Gastrojejunostomy Site Research Articles

Experience with the whipple procedure (pancreaticoduodenectomy) in a University-affiliated community hospital

Background The purpose of this report is to review the current standards of the Whipple pancreaticoduodenectomy and show that excellent results are achievable in a low-volume, university-affiliated community hospital. Methods A case series of consecutive patients operated on during the period November 1981 to June 1996 was evaluated retrospectively. Medical records were abstracted for demographic data, clinical presentation, comorbid factors, pathological diagnosis and staging, operative records, perioperative mortality, morbidity, and length of stay. Postoperative follow-up data were obtained from telephone interviews and from the primary referring physicians. Results A total of 29 patients underwent a pancreaticoduodenectomy procedure during this 15-year period. Twenty-eight patients underwent the standard Whipple resection and 1 patient underwent an extended resection owing to the extent of the disease. The average age was 64 years (range 41 to 82). Comorbid diseases were present in 59% of cases. Jaundice was the main presenting complaint (62%), loss of weight and appetite was present in 34%. The most common indication for this procedure was malignant periampullary disease (83% of cases). Of patients with adenocarcinoma of the pancreas, 67% were stage I and 33% were stage III. The operation lasted an average of 5.5 hours (range 3.5 to 8 h). The mean operative blood loss was 1153 mL (range 250 to 4,000). The median length of stay was 11 days (range 7 to 81). There was 1 operative mortality (3%), and the overall major morbidity rate was 28%. Three patients required reoperation (10%), 2 for intraabdominal hemorrhage and 1 for delayed gastric emptying. The major morbidity was hemorrhage at the gastrojejunostomy site (14%); 2 cases were intraabdominal and 2 were intraluminal. Pancreaticojejunostomy leak occurred in 1 patient, resulting in a localized intraabdominal abscess. Delayed gastric emptying, defined as the need for nasogastric suctioning for more than 10 days postoperatively, occurred in only 1 patient. Overall, an oral diet was tolerated after a median of 6 days (range 4 to 61). Seventy-two percent of patients had no major complications at all, 17% had one major complication, and 10% had two or more major complications. Pancreatic insufficiency was the major long-term complication, developing in about 50% of patients. There were no biliary strictures. The median survival for patients with carcinoma of the pancreas was 21 months and the 5-year survival was 15%. Conclusions The above study demonstrates that a complicated procedure like the Whipple Pancreaticoduodenectomy can be performed with excellent results in a community hospital. The most important prerequisite is that the surgeon be adequately trained in the procedure. In low-volume hospitals, the case load should be restricted to a minimal number of trained surgeons in order to concentrate the experience.

残胃空腸吻合部に発生した腺扁平上皮癌の1例

残胃空腸吻合部に発生した腺扁平上皮癌の1例

A CASE OF ADENOSQUAMOUS CELL CARCINOMA AT THE SITE OF THE GASTRQIEJUNOSTOMY

Adenosquamous cell carcinoma of thje stomach is uncommon, pasticularly that occurring in the residual stomach at the site of the gastrojejunostomy. This paper dealed with a case of adenosquamous cell carcinoma at the site of gastrojejunostomy 31 years after gastrectomy. A 57-year-old man who had had distal gastrectomy and gastrojejunostomy (Billoroth II) for benign duodenal ulcer was admitted to our hospital complaining of epigastric pain. Carcinoma at the site of gastrojejunostomy was found as a result of various examinations, and total resection of the residual stomach and combined resection of the pancreas and the transverse colon were performed. The infiltrative and ulcerative tumor at the site of gastrojejunostomy was 5.5×4.0cm in size. Histology revealed adenosquamous cell carcinoma. Six months after surgery the patient died of peritonitis carcinomatosa and the liver metastasis of the carcinoma.

Billroth II gastrojejunostomy in dogs. Stapling technique and postoperative complications.

Billroth II gastrojejunostomy was performed with surgical staplers in 6 dogs that were not irradiated and in 11 dogs that subsequently received radiation to the pancreas and proximal part of the duodenum. The dogs were monitored clinically for 135 days and then euthanatized and necropsied. Each gastrojejunostomy site was preserved in formalin and the stomal diameter was measured. No mechanical complications were encountered with the use of surgical staplers and no leakage was observed at the staple closure sites before abdominal closure. All dogs vomited approximately 100 ml of coagulated blood 4 to 8 hours after surgery, and 300 to 400 ml of brown fluid after approximately 24 hours. Vomiting was the most common clinical finding after the first 24 hours. Vomiting was subjectively graded from 1 to 3 with grade 1 representing the least severe problem and grade 3 the most severe. Grade 1 vomiting occurred in 12 of 16 dogs that survived 135 days; in the other four dogs, vomiting was classified as grade 2 or 3. All dogs with grade 1 vomiting had stomal diameters of 1.7 to 2.9 cm (mean, 2.2 +/- 0.4 cm standard deviation). Dogs with grade 2 or 3 vomiting had stomal diameters of 2.2 to 4.0 cm (mean, 3.2 +/- 0.8 cm standard deviation). The difference was statistically significant (p less than 0.005). The percentage of weight gained or lost was recorded for each dog. Two nonirradiated dogs gained body weight, whereas the other nonirradiated dogs and all irradiated dogs lost body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Near-Total gastrectomy for gastric cancer

Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.

Gastritis cystica polyposa.

Gastritis cystica polyposa was diagnosed in five patients between ages 29 and 61 years. All five had been operated on for peptic ulcer disease three to 26 years earlier, when gastroenteric anastomoses had been made. The presenting complaint was abdominal pain, nausea and vomiting, or gastrointestinal bleeding. The lesions, located on the gastric side of the anastomosis, consisted of polypoid mucosal changes associated with hyperplasia and cystic dilatation of glands. Radiologic and endoscopic findings were often nondiagnostic, and surgical intervention was necessary to relieve obstruction and to rule out carcinoma. Resection of the gastrojejunostomy site and choosing anastomotic techniques to minimize bile reflux into the stomach appear to be the preferred methods of treatment.

Stomal polypoid hypertrophic gastritis.A polypoid gastric lesion at gastroenterostomy site

Four cases of stomal polyps (the so-called gastritis cystica polyposa--GCP) at the gastroenterostomy site were studied with detailed description of their macroscopic and histologic features. Thirty-eight cases with reresection of the stomach including the site of previous gastroenterostomy were used for a comparative study. In 25 (66%) of the 38 cases localized mucosal hypertrophy of varying degrees was recognized near the site of anastomosis, the morphology corresponding well, though of the smaller scale, to that of the GCP both macroscopically and histologically. Macroscopic and histologic continuity was traced between the minimal protrusion of the stomal gastric mucosa and the stomal polyps. It is suggested that the GCP is an extreme occasion of stomal gastritis characterized by atrophy and pseudopyloric gland metaplasia of the fundic glands often with their submucosal invasion and hyperplasia of the surface and foveolar epithelia, these being probably caused by reflux of duodenal contents. It must be borne in mind that such lesions do exist at the site of gastrojejunostomy to be strictly differentiated from malignancies at the gastric stump.

Knotted intestinal decompression tube.

To the Editor:— Intestinal intubation is frequently employed in the management of small-bowel obstruction, a procedure from which complications have not been reported. 1 We recently encountered an intubation complication in a patient who had had a gastroenterostomy. The diagnosis was made from plain abdominal x-ray films and confirmed at surgery. The purposes of this report are to describe the roentgenographic findings and to propose a method of avoiding the complication. Report of a Case:— A 25-year-old woman had had a gastrojejunostomy two years previously at another hospital for peptic ulcer. The patient was admitted to our hospital in December 1967 with a perforated gastric ulcer just distal to the gastrojejunostomy site. Surgical closure was performed without gastric resection, and the patient was soon discharged on a strict ulcer regimen. Three days later, she was readmitted with intractable periumbilical and epigastric pain. Definitive resectional surgery was planned after several days of