biodata, clinical, and operative findings as well as treatment outcome were extracted for analysis. Of 55 patients eligible for analysis, 44 (80%) were males and 11(20%) females (M to F, 4:1). Their ages ranged between 18 and 65 years with a mean(SD) of 39.9 (13.5) years. Most of the patients, 34 (61.8%), were below 40 years of age and majority 39(71.0%) had a history suggestive of chronic peptic ulcer disease. Twenty six (47.3%) patients presented within 24 hours of perforation, while nine (16.4%) presented more than 72 hours afterwards. The latter group accounted for most, five(55.6%), of the mortality. All the perforations were anterior pyloroduodenal and all except one had simple closure with omental patch followed by a course of a proton pump inhibitor and Helicobacter pylori eradication therapy. Simple closure with omental patch followed by Helicobacter pylori eradication is effective in managing PDU with low morbidity and mortality despite patients late presentation in our center. This technique is recommended in place of a definitive ulcer surgery.

Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation☆

Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation. Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96). Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.

Does pyloroplasty following esophagectomy improve early clinical outcomes?

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

The Need for a Prophylactic Gastrojejunostomy for Unresectable Periampullary Cancer

To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy. Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients. Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70). Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months. Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

Surgical Palliation for Pancreatic Cancer: Will Biliary Bypass Alone Suffice?

Because a number of options are available to relieve the obstructed bile duct, stomach or both in patients with irresectable carcinoma of the pancreatic head, palliative surgery for this condition was reviewed retrospectively between 1971 and 1981 at the Royal United Hospital, Bath. One hundred and sixty-five patients underwent a biliary bypass procedure with (n = 37), or without (n = 128) gastric drainage. Thirty patients had a prophylactic gastroenterostomy to avoid gastric outlet obstruction: tumour encroachment made gastroenterostomy essential in seven others. After biliary bypass alone, operative mortality was 14%. After a concomitant gastroenterostomy, mortality was 27% (P less than 0.04). Within a year of biliary bypass alone, there was a 9% incidence of gastric outlet obstruction requiring gastric drainage, with an associated mortality rate of 18%. Survival after biliary bypass or biliary bypass with gastroenterostomy was equal (7-8 months). Except where gastric outlet obstruction is imminent, palliation for irresectable pancreatic head carcinomas should be by biliary bypass alone, because the addition of a gastroenterostomy almost doubles the mortality without any advantage in survival time.