Pyloric Ring Research Articles

580. ESTABLISHMENT OF A RAT MODEL OF GASTROESOPHAGEAL REFLUX DISEASE INDUCED CHRONIC MICROASPIRATION

Abstract Background Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in Japan, the world’s first super-aging society. Occult microaspiration due to GERD can cause respiratory infections especially in frail elderly individuals. The aim of the study was to establish an experimental in vivo model of GERD induced chronic microaspiration. Methods GERD was induced in 8-week-old male Wistar rats. A 2-cm midline incision was made in the upper abdomen. The border between the forestomach and the glandular portion (limiting ridge) was ligated with a 2–0 silk tie, and the duodenum near the pyloric ring was covered with a 2-mm-wide piece of an 18-Fr Nélaton catheter. CT scan and histopathological evaluation of the bilateral lungs were performed at 3 weeks after surgery. Results The 3-week survival rate was 80% (n=4/5). CT scan showed diffuse dilatation of the esophagus due to the reflux of gastric contents; however, there was no consolidation in the lungs similar to the healthy control. Based on macroscopic evaluation, the lungs had multiple spotted redness. Histopathological evaluation of hematoxylin and eosin staining showed multiple spotted aspiration pneumonia with peribronchiolar inflammatory cells, granuloma formation, goblet cell hyperplasia. Conclusions This model mimics human occult chronic microaspiration due to GERD, and may be useful in the investigation of drug efficacy and the evaluation for pathophysiology of GERD induced pulmonary disorders.

438. TECHNIQUE OF COMPLETELY ROBOTIC MCKEOWN (3-HOLE) ESOPHAGECTOMY WITH INTRA-CORPOREAL GASTRIC CONDUIT CREATION, AND CERVICAL ESOPHAGO-GASTRIC ANASTOMOSIS FOR MID-ESOPHAGEAL ADENOCARCINOMA

Abstract Background Esophageal cancer is the 7th leading cause of cancer deaths, with an estimated total case of 22,370 in both males and females in 2024. Adenocarcinoma and squamous cell carcinoma account for over 90% of histology at diagnosis. The incidence of adenocarcinoma continues to rise due to the rising incidence and prevalence of obesity, gastro-esophageal reflux disease and Barrett's esophagus. Multi-modality treatment is currently the standard of care for locally advanced disease. This consists of neoadjuvant concurrent chemotherapy and radiation therapy, followed by esophagectomy. Minimally invasive approaches to esophagectomy are associated with decreased post-operative morbidities and overall satisfactory outcomes. While the Ivor Lewis esophagectomy with intra-thoracic anastomosis is the most common surgical approach to resection of distal esophageal and gastroesophageal (GE) junction tumors, the McKeown (3-hole) esophagectomy with cervical esophago-gastric anastomosis is best suited for tumors located in the proximal and mid-esophagus. Methods We describe our technique of robotic McKeown (3-hole) esophagectomy for mid-esophageal adenocarcinoma after neoadjuvant concurrent chemo-radiation therapy for clinical stage uT3N0M0 tumor. The thoracic esophagus is completely mobilized from the esophageal hiatus of the diaphragm up to the thoracic inlet via a right thoracoscopic approach, with harvesting of the regional lymph nodes together with the specimen. The left neck incision is made along the anterior border of the sternocleidomastoid muscle and the inferior belly of the omohyoid muscle is transected. The cervical esophagus is then completely mobilized into the wound and secured using a Penrose drain. Using a laparoscopic approach, the entire stomach is mobilized with division of the left gastric vessels but careful preservation of the right gastro-epiploic arcade while transecting the greater omentum and the short gastric vessels. An intra-corporeal creation of the gastric conduit then follows. The gastric conduit, secured to the proximal stomach at the resection staple line, is subsequently tunneled via the esophageal hiatus and through the mediastinum to exit at the left neck incision by applying traction on the cervical esophagus. The specimen is separated from the conduit, and the cervical esophagus is transected at the desired location for the anastomosis. A stapled end-to-side but functional end-to-end esophago-gastric anastomosis (Orringer's technique) is then created. Results A completely robotic technique of McKeown (3-hole) esophagectomy without the need to exteriorize the stomach to fashion the gastric conduit via a (mini)laparotomy is successfully accomplished in the majority of our patients with proximal or mid-esophageal tumors. An uneventful postoperative recovery was made. Fluoroscopic esophagram on post-operative day 5 did not demonstrate leakage from the anastomotic site. Gastric conduit emptying was satisfactory despite the lack of a routine gastric drainage procedure or injection of botulinum toxin into the pyloric ring. Conclusion Robotic-assisted thoracoscopic esophageal mobilization combined with laparoscopic completely intra-corporeal fashioning of gastric conduit with cervical esophago-gastric anastomosis is a technically feasible minimally invasive approach to performing McKeown esophagectomy with satisfactory post-operative outcomes and conduit functioning. https://www.dropbox.com/scl/fi/gzc1vzdzhzqn7niz95b8t/Robotic-McKeown-Esophagectomy-Video-3.mp4?rlkey=c4ja7s1aob10ah6ps500z7y29&dl=0

Novel thin endoscope enables endoscopic submucosal dissection without retroflexion for tumor involving the whole pyloric ring.

Novel thin endoscope enables endoscopic submucosal dissection without retroflexion for tumor involving the whole pyloric ring.

Evaluation of Food Tolerance after Laparoscopic Sleeve Gastrectomy in Relation to the Distance of Resection from the Pyloric Ring

Evaluation of Food Tolerance after Laparoscopic Sleeve Gastrectomy in Relation to the Distance of Resection from the Pyloric Ring

Early Gastric Cancer Widespread Invading the Duodenum: A Case Report

Background: Gastric cancer has been observed to infrequently infiltrate the duodenum, with a prevalence of duodenal involvement ranging from 11.9%-23.8% [1] among patients with cancer in the gastric antrum. However, it is importantto note that the majority of these instances pertain to advanced gastric cancers, as the occurrence of duodenal invasion in early gastric cancer is exceedingly uncommon. Case presentation: A 62-year-old female patient presented with peripyloric thickening of the gastric antrum near the pyloric ring on gastroscopy. The lesion extended into the duodenum, appearing as a nodular and uneven intraduodenal lesion near the pyloric ring. The majority of the lesion exhibited a type 0-IIa flat elevation covered by White Opaque Substance (WOS). A CT scan with enhanced examination revealed no evidence of enlarged metastatic lymph nodes or distant metastasis. Biopsy of the intragastric lesion indicated high-grade intraepithelial neoplasia, with no surrounding enlarged metastatic lymph nodes observed. The lesion exhibited softness during the endoscopic insufflation test, indicating its conformity with Early Gastric Cancer (EGC) characterized by the encircling invasion of the duodenum. A laparoscopic-assisted major gastrectomy (D2) procedure was conducted, accompanied by B-II anastomosis. The surgical intervention and subsequent recuperation proceeded without complications, and there was no evidence of metastatic recurrence within a 13-month postoperative period. Conclusion: This case presents an unusual instance of early gastric cancer, providing additional evidence to support the notion that early gastric cancer can indeed infiltrate the duodenum by directly penetrating the mucosal layer.

Endoscopic submucosal dissection using ultrathin endoscope for early gastric cancer progressing from pyloric ring to bulb.

Endoscopic submucosal dissection using ultrathin endoscope for early gastric cancer progressing from pyloric ring to bulb.

Retroflexed endoscopic submucosal dissection of a lesion invading the pyloric ring, using a newly developed thin endoscope.

Retroflexed endoscopic submucosal dissection of a lesion invading the pyloric ring, using a newly developed thin endoscope.

Successful endoscopic submucosal dissection for early gastric cancer involving the pyloric ring using a combination of water and gel immersion with the tunneling method.

Successful endoscopic submucosal dissection for early gastric cancer involving the pyloric ring using a combination of water and gel immersion with the tunneling method.

Impact of intravenous injection of glucagon on anastomotic leakage in esophagectomy

BackgroundAnastomotic leakage after esophagectomy affects the early postoperative state and prognosis. However, effective measures to prevent anastomotic leakage in esophagogastric anastomosis have not been established. MethodsThis single-center, retrospective, observational study included 147 patients who underwent esophagectomy for esophageal cancer between 2010 and 2020. Glucagon was administered to extend the gastric tube in patients who underwent esophagectomy from January 2016. The patients were divided into two groups: a glucagon-treated group (2016–2020) and a control group (2010–2015). The incidence of anastomotic leakage was compared between the two groups for evaluation of the preventive effects of glucagon administration on anastomotic leakage. ResultsThe length of the gastric tube from the pyloric ring to the final branch of the right gastroepiploic artery was extended by 2.8 cm after glucagon injection. The incidence of anastomotic leakage was significantly lower in the glucagon-treated group (19% vs. 38%; p = 0.014). Multivariate analysis showed that glucagon injection was the only independent factor associated with a reduction in anastomotic leakage (odds ratio, 0.26; 95% confidence interval, 0.07–0.87). Esophagogastric anastomosis was performed proximal to the final branch of the right gastroepiploic artery in 37% patients in the glucagon-treated group, and these cases showed a lower incidence of anastomotic leakage than did those with anastomosis distal to the final branch of the right gastroepiploic artery (10% vs. 25%, p = 0.087). ConclusionsExtension of the gastric tube by intravenous glucagon administration during gastric mobilization in esophagectomy for esophageal cancer may be effective in preventing anastomotic leakage.

Bariatric endoscopic antral myotomy: first-in-human proof of concept of a novel therapeutic method to delay gastric emptying and induce weight loss

Bariatric endoscopic antral myotomy: first-in-human proof of concept of a novel therapeutic method to delay gastric emptying and induce weight loss

Ball Valve Syndrome Treated by Endoscopic Submucosal Dissection.

An 85-year-old female was diagnosed with cerebellar hemorrhage based on computed tomography (Figure A). She underwent a craniotomy to remove the hematoma. It has been 2 months since she started rehabilitation after the craniotomy but she still experiences repeated vomiting. Therefore, gastrointestinal transit disorders were considered a differential diagnosis. An esophagogastroduodenoscopy was performed for a detailed examination, which revealed an erythematous, mobile, and semi-pedunculated lesion approximately 40 mm in size near the pyloric ring in the gastric antrum. The lesion was entrapped in the duodenal bulb (Figure B and Figure C). With a diagnosis of early gastric cancer resulting in ball valve syndrome, endoscopic submucosal dissection was performed for symptom relief. A pathological examination demonstrated that the tumor was a mucosal gastric cancer and had been completely resected with free vertical and horizontal margins (Figure D and Figure E). The patient tolerated a progressive diet with no recurrence of vomiting after treatment. Although repeated vomiting is often an aftereffect of cerebrovascular disease, gastrointestinal transit disorders should be considered as possible causes in cases of persistent vomiting because elderly patients are also at the risk of the development of gastrointestinal neoplasms. Endoscopic submucosal dissection was effective for the treatment of ball valve syndrome caused by gastric cancer. We thank Natsuko Nakano for the pathological examination and Yo Matsui for the radiological diagnosis.

A novel triangle traction method using a clip-band traction device for endoscopic submucosal dissection of early gastric cancer involving the pyloric ring.

A novel triangle traction method using a clip-band traction device for endoscopic submucosal dissection of early gastric cancer involving the pyloric ring.

Pyloric ring section with a papillotomy knife for removing an ingested plastic bag closure penetrating the pyloric ring.

Pyloric ring section with a papillotomy knife for removing an ingested plastic bag closure penetrating the pyloric ring.

An unusual presentation of chordoma as a pyloric ring submucosal tumor: The first case report of a primary gastrointestinal lesion in humans.

Introduction and importanceChordomas are rare malignant bone neoplasms that are presumed to arise from chordal remnants in the fetal stage and typically occur along the axial skeleton. The extra-skeletal chordomas reported to date include soft tissue of the extremities and nasopharynx. Chordoma arising from the gastrointestinal wall has not been previously described.Case presentationWe report on a 42-year-old man with primary chordoma presenting as a gastroduodenal submucosal tumor centered on the pyloric ring. The patient was consistently asymptomatic, and the tumor was an incidental finding. However, during a follow-up at approximately 1.6 years, an increase in tumor size was identified on computed tomography (CT), and surgical resection was performed without a definite pathologic diagnosis. The patient was successfully treated with distal gastrectomy, and the histological diagnosis was a conventional chordoma. The diagnosis was confirmed via immunohistochemical staining for brachyury, pan-cytokeratin, S-100, and SOX9. Postoperative CT and magnetic resonance imaging revealed no recurrence or metastasis during the 1.5-year follow-up period.Clinical discussionPrimary chordomas of the digestive tract are rare. Embryologic development of the notochord does not explain the existence of remnants in the gastrointestinal wall. Moreover, notochordal remnants, as precursors of chordoma, were not identified in the current case. The gastroduodenal chordoma may not have originated from embryonic notochordal remnants but through aberrant brachyury activation without a notochordal precursor.ConclusionWe report the first case of primary gastrointestinal chordoma in humans. The tumor was completely removed surgically, without postoperative recurrence.

Gel immersion endoscopic mucosal resection for early gastric cancer near the pyloric ring.

Achieving complete resection of gastric tumors near the pyloric ring with conventional endoscopic mucosal resection (EMR) or endoscopic submucosal dissection is challenging. Limited working space, inadequate assessment of the distal margin, and peristaltic movements result in incomplete resection and/or a long procedure time. Underwater EMR has been recently reported to be effective for treating colorectal and duodenal epithelial neoplasms [1] [2]. Although earlier reports described gastric underwater EMR [3], it is sometimes difficult to accumulate and maintain sufficient water in the pylorus. Herein we present a case of early gastric cancer near the pyloric ring treated with gel immersion EMR.

Navigational tunnel technique for gastric peroral endoscopic pyloromyotomy: getting straight to the point (pylorus).

Background and AimsGastric peroral endoscopic pyloromyotomy (G-POEM) is emerging as a treatment option for patients with gastroparesis. The most technically difficult part of the procedure is creating a submucosal tunnel in the gastric antrum, which can be directionally challenging. We describe a novel navigational tunneling method that guides submucosal dissection in the direction of the pylorus and helps to identify the pyloric landmarks.MethodsConsecutive patients from September to December 2020 who underwent G-POEM for symptomatic gastroparesis were included. All cases were confirmed by prolonged gastric emptying study. The navigational tunnel technique was performed as follows: (1) mucosal cautery markings were made to outline the tunnel starting 3 to 4 cm proximal to the pylorus, (2) submucosal injection was done at the level of the pylorus and extended backward to the incision point, and (3) submucosal dissection was carried out after the prior submucosal injection straight to the pylorus.ResultsSix patients with gastroparesis underwent G-POEM with the navigational tunneling technique. The average time for submucosal injection was 2 minutes and 42 seconds, and the average tunnel time was 15 minutes and 36 seconds. There were no adverse events. All patients reported significant improvement (50%-85%) in symptoms.ConclusionsThis novel navigational tunneling technique appears to guide and facilitate G-POEM by providing a visual path for submucosal dissection straight to the pylorus. It may increase efficiency, decreasing the need to repeatedly exit the tunnel to check direction and preventing nonproductive wandering. It may also help identify the pyloric ring within the tunnel.

Button battery ingestion in children: Experience from a tertiary center on 56 patients.

The ubiquitous use of portable electronic devices has resulted in an increased incidence of button battery (BB) ingestion in children. BB ingestion represents a distinct category of ingested foreign body due to the associated high morbidity and mortality. The aim of this study was to report our experience in the management of BB ingestion in children. We reviewed the clinical and endoscopic characteristics of 56 children (≤ 18 years) who presented to our hospital emergency department (ED) with BB ingestion between December 2016 and November 2019. Data with respect to patient demographics, time of presentation to ED to endoscopic retrieval of BB, the endoscopic findings, and complications, if any, were collected. We encountered a total of 56 children with BB ingestions. While 10 BBs passed off spontaneously without any complication, 27 BBs were extracted endoscopically from the stomach. A total of 19 BB impactions occurred: 9 at the cricopharynx/upper esophageal sphincter (UES), 5 in the mid esophagus, 4 in the lower esophagus, and one at the pyloric ring. All impactions occurred with larger BBs (diameter ≥ 10 mm). Complications occurred in 3 children (5.35%) following retrieval; 2 developed upper esophageal strictures on follow-up, which were treated with serial dilations and one experienced esophageal perforation and peritonitis requiring laparotomy. There was no mortality in our study. A vast majority of ingested BBs pass off spontaneously or require minimal endoscopic intervention. Serious complications arise in a small minority especially in BBs > 10 mm in size with a potential for esophageal impaction.

The Effect of Antrum Size on Weight Loss, Glucagon-Like Peptide-1 (GLP-1) Levels, and Glycemic Control Following Laparoscopic Sleeve Gastrectomy in Adolescents with Obesity and Type 2 Diabetes.

The aim of this study was to compare the effect of antral resection versus antral preservation sleeve gastrectomy on the post-operative GLP-1, glycemic control, and weight loss in adolescents suffering from severe obesity and type 2 diabetes (T2D). This study included 36 adolescents. Patients were randomly divided into 2 groups: group (A) and group (B). Each group included 18 patients who underwent LSG, starting transection at 2 cm or 5 cm from the pyloric ring in group (A) and group (B), respectively. They were followed up at 1, 3, 6, 12, and 24 months post-operatively. The outcomes were the post-operative GLP-1 response, glycemic control, weight loss, and safety. The improvements in the body mass index and the percentage of excess weight loss (%EWL) were statistically significant within each group. The mean GLP-1 levels showed significant increase at the 1, 3, and 6 months but not in the 12 and 24 months in all the studied samples within each group. The mean HbA1c levels and post-prandial serum C-peptide significantly improved within each group (P < 0.05). No statistical differences in the weight loss, %EWL, GLP-1, HbA1c, C-peptide changes, and complication rates were observed between both groups. Diabetic remission was significantly higher (88.9%) in group (A). LSG resulted in generalized significant GLP-1 initial response that decreased over time. The reduced antrum size did not influence the GLP-1 response, glycemic control, or insulin resistance, but resulted in significantly better T2D remission. Since the study examines a small number of patients, further studies are needed. ClinicalTrials.gov Identifier: NCT04388059.

Laparoscopic Versus Conventional Y-U Pyloroplasty in Dogs: A Comparative Study of Pain, Stress, and Duration

BACKGROUND: Background: Y-U pyloroplasty is a surgical approach that is used to relieve pyloric stenosis. The study of different aspects of laparoscopic Y-U pyloroplasty instead of conventional approaches seems to be an appropriate alternative for the development of such surgeries in animals, as pyloric stenosis is an uncommon but important disease. OBJECTIVES: The present study aimed to describe the laparoscopic Y-U pyloroplasty in small animals as a new surgical technique, and to compare the duration of surgery, level of surgical stress, and postoperative pain of this method with the conventional Y-U pyloroplasty. It is important to note that this is the first time that laparoscopic Y-U pyloroplasty was performed in dogs. METHODS: A total of eight intact male and female mixed breed dogs were randomly divided into two groups of conventional (n=4) and laparoscopic (n=4) pyloroplasty. Operation time, blood glucose concentration, plasma cor-tisol levels, gastric emptying time, pyloric lumen, and diameter and width of pyloric ring, as well as the University of Melbourne Pain Scale (UMPS) were measured in both groups during pre and postoperative intervals. RESULTS: As a result, the mean operation time for conventional group was significantly lower than that for lapa-roscopic group (38.75±3.15 min vs. 116.25±14.34 min, p <0.05). Blood glucose concentrations in both groups elevated rapidly until 3 hours after surgery and then decreased until 24 hours. Plasma cortisol level in laparoscopic group, however, elevated rapidly until 5 hours after surgery. On the other hand, pyloric diameter and width of pyloric ring significantly increased in both groups. The UMPS in dogs undergoing conventional Y-U pyloroplasty was significantly higher than that in those undergoing laparoscopic Y-U pyloroplasty (p <0.001). Furthermore, pain and gastric emptying time decreased in all dogs. CONCLUSIONS: This study suggests that laparoscopic Y-U pyloroplasty is an applicable minimal invasive sur-gery that is performed through small incisions for the treatment of pyloric stenosis in dogs.

The pocket-creation method facilitates endoscopic submucosal dissection of gastric neoplasms involving the pyloric ring.

Background and study aims Endoscopic submucosal dissection (ESD) of superficial gastric lesions involving the pyloric ring is difficult. The pocket-creation method (PCM) with a small-caliber-tip transparent hood can overcome this difficulty by compressing the pyloric sphincter applying both traction and counter-traction. The aim of this study is to clarify the usefulness of the PCM for ESD of superficial gastric neoplasms involving the pyloric ring compared to the conventional method (CM). Patients and methods From October 2006 to August 2019, 66 gastric lesions requiring duodenal submucosal dissection beyond the pyloric ring in 66 patients were resected. The CM was mainly performed in the first period (CM group, n = 46) and the PCM in the second period (PCM group, n = 20). We retrospectively reviewed their medical records. Results Although no significant differences were observed in en bloc resection rates between the two groups, the PCM group had a significantly higher R0 resection rate than the CM group ( P = 0.047). There were no holes in resected specimens in the PCM group while three specimens in the CM group had a hole. The dissection speed in the PCM group tended to be higher than in the CM group, although it did not reach statistical significance ( P = 0.148). No significant differences were observed for the incidence of adverse events. Conclusions This is the first study reporting the advantages of the PCM over the CM for ESD of gastric lesions involving the pyloric ring. We believe that the PCM is an effective strategy to compress the pyloric sphincter and facilitates R0 resection.