Complications of pyloromyotomy for infantile hypertrophic pyloric stenosis

BACKGROUND: Few references exist regarding contemporary complications of pyloromyotomy (PM) for infantile hypertrophic pyloric stenosis (IHPS). Therefore, we reviewed the frequency and outcome of patients with IHPS who developed complications from PM. METHOD: A 25-year retrospective review was performed in two populations. The first group included all infants who had a PM for IHPS at two pediatric surgery centers. The second group included all infants referred from other institutions who developed complications following PM for IHPS. RESULTS: Between 1969 and 1994, 901 PMs were performed. Intraoperative complications occurred in 40 patients (4%), including 39 duodenal perforations and 1 difficult intubation requiring prolonged ventilation. No unrecognized duodenal perforations or incomplete PMs were found. Postoperative complications developed in 52 patients (6%). The wound infection rate was less than 1%. Postoperative vomiting occurred in 31 infants (3%). The mortality rate was 0.1%, with 1 death due to sepsis from delayed diagnosis of Hirschsprung's disease. During the same study period, 11 patients were referred from other hospitals for postoperative complications. Five had persistent vomiting treated successfully with expectant management. Six infants needed reoperation: 3 for persistent IHPS, 1 for gastric outlet obstruction, and 1 for small bowel obstruction secondary to adhesions; 1 required wound abscess drainage. CONCLUSION: Pyloromyotomy is not without complications. Duodenal perforation should be infrequent, but when it occurs, it can usually be readily recognized and treated with minimal morbidity. Postoperative vomiting can be managed nonoperatively, but if it persists longer than 5 days, radiologic evaluation should be performed. Incomplete PM is uncommon and should not occur. A second myotomy is needed when the diagnosis of incomplete myotomy is established. A single standard of care should be expected of all surgeons who perform PM for IHPS.     

Gastrointestinal and nutritional aspects of eating disorders

Anorexia nervosa (AN) and bulimia nervosa (BN) are potentially fatal eating disorders which primarily affect adolescent females. Differentiating eating disorders from primary gastrointestinal (GI) disease may be difficult. GI disorders are common in eating disorder patients, symptomatic complaints being seen in over half. Moreover, many GI diseases sometimes resemble eating disorders. Inflammatory bowel disease, acid peptic diseases, and intestinal motility disorders such as achalasia may mimic eating disorders. However, it is usually possible to distinguish these by applying the diagnostic criteria for eating disorders and by obtaining common biochemical tests. The primary features of AN are profound weight loss due to self starvation and body image distortion; BN is characterized by binge eating and self purging of ingested food by vomiting or laxative abuse. GI complications in eating disorders are common. Recurrent emesis in BN is associated with dental abnormalities, parotid enlargement, and electrolyte disturbances including metabolic alkalosis. Hyperamylasemia of salivary origin is regularly seen, but may lead do an erroneous diagnosis of pancreatitis. Despite the weight loss often seen in eating disorders, serum albumin, cholesterol, and carotene are usually normal. However, serum levels of trace metals such as zinc and copper often are depressed, and hypophosphatemia can occur during refeeding. Patients with eating disorders frequently have gastric emptying abnormalities, causing bloating, postprandial fullness, and vomiting. This usually improves with refeeding, but sometimes treatment with pro-motility agents such as metoclopromide is necessary. Knowledge of the GI manifestations of eating disorders, and a high index of suspicion for one condition masquerading as the other, are required for the correct diagnosis and management of these patients.     

Long-term survival and functional status in the elderly after cardiac surgery

Rumination is a syndrome characterized by repetitive regurgitation of small amounts of food from the stomach. The food is then partially or completely rechewed, reswallowed, or expelled. This syndrome is relatively common in infants and mentally challenged persons, but it also occurs in adults with normal intelligence. The rumination syndrome is an underappreciated condition in adults who frequently receive a misdiagnosis of vomiting due to gastroparesis or gastroesophageal reflux. Difficulties in establishing the correct diagnosis may be caused by a lack of awareness of the condition among physicians. This syndrome must be considered in the differential diagnosis of a patient with regurgitation, vomiting (especially postprandial), and weight loss. Reassurance, explanations, and behavioral therapy are currently the mainstays of treatment in adults with normal intelligence who have the rumination syndrome. Appropriately controlled trials are needed to establish the best therapy.     

Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients

BACKGROUND: Marginal ulceration (MU) after Roux-en-Y gastric bypass (RYGB) is a well-recognized complication. Its incidence varies between 1% and 16%. Factors associated with the development of MU include pouch size, pouch orientation, staple line integrity, and mucosal ischemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori may also contribute to MU, but their mechanism of action in the RYGB patient has not been studied. METHODS: In 1994 a prospective 3-year study was designed to document the incidence of MU after near-total gastric bypass (NTGB). In this procedure the transected pouch was limited to the cardia, and the gastrojejunostomy was made along the greater curvature. A total of 173 patients entered the study. All patients who experienced postoperative nausea, vomiting, or abdominal pain underwent endoscopic examination of the pouch, stoma, and proximal Roux-en-Y limb. Gastrograffin studies were used within the first 2 weeks of operation. RESULTS: One year after operation, MU was not identified in any patient. At 3 years follow-up, MU was documented in one patient (0.6%) with a dilated gastric reservoir (60 cc). CONCLUSION: This study reviews the etiology, diagnosis, and treatment of MU in the RYGB patient and offers specific recommendations to reduce its occurrence. It also confirms a preliminary impression that NTGB is an effective operation in preventing MU formation.     

Trichobezoars

Trichobezoars are accumulations of hair casts in the stomach associated with trichophagia. The typical patient is an adolescent female who presents with alopecia and an upper abdominal mass which on moving can cause intermittent gastric outlet obstruction. Only a minority of patients have severe psychiatric disorders. When hair strands extend from the main mass in the stomach, all along the small bowel and reaching the cecum, the condition is termed the Rapunzel syndrome. In about 5% of patients there are separate hair masses in the stomach. The clinical presentation includes abdominal pain, loss of appetite, weight-loss, vomiting, loose stools, pancreatitis, jaundice, anemia and hypoalbuminemia. These signs and symptoms raise the suspicion of malignancy. Complications of bezoars include ulcers, perforation of the bowel, obstruction and intussusception. Diagnosis can be established either by barium swallow or by CT scan. Ultrasound might suggest the diagnosis, but sonographic features are definitely not pathognomonic. Treatment is surgical, as endoscopic removal is usually unsuccessful. We present 2 children in whom trichobezoars were found.     

Contribution of gastrointestinal transit and pouch characteristics in determining pouch function

AIM: To determine the contributions of gastrointestinal transit and pouch characteristics to bowel frequency in patients with an ileoanal reservoir and no pouchitis. METHODS: Twenty one patients who had undergone restorative proctocolectomy, with ileostomy closure at least eight months previously, and who had no history of pouchitis were recruited. They were prospectively classified on the basis of their bowel frequency: 11 patients had good pouch function (bowel frequency less than six per day) and 10 had poor function (bowel frequency more than six per day). Gastrointestinal transit was studied using a dual isotope technique and anal and pouch physiological examination was performed on all patients. RESULTS: Lag phase, 25% and 50% gastric emptying, small bowel transit time, and 10% and 50% pouch filling times, all for solids and liquids, were not significantly different between patients with good and poor function. Anal manometry and pouch and anal electrical sensitivity were also similar in the two groups. The volume of air and water required to elicit an initial sensation and the urge to defaecate were similar in both groups, but the maximum tolerated volume to both air (525 v 245 ml, good v poor function, median values) and water (625 v 370 ml) infusion was significantly (both p < 0.02) lower in patients with poor function. CONCLUSION: Maximum tolerated volume in the pouch, which may reflect pouch size, sensitivity, compliance, or a combination of these is the major determinant of pouch function. Gastrointestinal transit does not seem to be an important determinant of function.     

Reducing early technical complications in gastric bypass surgery

BACKGROUND: The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution. METHODS: We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death. RESULTS: The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature. CONCLUSIONS: The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.     

Duodenal phytobezoar: a case report and review of the literature

Phytobezoars are an unusual cause of small bowel obstruction. We report a case of small bowel obstruction due to phytobezoar in a 63 year-old female patient who had undergone gastric surgery (truncal vagotomy with pyloroplasty) for duodenal ulcer disease complicated by gastric outlet obstruction 10 years ago. We diagnosed this bezoar case by radiologic methods and these methods keep their importance for the diagnosis of small bowel obstruction with phytobezoars.     

Tetralogy of Fallot with flap valve ventricular septal defect producing suprasystemic right ventricular pressure: echocardiographic observations

The study objectives were to gain insight into how the terms "dieting" and "binge eating" are understood and used by adolescents and to assess whether interpretations of these terms are consistent across age and gender. Twenty-five focus groups were conducted with 203 adolescents (138 girls and 65 boys) in urban public junior and senior high schools. Respondents were asked questions about dieting and binge eating behaviors. In the majority of groups (n=19), healthful eating behaviors, such as eating less fat or more fruits and vegetables, were mentioned in reference to dieting. However, in many of the groups (n=13) unhealthful eating behaviors, such as skipping meals or "starvation," were also described. Dieting was frequently described as an umbrella term for different behaviors aimed at weight control (ie, physical activity) or in nonbehavioral terms (ie, as a desire or plan for weight loss). Although binge eating was described as overeating by many participants, often it was not clear if youth were referring to uncontrolled overeating. In nearly half of the groups, participants indicated unfamiliarity with the term "binge eating." There was some confusion between binge eating and other forms of disordered eating. The findings suggest that prevalence rates of self-reported dieting and binge eating behaviors should be interpreted with caution and it should not be assumed that the majority of adolescents who self-report dieting are engaging in unhealthful behaviors. In providing nutrition counseling to youth, and in assessing dieting and binge eating behaviors in clinical settings and in research studies, specific behaviors should be defined.     

Laparoscopic anterior gastroplasty. A preliminary report of a new technique

BACKGROUND: The treatment of the morbidly obese patient is difficult because compliance with dietary regimens is poor. As a result, most weight reduction programs fail very quickly. Surgical treatment, on the other hand, provides a reliable method for sustained weight reduction. The most frequently performed procedure has been the vertical banded gastroplasty. Adaptation of the standard open procedure to laparoscopic techniques has been technically difficult and imprecise. We have developed, in the laboratory, an anterior wall banded gastroplasty that can be performed precisely and reproducibly using laparoscopic techniques. METHODS: Five Yorkshire pigs were used in attempt to laparoscopically perform the standard vertical banded gastroplasty. The procedure was difficult and was associated with a risk of staple line leak and with bleeding along the lesser curvature of the stomach. Furthermore, a reproducible pouch of proper dimension could not be created reliably. Fifteen animals were then used to develop a new technique using a small gastric pouch based on the anterior gastric wall. RESULTS: A reproducible pouch, 4 cm in length, was created over an 18-Fr nasogastric tube. A standard polyproylene band of 5.2 cm in length was utilized at the gastric pouch outlet. CONCLUSIONS: This operation can be reproduced accurately and has not demonstrated any leaks on postmortem examination.     

Medicinal plants and Alzheimer''s disease: Integrating ethnobotanical and contemporary scientific evidence

A patient cannot consent to an operation without being adequately informed. There are a number of different operations in use today for treatment of severe obesity. The variations are designed to (1) limit food intake and/or (2) create malabsorption. The surgeon has a duty, according to the law of informed consent, to provide all of the information necessary for a reasonable person to decide whether to consent to the operation recommended. Changes in anatomy, function and risk therefore need to be explained. When only limitation of intake is planned, as in vertical banded gastroplasty (VBG), the patient should know how large the pouch will be and how the outlet will be stabilized. When both intake restriction and malabsorption are planned, as in Roux-en-Y gastric bypass (RGB), or biliopancreatic diversion (BPD), the patient should know whether there will be a larger pouch (less restriction) and a short common channel (more malabsorption) as in BPD or a smaller pouch and less malabsorption. Patients should know that if they have an operation that uses maximum malabsorption to bring weight to a nearly normal level, the risk of malnutrition will be increased, which may require further hospitalization and possible operative treatment. When the duodenum is to be bypassed, the patient should know that this will impair iron and calcium absorption, and that access to this area for radiologic and endoscopic procedures may not be possible. Simple drawings can be used to explain what is planned and how the operation will determine body weight, side-effects, and risk.     

Gastric bypass for morbid obesity: results and complications

Seventy-five patients underwent a 90 percent distal gastric bypass for morbid obesity. The average weight was 121.4 kilogram, height 164 centimeters, and age 31.4 years in these 70 women and five men. There was a total of 20 surgical complications in the 75 patients, with wound infection being the most common. Sixteen chronic complications were noted and consisted of vomiting, diarrhea, reflux esophagitis, dysphagia, and vitamin deficiencies. None of the above complications were life-threatening or required dismantling of the bypass. Of 54 patients followed for 12 months or more after gastric bypass, there was a 24.5 percent average weight decrease at 6 months, and this progressed to 35.8 percent by 12 months. Fifty-two patients undergoing small bowel bypass previously at the same institution had a 25.4 percent weight reduction at 12 months. Of 54 patients, 83 percent followed for one or more years after gastric bypass have had an excellent or good clinical result, whereas only 42 percent of the 52 patients undergoing small bowel bypass have had an excellent or good clinical result with the same criteria. It is concluded that the Mason 90 percent distal gastric bypass is a suitable form of surgical treatment for the morbidity obese patient who cannot lose weight by dietary measures.     

Management and therapy of postoperative complications after "gastric banding" for morbid obesity

Laparoscopic gastric banding has become a common procedure in bariatric surgery. Early as well as late complications are, in comparison to conventional techniques, rare. Complications arising from the operative technique are: perforation, early pouch dilatation, gastric slippage, infections of the port and the band, erosion and defects of the band tube. Insufficient weight loss and late pouch dilatation arise from unsatisfactory compliance on the part of the patient. In 7.5% of 146 cases, reoperations were necessary. Obstruction of the pouch stoma and a slippage resulted in total food intolerance. After radiologic diagnosis the band system should be deflated first and a naso-gastric tube applied. If this does not result in the pouch collapsing, a revision operation is needed.     

Radiology of ileal pouch-anal anastomosis: normal findings, examination pitfalls, and complications

Ileal pouch-anal anastomosis (IPAA) is a procedure in which an ileal reservoir is constructed after total colectomy and anastomosed to the anus. IPAA is a well-established option for patients who require surgery for chronic ulcerative colitis or familial adenomatous polyposis. Although excellent functional results can be achieved with IPAA, the procedure is associated with an appreciable number of complications, including small bowel obstruction, pouch fistula, anastomotic separation, anastomotic leakage, pelvic infection and abscess, stricture, and pouchitis. However, most of these complications do not require surgical intervention and can be managed with aggressive medical treatment and delay of ileostomy closure. Radiography of the IPAA pouch is routinely performed before closure of the diverting ileostomy to evaluate the integrity of the pouch and anastomosis. Such radiography can demonstrate many of the complications of IPAA, thus allowing identification of patients who may require intervention or delay before closure of the ileostomy.     

Hyperplastic gastric polyp causing progressive gastric outlet obstruction

Hyperplastic polyps represent 75 to 90% of gastric polypoid lesions. The manifestations of these unique gastric neoplasms vary, including abdominal pain, nausea, and vomiting or gastrointestinal bleeding. The vast majority of these lesions are small, asymptomatic, and found incidentally on radiologic evaluation or endoscopic examination of the upper gastrointestinal tract. Herein we describe a large, benign, pedunculated hyperplastic polyp that led to progressive gastric outlet obstruction. In addition, we provide an overview of gastric polyps and a review of the literature. Excision of gastric polyps by endoscopic or surgical means is recommended as prudent treatment to eliminate occurrence of malignant foci.     

Fusiform dilatations of the esophagus secondary to protracted distention and emetogenic injury

We report the case of a 74-year-old woman who presented with a 2-year history of dysphagia, weight loss, nausea, and vomiting. She was diagnosed as having secondary achalasia due to external compression probably by a tumor of the lower part of the esophagus. At autopsy, however, no tumor was found at that site, whereas a pancreatic microcystic serous adenoma and multiple gastric leiomyomata--one of which occupied the pyloric sphincter area leading to gastric outlet obstruction--were noted. The esophagus displayed two fusiform dilatations located at the lower and midportions, the latter being associated with rupture and necrosis of the muscularis and adventitial wall layers. The lower dilatation showed only attenuation of the muscularis, without necrosis. The epithelium was intact in both dilatations. This was an unusual series of pathogenetic events, leading from gastric outlet obstruction to secondary achalasia and protracted vomiting, followed by spontaneous partial esophageal wall rupture (a variant of intramural hematoma) or atrophy of the muscularis, morphologically evident as fusiform dilatations.     

Unusual presentation of hemoptysis in a 78-year-old with previous Nissen fundoplication

A 78-year-old individual, who had a previous transthoracic Nissen fundoplication 20 years earlier, presented to our institution with hemoptysis. Initial workup included chest roentgenogram, upper gastrointestinal series, and upper endoscopy, all of which were nondiagnostic. A repeat upper endoscopy diagnosed a gastrobronchial fistula by revealing a large gastric ulcer that penetrated into the lung parenchyma. The patient underwent surgery for takedown of the fistula. One of the most common symptoms associated with gastrobronchial fistula is hemoptysis, although insidious cough, recurrent pneumonia, or gastrointestinal bleeding are also observed. The most useful diagnostic study is an upper gastrointestinal series, which must be read with a high index of suspicion. Gastrobronchial fistula is most commonly a long-term complication from hiatal hernia repair. The most frequently used procedure for repair of this disorder is the Nissen fundoplication. This can be done from either an abdominal or transthoracic approach. When the procedure is done such that the gastric wrap is left above the diaphragm, serious complications can occur. These include gastric ulceration, gastric herniation with gastric outlet obstruction, slippage or perforation of the wrap, and gastrobronchial fistula. Because of these serious complications, the Nissen fundoplication with the wrap left above the diaphragm should only be used in certain situations, such as obesity and shortened esophagus.     

Gastric myoelectrical activity in patients with gastric outlet obstruction and idiopathic gastroparesis

OBJECTIVE: The cause of gastroparesis may be uncertain in some patients. Mechanical obstruction of the stomach or duodenum should be excluded in patients with idiopathic gastroparesis. The objective of this study was to compare gastric myoelectrical activity in patients with idiopathic gastroparesis with that of patients with gastroparesis due to mechanical obstruction of the stomach or duodenum. METHODS: Electrogastrography techniques were used to record gastric myoelectrical activity in 20 patients with idiopathic gastroparesis and in nine patients with gastroparesis secondary to gastric outlet obstruction. Four of these nine patients initially were thought to have idiopathic gastroparesis. Electrogastrograms (EGGs) were recorded from 29 healthy subjects who served as controls. EGGs were recorded for 20-30 min 2 h after a standard 200-Kcal meal and were analyzed visually and by computer. RESULTS: Patients with gastroparesis due to outlet obstruction had high-amplitude and excessively regular 3-cycles-per-minute (cpm) EGG patterns, whereas patients with idiopathic gastroparesis had primarily 1- to 2-cpm patterns and little 3-cpm EGG activity. The percentage of total EGG power in the 3-cpm range was approximately 50% in patients with gastric outlet obstruction compared with 20% in patients with idiopathic gastroparesis (p < 0.001). The percentage of EGG power in the normal 3-cpm range was greater in the obstructed patients (50%) than in the healthy controls (35%; p < 0.052). CONCLUSIONS: Gastric myoelectrical patterns recorded in the EGG distinguish mechanical and idiopathic causes of gastroparesis and may be useful in evaluating patients with nausea, vomiting, and gastroparesis of unknown cause.     

Safety and long-term durability of completion gastrectomy in 81 patients with postsurgical gastroparesis syndrome

Postsurgical gastroparesis syndrome (PGS) is characterized by postcibal nausea and vomiting and is associated with functional gastric dysmotility. Patients frequently present with marked weight loss and malnutrition requiring hospitalization and prolonged parenteral nutrition. Typically, these patients fail to respond to prokinetic agents. Gastric reoperations are frequent and usually unsuccessful. Near-completion gastrectomy (NCG) has proved useful in small series of patients, but long-term follow-up has been lacking. The purpose of this study is to assess the safety and durability of NCG in a large group of patients with PGS. Eighty-one patients with documented PGS who failed to respond to prokinetic drug therapy were treated with NCG over an 11-year period. NCG was standardized with a 55-cm Roux-en-Y reconstruction. Patients were evaluated by a retrospective chart review and a prospective phone interview that compared pre- and postoperative health status based on a standardized severity of symptoms score. There were no operative deaths or complications related to the anastomosis. Average patient follow-up was 56.1 months (range, 2-142 months). Fifteen patients died of unrelated causes, and 14 patients were lost to follow-up. The remaining 52 patients showed a significant overall decrease in severity of symptoms score largely due to reduction in gastrointestinal symptoms and to a smaller but significant reduction in systemic symptoms. Nearly 80 per cent of patients reported long-term relief of symptoms. NCG is the procedure of choice for carefully selected patients with documented. Low morbidity and durable results can be anticipated in the majority of patients.     

Brush border enzyme activities in the small intestine after long-term gliadin feeding in animal models of human coeliac disease

BACKGROUND: Gastric outlet obstruction is commonly considered a complication of peptic ulcer disease. Malignancy accounts for up to 39% of gastric outlet obstruction. The object of this study was to evaluate the reliability of endoscopic biopsies in excluding malignancy as the cause of gastric outlet obstruction. METHODS: A retrospective study of 40 consecutive patients admitted with gastric outlet obstruction was conducted. Patient demographics, their use of H2-receptor antagonists or nonsteroidal anti-inflammatory drugs, and history of peptic ulcer disease were recorded. Histopathologic results of the endoscopic biopsy and surgical specimen were reviewed. The diagnosis based on the surgical specimen was considered the gold standard. RESULTS: Sixteen patients (40%) had malignant gastric outlet obstruction. Seven patients had gastric adenocarcinoma and nine had extragastric tumors. The patients with malignant obstruction were significantly older (> 55 years) (p = 0.03; odds ratio: 95% CI: 5.21 [1.05-23.49]). Gastric cancer patients had less frequently a history of peptic ulcer disease when compared with patients with benign gastric outlet obstruction (p = 0.04; odds ratio: 95% CI: 5 [1.04-38.13]). Endoscopic biopsy to detect malignant obstruction had poor sensitivity (i.e., 37%) when compared with biopsies of the surgical specimen. In three of seven patients with gastric cancer (40%), repeated jumbo biopsies were negative for malignancy. CONCLUSION: Patients with gastric outlet obstruction who had endoscopic biopsies negative for cancer should be explored surgically before embarking on medical therapy. The surgical exploration is especially important in gastric outlet obstruction patients who are considered at high risk for malignancy, that is, those who are older and have no history of peptic ulcer disease.