Posterior Gastrojejunostomy Research Articles

Superior Mesenteric Artery Syndrome: A Vicious Cycle?

CASE REPORT Superior mesenteric artery syndrome (SMAS) is a rare syndrome where the third part of the duodenum is compressed between the abdominal aorta and the superior mesenteric artery (SMA).1 The loss of the intervening mesenteric fat pad causes the aortomesenteric angle to decrease from its normal value of 38°–65° to less than 25°, decreasing the aortomesenteric distance to less than 10 mm and causing duodenal compression. Its incidence in the general population is between 0.1% and 0.3% with a female predominance.2 A 22-year-old woman presented to the emergency department of our hospital with complaints of vomiting and a marked decrease in appetite for the past 4 months. The vomiting was nonbilious and nonprojectile and would only occur postprandially. She also reported past episodes of watery diarrhea associated with anorexia and experienced intermittent episodes of fever, documented at 101°F–102°F. Since the start of her symptoms, she had lost 27 kg. An upper abdominal computed tomography scan in both plain and contrast films revealed significant gastric distention, distention of the duodenum up to the second and third parts, and a relatively collapsed small bowel distal to the presumed crossing of SMA (Figure 1). The computed tomography scan displayed downward inclination of SMA and significant compression of the left renal vein between the abdominal aorta and SMA, confirming the existence of left renal vein entrapment syndrome in our case (Figure 2). In addition, there was a reduced aortomesenteric angle of 11.8°, and a distance of 8 mm was observed (Figure 3). In lieu of the above findings, SMAS was suspected. The patient initially received conservative treatment and was started on nasogastric feeding tube. Owing to intolerance, a total parenteral nutrition regimen was used to stabilize the patient's weight. Only 2 kg were gained by the patient over the course of 4 weeks. Her symptoms continued to worsen despite her slight weight gain. Having failed to achieve a satisfactory outcome with conservative management, an exploratory laparotomy was performed. The peritoneal cavity was exposed through a midline skin incision. There was gross distention of the second part of the duodenum, and the third part of the duodenum was compressed. Owing to grossly dilated duodenum, the decision was taken to perform gastrojejunostomy instead of duodenojejunostomy. Stapled posterior gastrojejunostomy was performed to bypass the compressed duodenum, and an anastomosis was made between the stomach and the proximal loop of the jejunum (Figure 4). The intraperitoneal drain was kept in place. An uneventful recovery followed the patient's extubation.Figure 1.: Computed tomography scan showing compression of the third part of the duodenum. Arrow is pointing toward the compressed duodenum.Figure 2.: Computed tomography scan showing compression of the left renal vein. Arrow is pointing towards the compressed left renal vein.Figure 3.: Computed tomography scan showing compression of the third part of the duodenum. Angle denoting a reduced aortomesenteric angle value of 11° (normally>38°).Figure 4.: Computed tomography scan after gastrojejunostomy displaying the anastomosis made between the stomach and the proximal loop of the jejunum. Arrow pointing towards the anastomotic site.This case report presents an early preoperative diagnosis of a rare disease entity based on its radiological presentations. When women with a low body mass index present with chronic, refractory symptoms of the upper digestive system, SMAS should be suspected. It can also often be confused with other etiologies of mega duodenum such as diabetes mellitus, systemic lupus erythematosus, amyloidosis, myotonic dystrophy, scleroderma, and chronic idiopathic intestinal pseudo-obstruction. This necessitates the need of a multidisciplinary approach based on symptoms to diagnose SMAS by clinicians. DISCLOSURES Author contributions: A. Jawed collected patient information and followed up after discharge and wrote the manuscript. A. Jawed wrote the manuscript. ME Anis identified the case and treated the patient, revised the manuscript, and is the article guarantor. MA Qadeer and Z. Abbas revised the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.

An incidental concurrence causing gastric outlet obstruction

Phytobezoar which is described as an undigested or incompletely digested food. It is an odd cause of gastric outlet obstruction (GOO). The aim of this study is to present and discuss a case of GOO caused by cicatrised duodenal ulcer with a phytobezoar. 71-year-old male, presented with abdominal pain and vomiting (non-bilious) since 3days with peptic ulcer disease for 4 years. Examination and investigations revealed a bezoar requiring emergency surgical intervention. An exploratory laparotomy was conducted. A bezoar was palpated in the stomach and removed through posterior gastrotomy. Vagotomy with Posterior Gastrojejunostomy was done as drainage procedure for cicatrised Duodenal ulcer. GOO caused by phytobezoar can co-exist in patients with previous history of peptic ulcer disease and cicatrised duodenal ulcer. Urgent laparotomy may be indicated.

In the era of PPI, laparoscopic truncal vagotomy and gastrojejunostomy still plays an important role: A tertiary care centre experience in India

Background: This study aims at sharing our experience with laparoscopic truncal vagotomy (TV) and gastrojejunostomy (GJ) and to highlight modifications in the form of posterior TV alone instead of anterior and posterior TV in elderly to reduce associated morbidity of prolonged gastric stasis. Methods: From 2017 to 2020, 16 patients underwent laparoscopic TV and GJ. Anterior and posterior TV was performed in patients younger than 60 years and posterior only TV was performed in patients older than 60 years. Antecolic, posterior, juxta-pyloric and isoperistaltic GJ was created using stapler. During follow up, patients were classified into Visick grading. Dumping syndrome was assessed using Dumping Syndrome Rating Scale (DSRS). Results: Mean age of patients was 58 years. Male:female ratio was 1.7:1. There were no conversions or perioperative mortality. Two patients required laparoscopic assisted GJ. Mean operative time was 117 minutes with mean blood loss of 23.89 ml. Thirteen patients were discharged by postoperative day seven; four had delayed gastric emptying which settled with conservative management and were discharged within second week. Incidence of prolonged gastric stasis was more in patients undergoing laparoscopic anterior and posterior TV and GJ as compared to those undergoing laparoscopic posterior TV and GJ (33.33% vs 20%, p>0.05). During average follow-up period of 22 months, one patient died due to unrelated cause. Patients were classified as Visick I (n=9), II (n=6), III (n=1), and IV (n=0) at the end of last follow-up. Two patients developed dumping syndrome which was managed by dietary modifications. None developed recurrent obstruction. Conclusion: Laparoscopic TV and GJ is feasible and safe for GOO secondary to PUD and is associated with satisfactory perioperative and post-operative outcomes. Posterior GJ using stapler is associated with reduced complication and operative time as well as hastened learning curve. Elderly patients tolerate posterior only TV better.

A rare case of D2 perforation in blunt injury abdomen

A 47-year-old female brought by attenders to casualty with alleged history of accidental injury, struck against iron rail in bus 1 day before sustained injury in abdomen. Presented with complaints of abdominal pain, vomiting for 2 days. Previous history of duodenal ulcer - Gastric outlet Obstruction & undergone bilateral truncal vagotomy with posterior Gastrojejunostomy 1year before. She was dehydrated, hemodynamically unstable bp not recordable, pulse feeble, with upper midline healed laparotomy scar in abdomen and tenderness in upper abdomen, diffuse swelling progressively increasing in size noted in epigastric region, guarding present. Patient was resuscitated. Supine Xray abdomen showed dilated bowel loops. CT abdomen showed pneumoperitoneum, free fluid in pelvis, no solid organ injury. Patient was taken for emergency laprotomy. Intraoperatively Omental adhesions to previous scar and about 300ml of turbid fluid noted, Status postoperative posterior Gastrojejunostomy. Colon-free from injuries. Diffuse saponification noted in omentum. Bile staining present. D2 perforation of size 2×2cm noted in anterolateral aspect. Pyloric exclusion, primary closure of duodenal injury and Tube duodenostomy done. Ryles tube passed through distal limb of GJ for feeding purposes postoperatively.

Acid corrosive injury of stomach: management and long-term outcome

Background: Acid corrosive injury to stomach is not uncommon in India due to easy availability. Corrosive ingestion results in significant morbidity. We present our experience in surgical management of such cases. The aims and objectives of this study to review the experience of surgical management of gastric corrosive injury and to assess long term outcome and functional results.Methods: This study was retrospective analysis of prospectively collected data of 23 cases of acid corrosive injury managed in a single surgical unit.Results: Median age was 31 years, male to female ratio was 12:11. Surgical procedures were tailored according to extent and degree of stricture. Posterior gastrojejunostomy was done in 8 (38.0%) cases, near total gastrectomy in 3 (14.3%) cases, total gastrectomy and Billroth I in 2 (9.5%) cases each. 4 cases were lost to follow up after preliminary feeding jejunostomy. 2 cases had mortality after feeding jejunostomy. 2 cases were managed successfully without active surgical intervention. All patients undergoing definitive procedure had good results in terms of nutritional status and symptoms of gastric outlet obstruction.Conclusions: The outcome of gastric stricture secondary to acid ingestion can be significantly improved by adequate preoperative preparation and planned approach depending upon type of injury.

Gastric outlet obstruction: clinical presentations and its surgical management

Background: Gastric outlet obstruction (GOO) mechanically impedes gastric emptying, normal emptying of the stomach. It is a diagnostic and therapeutic challenge for general surgeons in their daily practice. This paper highlights the etiology, clinical presentation and treatment outcome of GOO.Methods: A Prospective study was conducted on patients with GOO treated at Rajarajeswari medical college and hospital, Bangalore during September 2015 to august 2017. Data was tabulated and analyzed using descriptive statistical methodology.Results: Carcinoma stomach with antral growth and cicatrized duodenal ulcer (both 41.5%) were the most common cause of gastric outlet obstruction. Male were more affected than females (2.5:1). Most common symptom was vomiting and abdominal pain (noted among all), followed by loss of appetite (83%) and loss of weight (82.35%). 94.1% patients of Cicatrized duodenal ulcer underwent truncal vagotomy with posterior gastrojejunostomy and 5.9% underwent truncal vagotomy with antrectomy. 58.8% patients of carcinoma stomach, underwent distal gastrectomy with ante-colic Roux-en-Y gastro- jejunostomy, 12.1% patients underwent subtotal gastrectomy with ante-colic and Roux-en-Y gastro jejunostomy and 4.8% patients underwent palliative gastrojejunostomy. In corrosive antral stricture Billroth I gastrectomy was done. Patients of pancreatic malignancy underwent palliative anterior gastrojejunostomy and pseudo- pancreatic cyst was treated by cystojejunostomy. The average hospital stay was 10-14 days and an overall mortality of 5.8% for malignant patients was noted.Conclusions: Study concludes that gastric outlet obstruction is an important and a common surgical condition in tertiary hospital. Malignancy and benign cicatrized duodenal ulcer being the most common cause.

Gastrojejunocolic Fistula Changing Trends in Management

Introduction: Gastrojejunocolic fistula (GJCF) is a rare, preventable and debilitating complication of surgery for peptic ulcer. It commonly follows posterior gastrojejunostomy without/with incomplete vagotomy for peptic ulcer disease. Over period of time, with advances in medical science the modalities used in diagnosis and the treatment have changed. GJCF is associated with high morbidity and mortality. The objective of this study was to analyze our experience in the management of GJCF. Materials and methods: Between 1993 and 2017, 13 patients presented with GJCF after surgery for peptic ulcer disease at our hospital for elective surgery. Data from the records of these patients was analyzed retrospectively. Weight loss, faeculant vomiting and diarrhoea were the common symptoms. Diagnosis of GJCF was made by barium enema, upper gastrointestinal endoscopy, colonoscopy and CT scan abdomen. All patients underwent surgery- single stage 9 patients, two stages 2 patients and closure of fistula with distal gastrectomy in 2 patients. Conclusion: GJCF should be considered as a diagnosis in patients presenting with one or more of the clinical symptoms- faeculent vomiting, chronic diarrhoea, weight loss after surgery for peptic ulcer. Diagnosis of GJCF has evolved for barium enema to colonoscopy and CT scan. Depending on the nutritional status of patient the trend in the surgery has changed from multiple stages to single stage surgery.

A clinical study of gastric outlet obstruction

Background:From the standpoint of pathology, the term pyloric stenosis is usually inaccurate at least in adult patients, since the site of obstruction is rarely situated at the pylorus itself but, is more often placed immediately proximal to the spinchter where the diagnosis of carcinoma is most probable or more distally in the duodenal bulb where the cause is almost invariably a duodenal ulcer. The aim was to study infantile hypertrophic pyloric stenosis, benign peptic ulcer and gastric carcinoma and evaluation of electrolyte abnormalities in gastric outlet obstruction, to study various modalities of treatment and to assess pertaining to recovery from paralytic ileus. Methods: This was a clinical observational study comprising of 40 cases of gastric outlet obstruction. The patients for this study have been selected from Prathima Institute of Medical Sciences, Karimnagar, Telangana, India from December 2013- November 2015. The cases were selected who were willing to undergo surgery.Results:Congenital hypertrophic pyloric stenosis (CHPS) is more common among first born male infants. Parental consanguinity is associated with increased incidence of congenital hypertrophic pyloric stenosis. CHPS is common in the age group of first 3-6 weeks of life (average 4 weeks). Males are more commonly affected with gastric outlet obstructions in adults. Cicatrized duodenal ulcer is more common in the age group of 30-40 years, while carcinoma stomach is more common in age group of 50-60 years. Vomiting and visible gastric peristalsis are the most common and constant symptom and sign of gastric outlet obstruction, more so in cases of cicatrized duodenal ulcers.Conclusions:Ramstedt’s pyloromyotomy is the gold standard treatment for CHPS. Patients with gastric outlet obstruction due to cicatrized duodenal ulcer require truncal vagotomy with posterior gastrojejunostomy. Vagotomy is optional in view of better response with drugs for APD. Antral carcinoma cases require curative or palliative surgery depending on the stage of the disease.

Afferent loop syndrome: a case report

Afferent loop syndrome (ALS) is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. A male patient aged 36 years who had undergone posterior gastro-jejunostomy 9 years back (in 2006) was admitted in the Department of Surgery of Gazi Medical College Hospital through OPD with abdominal pain, nausea, anorexia, abdominal discomfort after meal and sometime bilious vomiting. All the necessary investigations including endoscopy, colonoscopy, CT scan of the abdomen and Brain, Ba-meal X-ray were repeatedly done. There was suspicious distention of afferent loop during endoscopic investigation. The main diagnostic base was the history of the disease and clinically diagnosed ALS. It is a surgical urgency. During re-laparotomy, Roux-en-Y anastomosis with ‘Tanner’s 19’ modification was done. The patient did not have any complain during follow up after 10 days of the discharge from the hospital.Mediscope Vol. 3, No. 2: July 2016, Pages 39-43

Retrograde jejunogastric intussusception: A rare case report and review of literature

Retrograde jejunogastric intussusception (JGI) is an unusual complication following gastrojejunostomy and Billroth II gastrectomy. It was first described in 1914 by Bozzi in a patient with gastrojejunostomy, and about 300 cases have been reported so far in the medical literature. High index clinical suspicion is required to make the diagnosis. Pyloroplasty is one of the well-accepted and proven surgical options in such cases. We report a case of retrograde JGI involving both loops of jejunum in a male patient who underwent truncal vagotomy and posterior gastrojejunostomy for chronic duodenal ulcer 6 years ago.

Comparative Study between Staplers and Conventional(Hand-Sewn) Anastomosis in Gastrointestinal Surgery

Conventional (hand-sewn) technique of intestinal anastomosis has been in vogue for decades. Staplers which were developed to simplify surgery began to have significant impact. To compare staplers versus conventional anastomosis with respect to certain intra operative and post operative parameters. Prospective study from November 2008 to October 2010 in Hyderabad at OSMANIA, GANDHI, MNJ CANCER hospitals. 120 patients were divided into three groups of 40 each, depending on the surgery like posterior gastrojejunostomy, distal gastrectomy and reconstruction (Billroth II) and colorectal anastomosis. Of these 40 patients, 20 were in hand-sewn group and the other 20 in stapler group. Unpaired 't' test was used to find 'p' value . 'p' value less than 0.05 was considered statistically significant. Total operating time was shortened in stapler group. No significant difference was found in terms of restoration of intestinal function, post-operative hospital stay, post-operative complications like anastomotic leak. Staplers can expedite surgery. They have better access to difficult-to-reach areas. Thus staplers can be beneficial though one should not forget the art of conventional suturing.

Isolated corrosive pyloric stenosis without oesophageal involvement: An experience of 21 years

Background and study aims Corrosive ingestion is common in Asia and it is a frequent cause of morbidity secondary to intense fibrotic reaction and stricture formation of the oesophagus. Isolated corrosive pyloric stenosis without oesophageal involvement is an uncommon phenomenon. Patients and methods All consecutive patients, with corrosive ingestion in the last two decades, were reviewed and analysed. Eleven out of 201 patients with corrosive ingestion had isolated gastric outlet obstruction. Results Patients’ age ranged from 11 to 29 years with a male:female ratio of 1.75:1. All patients developed pyloric stenosis following ingestion of solution of acids. Barium study revealed complete/near-complete gastric outlet obstruction in all patients. On laparotomy, there was gastric dilatation in 10 patients, who underwent posterior gastrojejunostomy, whereas the stomach was contracted in one patient, and hence anterior gastrojejunostomy was performed. Seven patients were completely relieved of their symptoms; persistent postprandial epigastric fullness and/or dyspepsia was observed in four patients whose gastrojejunostomy stoma was found adequate on barium study, suggestive of gastric motility disorder. We did not encounter gastrojejunostomy-related complication of stomal ulcer/stenosis in our patients. Conclusion Isolated corrosive pyloric stenosis is not as rare as is commonly thought. Gastrojejunostomy is effective, although a fair percentage of patients appear to develop gastric motility disorder secondary to corrosive injury.

Laparoscopy-assisted truncal vagotomy with antecolic posterior gastrojejunostomy for benign gastric outlet obstruction

The aim of this study is to highlight the role of minimally invasive surgery in the form of laparoscopy-assisted truncal vagotomy (TV) with ante-colic posterior gastrojejunostomy (PGJ) for benign gastric outlet obstruction (GOO). GOO is relatively common in southern India due to various factors. From 1994 to 2004, 762 patients with GOO were operated on (open TV with PGJ) in our center. From November 2003 to November 2004, 18 patients with GOO underwent the laparoscopic procedure in our unit. The procedure involves laparoscopic TV followed by the ante-colic PGJ performed extracorporeally through a 3.5-cm transverse incision in the upper abdomen. The advantages of this procedure are that pain, hospital stay, size of wound, incidence of incisional hernia, and postoperative complications are reduced and the patient returns to work earlier. The results are comparable to those of a totally laparoscopic TV with PGJ. This procedure is relatively easy to perform because the anastomosis is done extracorporeally, and it is less expensive than the use of endostaplers. Thus, more surgeons should be encouraged to perform laparoscopic TV with PGJ.

Hematemesis: A Rare Cause From Gangrenous Retrograde Jejunogastric Intussusception

A case of retrograde intussusception (acute type) of efferent limb into the stomach through the stoma of gastrojejunostomy (GJ) is rare and life threatening complication. We report a case of intussusception of efferent of GJ with gangrene that occurred in an adult 12 years after truncal vagotomy and posterior GJ. Emergency laparatomy and resection of gangrenous jejunum after reduction was done. Patient had uneventful recovery.

Corrosive gastritis

Cases of corrosive gastritis are relatively few in the literature. Fifteen patients with combined corrosive esophagogastritis are reported on herein. In the acute stage (with severe degree of esophagogastritis) feeding jejunostomy was recommended, whereas in the chronic stage (with gastric obstruction) posterior gastrojejunostomy was performed for all patients. Patients were classified into three grades depending on the extent of associated esophagitis. We conclude that corrosive gastritis is a possible associated complication of corrosive intake (particularly for suicide) and requires a latent period of time to be clinically evident.

Contraction of the Gastric Antrum Following a Long-Term Gastroenterostomy

It is not generally appreciated that the gastric antrum may become atrophic and contracted long after simple gastroenterostomy. The radiologic appearance of the antrum in these cases may be confused with that of an infiltrating carcinoma. A needless laparotomy may be avoided by an awareness of this diagnostic possibility. The condition is illustrated by the following two cases. Case Reports Case I: B. F., a 57-year-old white male, was referred to the University of Michigan Medical Center because of anemia and diarrhea of two months duration. Thirteen years previously he had had a bilateral partial vagotomy and gastroenterostomy, without gastric resection, for a peptic ulcer. His blood hemoglobin was 11.5 g per 100 cc, and the hematocrit was 36. Multiple stool examinations for occult blood were negative. Radiologic examination of the upper gastrointestinal tract showed a normally functioning gastroenterostomy, but the distal antrum appeared contracted and there was a question of some mural rigidity in this region. The proximal antrum beyond the stoma was distensible. The mucosal folds in the proximal antrum were scarcely visible and were completely absent in the contracted portion. On some films there was a question of a double contour at the junction of the proximal and distal antra. A pedunculated, smoothly marginated filling defect measuring 1 cm in diameter was demonstrated in the midpart of the antrum (Figs. 1 and 2). At laparotomy the gastric antrum was found to be thin, soft, and pliable. The mucosa was atrophic and friable, and an antral polyp was identified. The midantrum was adherent to the anterior abdominal wall, probably accounting for the double contour noted in the roentgen examination. Pathologic examination of the resected antrum revealed chronic gastritis with scattered Russell-Plimmer bodies, an inflammatory polyp, and slight hypertrophy of the muscularis mucosa. A neoplasm was not present. The patient was alive and well four years later. Case II: D. P., a 24-year-old white male, was examined because of flatulence and vague abdominal distress. A posterior gastrojejunostomy without vagotomy had been performed twelve years previously for a gastric ulcer which was associated with steroid therapy administered for ulcerative colitis, Examination of the upper gastrointestinal tract revealed a markedly contracted antrum with only a trickle of barium passing through the residual antral lumen. The entire antrum beyond the gastrojejunostomy was involved (Fig. 3). An examination three years later revealed no change. The patient was in good health five years after the initial examination. Discussion It is particularly important that radiologists be familiar with contraction of the antrum after gastroenterostomy because, now more than ever, elderly individuals are receiving benefits of extended medical care.

POSTGASTRECTOMY INTERNAL HERNIA.

Any gastric operation resulting in gastrojejunostomy produces a potential internal hernia ring which may be lethal in the immediate or remote postoperative period. It is the purpose of this paper to report two nonfatal cases, to alert the clinician to this possibility, and to remind the surgeon that this ring may be easily and expeditiously eliminated at the time of the original operation. Report of Cases Case 1, a 75-year-old female, was admitted because of recurrent abdominal pain and distention with nausea and vomiting. Each episode lasted for a few hours and subsided spontaneously. One episode required hospitalization but subsided shortly after admission. The patient had a partial gastrectomy and posterior gastrojejunostomy two years previously for upper gastrointestinal hemorrhage. Physical examination revealed a moderately distended abdomen with visible peristalsis. There was generalized tympany. Bowel sounds were normal and there was an epigastric mass. Tenderness was primarily in the left upper

When should proximal colostomy be performed for gastrojejunocolic fistula.

Gastrojejunocolic fistula in the majority of cases is a complication of inadequate surgery for peptic ulceration. Its history is the history of peptic ulcer surgery. In 1881 the first anterior gastrojejunostomy was performed by Wolfler. In 1885 the first posterior gastrojejunostomy was done. This was carried out by von Hacker. As soon after this as 1889, the first stomal ulcer was reported by Braun, and by 1902 the succession of complications of recurrent ulcer was complete. In that year Czerny closed the first gastrocolic fistula. Since then this surgical disease has come to be well recognized, and excellent reviews have appeared. 1,2 The principles in the management of these cases are now generally agreed upon. They are, namely, to diagnose the fistula early, to close it as soon as the patient is fit, and to prevent its recurrence by adequate surgery designed to reduce the acidity. For patients who are

Fibrous stricture of the stomach due to iron (feosol) poisoning; report of a case and brief review of the literature.

Iron poisoning in children has been reported with increasing frequency in recent years. Most of the cases have resulted from accidental ingestion of ferrous sulfate tablets, many of which are of attractive color and taste, which appeal to children. The acute symptoms of iron poisoning are now well known. They may begin thirty to sixty minutes after ingestion; with less soluble products, damage may be delayed as long as twenty-four hours. The symptoms are vomiting, diarrhea, dehydration, shock, and coma. Severe acidosis has been reported in some cases. Dehydration, shock, and acidosis have resulted in death in about half of the reported cases. The usual treatment includes gastric lavage, cathartics, enemas, intravenous fluids, plasma, and blood. At autopsy the most striking lesions are seen in the gastrointestinal tract, consisting in mucosal necrosis, congestion, and focal hemorrhages. Hepatic and renal lesions are also noted. Davis and Gibbs recently reported a case in which a necrotic segment of gastrointestinal mucosa was passed per rectum. Less familiar than the acute symptoms of iron poisoning mentioned above is the occurrence of fibrous stricture of the pylorus and stomach, occurring as a late complication. Up to the present time, 5 such cases have appeared in the British literature. Crosskey reported in 1952 what he believed was the first case of pyloric stenosis as a complication of ferrous sulfate poisoning to be published in Great Britain. Since that time, Forshall and Rickham have reported 2 cases of pyloric obstruction due to ferrous sulfate, Elliot-Smith and Davies have reported 1 case, and Ross has reported a case of pyloric stenosis and fibrous stricture of the stomach. In the British cases symptoms of gastric or pyloric stricture did not develop until ten days to six weeks after iron ingestion. The patients usually were seen with the complaint of vomiting one to two months after the accident. Four of the 5 did well after operations, which included 2 Mikulicz procedures, 1 posterior gastrojejunostomy, and 1 gastric resection with a Billroth I anastomosis. The fifth patient died as a result of acute peritonitis following a jejunostomy. Report of Case M. M., a two-and-a-half-year-old Negro girl, was admitted to Denver General Hospital on July 23, 1956, following the ingestion of an undetermined number of “Feosol” pills. Her mother found her shortly before admission, after she had vomited some green pills. At the time of admission, the child was semicomatose, arousing herself only for brief periods during gastric lavage (with sodium bicarbonate). She received 250 c.c. of whole blood on admission and was given antibiotics. For the first five days in the hospital she was maintained on fluids administered intravenously. Initially she ran a febrile course with bouts of abdominal distention. An abdominal roentgenogram was compatible with paralytic ileus.

Multiple duplicative cysts of the duodenum causing acute intestinal obstruction in a girl five and one-half years of age

Congenital duplications can affect any portion of the alimentary tract. If the mucosal component of the resulting cyst becomes active, the retained secretions produce a cystic tumefaction which can obstruct the parent structure by exerting extrinsic pressure. The duodenum is seldom affected by these congenital duplications as only nine cases have been reported in the literature. The case herein reported is that of a girl, five and one-half years of age, who had two duplicative cysts of the duodenum which produced a compressive obstruction of the descending and transverse duodenal segments. These duplicative cysts present the clinical picture of acute duodenal obstruction. They closely mimic the symptoms of hypertrophic pyloric stenosis, pylorospasms, diverticula and atresias of the duodenum. An accurate diagnosis can always be made by adequate roentgenologic studies. The obstructed duodenum will appear to be rotated, displaced and compressed by an extrinsic tumor mass. Remedial surgery affords the only opportunity for survival. Resection of the duodenum and its contiguous cyst combined with posterior gastrojejunostomy can be employed in special cases. If the enterogenous cyst is small, the mucosal lining which separates it from the duodenal lumen can be removed thus permitting the cystic fluid to drain into the intestinal tract. There is no assurance, however, that the newly formed duodenal diverticulum will not produce annoying symptoms. In our case the mesially placed cyst was completely removed while the one lying adjacent to the duodenum was opened, its mucosal lining completely removed, and its walls were utilized to reinforce the congenitally weak walls of the involved duodenum. Such operations should be combined with posterior gastro-enterostomy. A complete study of the embryology, anatomy, symptomatology, diagnosis and treatment of this unusual congenital deformity is presented.