Remnant Gastrectomy Research Articles

Conversion surgery for gastric remnant cancer with liver metastasis after nivolumab combination chemotherapy achieving pathological complete response: a case report and literature review.

Nivolumab combination chemotherapy has recently emerged as a potential first-line treatment for patients with unresectable or metastatic gastric cancer (GC). Further research has indicated that R0 resection by conversion surgery could be an effective treatment strategy to improve overall survival. However, there have been limited reports on the successful application of conversion surgery following combination chemotherapy achieving pathological complete response (pCR) in cases of advanced gastric remnant cancer with liver metastasis. Here, we present a case of long-term survival in a patient who underwent this treatment. A 54-year-old man was initially referred to our department for treatment of stage III (cT3N1M0) gastric cancer where he underwent laparoscopic distal gastrectomy and D2 lymph node dissection. After a year of uneventful follow-up, the patient was diagnosed with a tumor in the gastric remnant combined with liver metastasis, resulting in a diagnosis of stage IV (cT3N0M1) gastric remnant cancer. Subsequently, the patient was treated with four cycles of TS-1, Oxaliplatin, and Nivolumab as the first-line regimen. Remarkably, both the remnant tumor and liver metastasis exhibited significant shrinkage, and no new lesions were found. Given this response, conversion surgery was performed to achieve complete resection of the remnant gastric cancer and liver metastasis, followed by laparoscopic remnant gastrectomy and partial hepatectomy. Pathological examination revealed the absence of residual carcinoma cells and lymph node metastases. Postoperatively, the patient was treated with adjuvant chemotherapy with S-1 for 1 year, and survived without recurrence for 18months after conversion surgery. Nivolumab combination chemotherapy shows promise as a clinically beneficial treatment approach for gastric remnant cancer with liver metastasis, particularly when pCR can be achieved following conversion surgery.

410. IMPACT ON BODY WEIGHT OF REMNANT STOMACH PRESERVING ESOPHAGECTOMY FOR THE PATIENTS WITH PAST MEDICAL HISTORY OF GASTRECTOMY

Abstract Background Esophagectomy has a great impact on patients’ nutritional status. Particularly for the patients with past medical history of gastrectomy, there is a concern that surgical procedure of esophagectomy accommpanying remnant gastrectomy may potentially deteriorate nutritional status more than standard esophagectomy, resulting in excessive body weight loss. In order to reduce such negative impact, we perform remnant stomach preserving esophagectomy. The purpose of this study is to assess the impact on body weight of this procedure. Methods The patients with past medical history of gastrectomy who underwent remnant stomach preserving esophagectomy in our institute from 2015 to 2022 were enrolled in this study. All the measured body weights were collected from the electronic medical record retrospectively and all data point were plotted as BMI over time to see any transitional trend. The day of esophagectomy was defined as day0. The enrolled patients were divided into two groups according to the median initial BMI; lower BMI group and higher BMI group. The BMI transitional trends were detected in each group. Results Totally 37 patients were eligible in this study. Median age was 72 (57–88), the number of female was 1 (36 male), cStage1/2/3/4 of esophageal cancer were 9/9/13/5, median time period from gastrectomy was 21.0 years (0–54.5), and median initial BMI was 20.7 (15.1–27.7). All BMI data points from every patient according to the higher/lower initial BMI groups were shown in the figure. The decreasing trend in BMI until about 3 months after the esophagectomy was seen in the higher BMI group whilst relatively plateau trend in such period was seen in the lower BMI group. Conclusion Efficacy of the remnant stomach preserving esophagectomy in terms of reducing body weight loss could be more apparent in lower BMI patients than higher BMI patients. When you see an esophageal cancer patient with past medical history of gastrectomy, the remnant stomach preserving procedure should be considered particularly when the BMI is low.

Gastric Adenocarcinoma of the Remnant Stomach Presenting With a Cystic Intra-abdominal Mass 11 Years After Roux-en-Y Gastric Bypass.

CASE REPORT Morbid obesity defined as a body mass index of ≥ 40 kg/m2 is associated with increased morbidity and all-cause mortality.1 Roux-en-Y gastric bypass (RYGB) is the desired surgical intervention because of its proven benefits.1,2 Morbid obesity is associated with increased risk of gastric cancer; however, the altered anatomy of the stomach after bypass is challenging for ongoing surveillance of the remnant stomach.2 To date, only 17 cases of gastric remnant malignancy after RYGB are reported.2 We present a rare case of gastric remnant adenocarcinoma 11 years after RYGB presenting with abdominal pain and weight loss due to a large intra-abdominal cystic mass abutting the gastric remnant. Abdominal computed tomography without contrast revealed a large cystic structure abutting the stomach and pancreas (Figure 1). An esophagogastroduodenoscopy was normal. An endoscopic ultrasound (EUS) revealed a single round anechoic lesion >100 mm in size in the peripancreatic and perigastric peritoneal space (Figure 2). Typical mucosal, submucosal, and muscular propria layers were noted within the wall of the cystic structure without communication to the excluded stomach (Figure 3). Fine-needle aspiration of fluid (Expect 19 Gauge Flex Needle [Boston Scientific, Marlborough, MA]) demonstrated 750 mL of brown fluid with unremarkable cytology and normal lipase and amylase levels. The carcinoembryonic antigen (CEA) level in the cystic fluid was markedly elevated at 2,358 ng/mL when compared with serum CEA of 76.6 ng/mL.Figure 1.: Axial images of the abdomen and pelvis show the cystic dilation.Figure 2.: The cystic structure seen before fine-needle aspiration (FNA) (thick arrow).Figure 3.: Endoscopic ultrasound (EUS) images revealing the wall layers of the cystic structure (thick arrow) is seen after cyst fluid fine-needle aspiration (FNA), which demonstrates that it is not a cyst but a gastrointestinal structure.A second EUS performed because of recurrent abdominal distension showed a persistent cystic structure. Injection of contrast within the cystic structure demonstrated communication between the cyst and the excluded stomach. Fine-needle biopsy (Acquire 25 Gauge Needle [Boston Scientific]) of an area of the thickened gastric wall demonstrated poorly differentiated adenocarcinoma (Figure 4).Figure 4.: The area of the excluded stomach (thick arrow) with abnormal thickening of the stomach wall was biopsied revealing adenocarcinoma.Diagnosis of gastric remnant malignancy is usually confirmed at a median of 9 years after RYGB (range is 1–22 years) with abdominal computed tomography scans.2 EUS and transgastric endoscopy may be considered as alternatives to double-balloon enteroscopy for tissue biopsy in the setting of technically difficult access of the gastric remnant.3,4 Prevention and surveillance methods including remnant gastrectomy proposed in regions with a high prevalence of gastric cancer remain controversial and not well established. More studies are needed to determine whether CEA can be considered for screening of the cancer in the excluded stomach in patients with a history of morbid obesity and RYGB.5 DISCLOSURES Author contributions: GW Khneizer and BL Bick conceived and drafted the work. N. Mahendraker designed and critically revised the work, and all authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. GW Khneizer is the article guarantor. Financial disclosure: None to report. Informed consent could not be obtained from the family of the deceased. All identifying information has been removed from this case report to protect patient privacy.

Successful closure of a suture line leak following remnant gastrectomy using an over-the-scope clip

Successful closure of a suture line leak following remnant gastrectomy using an over-the-scope clip

S2345 A Rare Case of Bleeding Ulceration From the Excluded Stomach After Roux-en-Y Gastric Bypass Surgery

Introduction: Roux-en-Y gastric bypass (RYGB) is among the most common bariatric surgeries for treatment of morbid obesity, with >450,000 RYGB performed in the United States since 2011. Formation of an excluded stomach and duodenum that are difficult to access via conventional endoscopy can pose a unique challenge for diagnosis and treatment of gastrointestinal (GI) bleeding in post-RYGB patients. Case Description/Methods: A 60-year-old man with a history of morbid obesity and status post RYGB in 2017 presented in January 2021 with black tarry stools and a hemoglobin of 7.4 from a baseline of 13 g/dL without recent NSAID or tobacco use. He underwent upper endoscopy, colonoscopy, push enteroscopy and video capsule endoscopy without identification of a bleeding source. He was ultimately discharged home after stabilization and no further bleeding. Due to concern for an unidentified source of bleeding, further outpatient workup was pursued. CT enterography was unrevealing. Attempted endoscopic ultrasound (EUS)-guided gastrotomy to access the excluded stomach was unsuccessful due to inability to pass an Axios stent into the excluded stomach. Antegrade balloon enteroscopy failed to reach the jejuno-jejunal anastomosis. The patient was re-admitted in April 2021 for recurrent melena and a hemoglobin of 8.3 g/dL. Laparoscopic gastrotomy was performed with intraoperative transgastric endoscopy which revealed blood in the excluded stomach and duodenum. An ulcer in the excluded stomach was discovered and excised via subtotal gastrectomy. Pathology revealed focal transmural ulceration without dysplasia; H. pylori testing was negative. The patient was discharged home without recurrence of bleeding. Discussion: Alteration in GI anatomy after RYGB impedes access to excluded segments of the upper GI tract. Access to the excluded segments may be achieved by balloon enteroscopy depending on the length of the alimentary limb, EUS-assisted gastrotomy or laparoscopic formation of a temporary gastrotomy with transgastric endoscopy. A review of post-RYGB cases of excluded segment ulceration found that 93% of patients required surgery for definitive treatment. The most common interventions were remnant gastrectomy and oversewing of perforated ulcers with a 94% cure rate at short-term follow-up. Our case demonstrates that a high degree of suspicion for bleeding from the excluded gastric or small bowel segments should be maintained in patients with RYGB presenting with upper GI bleeding and initial negative GI tract evaluation.Figure 1.: Transmural ulceration in the remnant stomach status post subtotal gastrectomy

Successful treatment of remnant gastric cancer with afferent loop syndrome managed by percutaneous transhepatic cholangial drainage followed by elective gastrectomy: a case report

BackgroundThere are only few reported cases of remnant gastric cancer with concomitant afferent loop syndrome. Emergency surgery is the standard treatment strategy for this disease. However, some afferent loop syndrome cases, especially those with complete obstruction, can lead to a septic state, which makes performing emergency surgery risky. We describe a case of remnant gastric cancer with complete afferent loop obstruction, which was successfully managed by radical surgery following percutaneous transhepatic cholangial drainage of the afferent loop.Case presentationA 71-year-old man presented with nausea and abdominal discomfort. When he was 27 years old, he had undergone distal gastrectomy for a benign gastric ulcer, with gastrojejunostomy (Billroth II reconstruction). Abdominal computed tomography revealed thickening of the anastomosis site and significant dilation of the afferent loop. Gastrointestinal fiberscopy revealed advanced remnant gastric cancer at the anastomosis site, and the stoma of the afferent loop was completely obstructed. We diagnosed the patient with remnant gastric cancer with afferent loop syndrome. Percutaneous transhepatic cholangial drainage was performed twice before surgery to decompress the afferent loop. This provided more time for the patient to recover. Radical surgery of total remnant gastrectomy and Roux-en-Y reconstruction were performed electively. There were no severe postoperative complications. The patient died 8 months following the operation owing to peritoneal dissemination recurrence.ConclusionWe encountered a case of remnant gastric cancer with afferent loop obstruction, which was successfully managed by radical surgery following decompression of the afferent loop by percutaneous transhepatic cholangial drainage. Percutaneous transhepatic cholangial drainage effectively managed the afferent loop syndrome, resulting in the safe performance of elective surgery.

T stage and venous invasion are crucial prognostic factors for long-term survival of patients with remnant gastric cancer: a cohort study

BackgroundThe incidence of remnant gastric cancer (RGC) after distal gastrectomy is 1–5%. However, as the survival rate of patients with gastric cancer improves due to early detection and treatment, more patients may develop RGC. There is no consensus on the surgical and postoperative management of RGC, and the clinicopathological characteristics correlated with the long-term outcomes remain unclear. Therefore, we investigated the clinicopathological factors associated with the long-term outcomes of RGC.MethodsWe included 65 consecutive patients who underwent gastrectomy for RGC from January 2000 to December 2015 at the Osaka Medical and Pharmaceutical University Hospital, Japan. The Kaplan–Meier method was used to create survival curves, and differences in survival were compared between the groups (clinical factors, pathological factors, and surgical factors) using the log-rank test. Multivariate analyses using the Cox proportional hazard model were used to identify factors associated with long-term survival.ResultsNo significant differences were noted in the survival rate based on clinical factors (age, body mass index, diabetes mellitus, hypertension, cardiovascular disease, pulmonary complications, liver disease, diet, history of alcohol drinking, and history of smoking) or the type of remnant gastrectomy. Significant differences were noted in the survival rate based on pathological factors and surgical characteristics (intraoperative blood loss, operation time, and the number of positive lymph nodes). Multivariate analysis revealed that the T stage (hazard ratio, 5.593; 95% confidence interval [CI], 1.183–26.452; p = 0.030) and venous invasion (hazard ratio, 3.351; 95% CI, 1.030–10.903; p = 0.045) were significant independent risk factors for long-term survival in patients who underwent radical resection for RGC.ConclusionsT stage and venous invasion are important prognostic factors of long-term survival after remnant gastrectomy for RGC and may be keys to managing and identifying therapeutic strategies for improving prognosis in RGC.

Pancreatoduodenectomy for Ampullary Cancer after Roux-en-Y Gastric Bypass – An Extremely Rare Case Report

Introduction: Obesity is a known risk factor for periampullary carcinoma. However we have identified in the international literature only 1 case of a patient with ampullary carcinoma and history of gastric bypass submitted to curative surgery. And it is considered a surgery challenge. We present here the second case. Methods: This clinical case describes a female patient, 70 years old, clinically classified as a periampullary neoplasia with resectability criteria and without metastization evidence (cT2N0M0). This patient has a surgical history of a laparoscopic Roux-en-Y gastric bypass in 2017. This clinical case was discussed in the multidisciplinary hepatobilopancreatic meeting, resulting in a curative surgery as proposal. Results: The patient was subjected to a pancreatoduodenectomy (with a terminolateral pancreatojejunal anastomosis and a terminolateral hepaticojejunal anastomosis) with remnant gastrectomy in December of 2020. Postoperative care had no complications, resulting in a clinical discharge thirteen days later. The histological result of the surgical piece showed an ampullary adenocarcinoma moderately differentiated with invasion of peripancreatic adipose tissue, with surgical margins free of neoplasia and 29 nodes were removed (6 with metastasis) (pT4, pN1). Conclusion: There are multiple types of possible reconstruction for patients after a Roux-en-Y gastric bypass. The rarity of clinical cases is the main factor for the poor evidence to the best clinical practice and for the big surgical challenge that it presents.

A638 Laparoscopic Conversion from Gastric Sleeve to Roux-en-Y Gastric Bypass with Remnant Gastrectomy using Fluorescent Angiography

A638 Laparoscopic Conversion from Gastric Sleeve to Roux-en-Y Gastric Bypass with Remnant Gastrectomy using Fluorescent Angiography

1974 Seeing Isn’t Always Believing! Recurrent Hematemesis Due to Factitious Disorder

INTRODUCTION: Gastrointestinal bleeding is a common inpatient diagnosis with a cost >$5 billion in the US. Typically patients undergo endoscopic evaluation, capsule studies, CT imaging with/without embolization and in severe bleeding, surgical management may be pursued. We present a case of recurrent GI bleeding due to factitious disorder. CASE DESCRIPTION/METHODS: 52-year-old female veterinary tech with a complex surgical history presented to the ER for acute recurrent hematemesis with bright blood seen in ER. In 2017, she developed recurrent upper GI bleeding. Previous EGD showed Dieulafoy lesions that were clipped and she underwent partial gastrectomy. Physical examination showed normal vitals and diffuse mild abdominal tenderness. Labs showed stable normocytic anemia (Hgb 9-10), normal iron stores, LFTs, INR, and platelets. She underwent extensive workup including angiogram, multiple endoscopies, and multiple CTA A/P with no identifiable source of bleeding. Given ongoing visualized bleeding and almost weekly hospitalizations she underwent remnant gastrectomy for definitive management and pathology confirmed Dieulafoy lesions. During the hospitalization, she was found to have 2 blood-filled syringes in her pillowcase. She had multiple concerning signs for a psychiatric disorder: "la belle indifference", no active bleeding on endoscopy, no melena, persistent bleeding despite gastrectomy, stable Hgb, female with medical training, and no further bleeding after sitter placed. Psychiatry team was consulted and discovered she had been ingesting blood drawn from a PICC line to stimulate bleeding. A diagnosis of Munchausen’s disorder was made. DISCUSSION: Munchausen’s disorder occurs when patients intentionally produce physical or psychiatric symptoms (usually of dramatic nature), allowing them to assume a sick role and gain medical attention. This is a difficult diagnosis and often results in the excessive use of medical resources. Risk factors include a serious illness/trauma during childhood, loss of a loved one, personality disorder, and being a healthcare worker. The motive is mainly to gain sympathy and attention. Physicians should confront patients with the diagnosis if a good therapeutic relationship has been established and patients benefit from psychotherapy and close medical and psychiatric follow up. Prognosis tends to be poor however, with most patients refusing psychiatric evaluation and leaving AMA. This case adds to literature suggesting factitious disorder with hematemesis is not as rare as expected.

Gastric Leiomyoma Causing GOO in a Roux-en-Y Gastric Bypass Patient

Gastric leiomyomas (GLM) are rare tumors of the stomach, and they account for about 2.5% of all gastric tumors. They are classified as superficial or deep depending on origination. Symptoms are rare unless there is bleeding, malignant transformation, or significant growth to cause an outlet obstruction. Here we will discuss a case about a 57-year-old, African American female with history of Roux-en-Y gastric bypass who presented with gastric outlet syndrome that was later found to be due to GLM. A 57-year-old female with history of uterine leiomyoma and history of Roux-en-Y gastric bypass presented with abdominal pain associated with nausea and vomiting in the emergency department. CT scan of her abdomen/pelvis showed the gastric remnant to be distended, measuring 6.0 x 5.4 cm with an air-fluid level. There was also thickening of the pylorus and proximal duodenum suggesting a gastric outlet obstruction. She was taken to the operating room for laparoscopic evaluation with intraoperative endogastroduodenoscope (EGD). Gastrotomy was made in the gastric remnant which allowed the EGD to pass into it. The EGD was able to transverse the pyloric channel and get into the duodenum. On withdrawing of the EGD, the GI team found a bilobulated 2-3 cm polypoid mass on the gastric antrum side of the pylorus forming a ball-valve obstruction of the pyloric channel. The mass was removed via anterior gastrostomy laparoscopically by sharp scissor. The histomorphology and immunoprofile support the diagnosis of leiomyoma of the stomach. Her recovery was unremarkable and she was discharged four days after the surgery. The above patient's altered anatomy from the Roux-en-Y made the diagnosis challenging and noteworthy. Her gastric bypass was done in 2000 without screening EGD. Current guidelines suggest that the decision to perform preoperative EGD should be individualized in patients scheduled to undergo bariatric surgery. Most bariatric surgeons request screening EGD prior to bypass surgery to look for any lesions that might need surveillance such as ulcers, polyps, or tumors. If these lesions are found before the bariatric surgery, then they can be treated. Otherwise the patient can be offered remnant gastrectomy if the lesion requires surveillance. Current guidelines should consider adding that a preoperative EGD be completed on all gastric bypass patients to assess the risk of developing disease in the gastric remnant.

Successful conversion surgery for unresectable gastric cancer with giant para-aortic lymph node metastasis after downsizing chemotherapy with S-1 and oxaliplatin: a case report

BackgroundAlthough patients with stage IV gastric cancer who respond well to systemic chemotherapy can be treated with gastrectomy, the prognosis of patients with unresectable gastric cancer with para-aortic lymph node metastasis is poor. We herein report a case of remnant gastric cancer with para-aortic lymph node metastasis that was treated with potentially curative conversion surgery after showing a complete response to chemotherapy with S-1 and oxaliplatin (SOX).Case presentationAn 81-year-old man was diagnosed with type 3 remnant gastric cancer with giant para-aortic lymph node metastasis, and he received SOX chemotherapy. After three courses of SOX chemotherapy, the primary tumor and para-aortic lymph node metastases markedly reduced in size, indicating a partial response. Because conversion surgery was possible, the patient underwent total remnant gastrectomy with D2 and para-aortic lymph node dissection. Histological examination revealed no residual cancer cells in the resected stomach and lymph nodes. The patient was diagnosed with a complete pathological response and was discharged on postoperative day 24. Currently, 1 year after surgery, the patient is alive and has not shown any tumor recurrence.ConclusionTo the best of our knowledge, this is the first case of advanced remnant gastric cancer with giant para-aortic lymph node metastasis that showed a pathological complete response and favorable outcome after SOX chemotherapy.

Bile reflux of the remnant stomach following Roux-en-Y gastric bypass: An etiology of chronic abdominal pain treated with remnant gastrectomy

Bile reflux of the remnant stomach following Roux-en-Y gastric bypass: An etiology of chronic abdominal pain treated with remnant gastrectomy

A5039 - Gastric Bypass with Remnant Gastrectomy for Type I Neuroendocrine Tumor in a Patient with Morbid Obesity

A5039 - Gastric Bypass with Remnant Gastrectomy for Type I Neuroendocrine Tumor in a Patient with Morbid Obesity

Pancreatoduodenectomy after Roux-en-Y gastric bypass: technical considerations and outcomes

BackgroundPatients with altered anatomy due to Roux-en-Y gastric bypass (RYGB) present unique diagnostic and therapeutic challenges when they present with periampullary pathology. We describe a series of patients who underwent pancreatoduodenectomy (PD) after gastric surgery with Roux-en-Y reconstruction and review the literature to highlight technical considerations and outcomes. MethodsPatients from two institutions were identified and data regarding preoperative workup, operative conduct, and pathologic and clinical outcomes were collected. ResultsEleven patients were included in the institutional series. At the time of periampullary pathology, the median age was 64 years and time since RYGB was 10 years. Median operative time was 361 minutes, estimated blood loss was 500 mLs, and length of stay was 6 days. Remnant gastrectomy was performed in nine patients and reconstruction was performed using the biliopancreatic limb (BP) without revision of the jejuno-jejunostomy in ten patients. Pathology revealed pancreatic cancer (8), chronic pancreatitis (2), and duodenal cancer (1). Three patients experienced major complications and there were no 90-day mortalities. ConclusionPancreatic surgeons will see an increasing number of patients with Roux-en-Y anatomy who will require evaluation and resection for periampullary diseases. For PD after RYGB, we recommend remnant gastrectomy with reconstruction using the BP limb.

Temporary Biliary Stent Placement for Benign Stricture with Laparoscopic-Assisted Endoscopic Stent Retrieval in a Patient Status Post Roux-en-Y Gastric Bypass: A Multidisciplinary Approach to a Complex Condition

AbstractBenign biliary strictures are multifactorial in etiology and can be difficult to treat, causing significant morbidity and mortality. In patients with prior upper gastrointestinal surgery, such as Roux-en-Y gastric bypass, options for intervention are limited by the inability of an endoscope to reach the biliary ductal system due to altered anatomy. In patients with an inaccessible ductal system by endoscopic retrograde cholangiopancreatography (ERCP), percutaneous bile duct stent placement for benign strictures has traditionally been reserved for cases of failed cholangioplasty without additional surgical options. Our case details a novel multidisciplinary management approach for the treatment of a refractory biliary stricture in a patient with Roux-en-Y gastric bypass anatomy with remnant gastrectomy. Following interventional radiology-guided retrievable biliary stent placement and subsequent remodeling, laparoscopy-assisted ERCP with stent retrieval was performed through the combined efforts of minimally invasive surgery and gastroenterology.

Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass.

Patients with prior Roux-en-Y gastric bypass (RYGB) operations for weight loss present reconstruction challenges during a pancreaticoduodenectomy (PD). With over 60,000 RYGB performed annually, the increasing odds of encountering such patients during a PD make it imperative to understand the RYGB anatomy and anticipate reconstruction options. This article describes the possible reconstruction options and their rationale. We reviewed our PD reconstruction options, compared them to what have been described in the literature, and derived a consensus from internal conferences comprising bariatric and hepatopancreatobiliary surgeons to describe known reconstruction options. In general, reconstruction options can include one of three options: (1) remnant gastrectomy, (2) preservation of gastric remnant, or (3) reversal of gastric bypass. This article describes individualized reconstruction options for RYGB patients undergoing PD. The reconstruction options can be tailored to the needs of the patient.

Bile reflux of the remnant stomach following Roux-en-Y gastric bypass: an etiology of chronic abdominal pain treated with remnant gastrectomy

BackgroundBile reflux gastritis of the remnant stomach following Roux-en-Y gastric bypass (RYGB) causing chronic abdominal pain has not been reported. We report a series of symptomatic patients with remnant gastritis treated effectively with remnant gastrectomy (RG). ObjectiveThe objective was to report our experience with bile reflux remnant gastritis after RYGB and our outcomes following RG. SettingCommunity teaching hospital. MethodsAll patients undergoing RG were retrospectively reviewed for presenting symptoms, diagnostic workup, pathology, complications, and symptom resolution. ResultsNineteen patients underwent RG for bile reflux gastritis at a mean of 4.4 years (52.3 mo, range 8.5–124 mo) after RYGB. All patients were female and presented with pain, primarily epigastric (18/19; 95%), and described as burning (11/19; 58%), with 10 (53%) reporting nausea. Endoscopy was performed preoperatively on all patients with successful remnant inspection in 13 (68%), using push endoscopy (n = 10) or operative assist (n = 3), with 12 (of 13; 92%) biopsy-positive for reactive gastropathy. Seventeen (90%) completed a hepatobiliary scintigraphy scan with 100% positivity demonstrating bile reflux across the pylorus. Surgical approach was laparoscopic or robotic in 18 (95%) with a hospital length of stay of 2.7 days (range 0–12 d), with no major complications or readmissions. Pathology of the remnant confirmed reactive gastropathy in 90% (n = 17). Ninety percent of patients (n = 17) reported sustained symptom resolution, and 11% of patients (n = 2) remained symptomatic at last follow-up. We followed all patients for a mean of 6.6 years (1–194 mo). ConclusionBile reflux gastritis of the remnant stomach is a new consideration for chronic abdominal pain months to years following RYGB. Hepatobiliary scintigraphy imaging and endoscopic biopsy are highly suggestive. RG is safe and effective treatment.

Adenosquamous Carcinoma of the Remnant Stomach: A Case Report and Literature Review

Adenosquamous carcinoma (ASC) in the stomach is rare. Furthermore, it is even rarer in the remnant stomach. To our knowledge, few case reports related to ASC of the remnant stomach have been published to date. The progression of the cancer is extremely rapid, and the prognosis of this condition is generally poor. A 62-year-old Japanese man who underwent a distal gastrectomy with Billroth II anastomosis for a gastroduodenal ulcer 43 years ago was admitted for severe anemia. A gastrointestinal examination revealed a ulcerated tumor at the anastomosis of the gastric remnant. An abdominal computed tomography scan showed gastric wall thickening and no metastatic lesions. He was given a diagnosis of gastric remnant cancer, and he underwent remnant gastrectomy, splenectomy, and lymph nodes resection. Peritoneal cytologic diagnosis and lymph node metastasis were positive. The histopathologic diagnosis was adenosquamous carcinoma. Although the early postoperative course was uneventful, peritoneal dissemination was revealed 3 months later. Although ASC of the remnant stomach is rare, it is an aggressive cancer, and patients usually receive a poor prognosis. Following patients for a long-term basis after gastrectomy is important to detect cancers at an early stage.

腹部手术后早期大出血的原因与防治

目的：探讨腹部手术后早期大出血的原因与防治。方法：对56例腹部手术后早期(72 h内)出现腹腔内及消化道大出血的临床资料进行回顾性分析。结果：术后大出血原因有血管结扎线滑脱出血19例，术后创面大量渗血17例，胃小弯断端出血6例及胃切开缝合处出血1例，吻合口出血13例。再次手术方式包括结扎线脱落血管再缝扎19例，出血部位缝扎止血15例，胃(肠)切开 + 缝合止血18例，残胃全切除1例，吻合口切除 + 再吻合1例，出血创面缝合结扎 + 电灼 + 生物胶物胶或止血纱覆盖止血2例。本组再手术治疗病例中治愈53例，死亡3例。结论：腹部手术后早期大出血主要与手术操作失误和吻合器械操作不当有关，早期再次手术是抢救的关键，认真仔细操作是预防的根本。 Objective: To analyze the reason, treatment and prevention of early postoperative massive he-morrhage after the abdominal procedure. Methods: The clinical data of 56 cases with early (less than 72 hours) postoperative intra-abdominal and gastrointestinal massive hemorrhage after the abdominal procedure were analyzed retrospectively. Results: The reasons of postoperative he-morrhage included loosening of blood vessel ligation in 19 cases, blood oozing from the wound surface in 17 cases, hemorrhage from the gastric remnant margin (staple-line) of lesser curvature in 6 cases and hemorrhage from gastrotomy site in 1 case, hemorrhage from anastomosis (gastro [esophago]-jejunostomy, colorectal [anal] anastomosis) in 13 cases. The surgical procedures of reoperation were re-exploration and surgical ligation in 19 cases, re-exploration and suturing li-gation in 15 cases, gastrotomy and suturing ligation in 18 cases, total removal of remnant gastrec-tomy in 1cases, resection of gastrojejunostomy and re-anastomosis in 1 case, re-exploration and suturing ligation with oppression of absorbable hemostatic gauze in 2 cases. 53 cases were survived and 3 cases were died. Conclusions: Maltreatment of blood vessel during operation and in-appropriate application of staple were the main causes of early postoperative massive hemorrhage after the abdominal procedure. Diagnosis at early stage and secondary operation on time are essential for success of rescue, and careful manipulation is principle for prevention of this post-operative complication.