Retrospective Clinical Study of Afferent Loop Syndrome Report of 29 cases of postgastrectomy afferent loop obstruction

BACKGROUND: Afferent loop syndrome is an uncommon complication of a gastric resection in which intestinal continuity has been restored by using a gastrojejunostomy. It may cause symptoms at any time from the first postoperative day to many years after the gastrectomy, although most symptoms are manifestated during the second postoperative week. Due to difference in the degree and the permanence of the obstruction, the symptoms and the courses of patients with afferent loop syndrome may be acute or chronic. METHODS: We performed a retrospective clinical analysis of 29 patients who had been treated with operations from January 1982 to December 1996 at the Department of Surgery, Catholic University Medical Center. RESULTS: Afferent loop syndrome occurred in 29 cases (0.46%) of gastric surgery involving 1882 peptic-ulcer cases and 4390 stomach cancer cases. The original conditions requiring gastric surgery were gastric ulcers (8/752, 1.06%), duodenal ulcers (10/1130, 0.88%), and stomach cancer (11/4390, 0.25%). This syndrome occurred more frequently for a truncal vagotomy and a Billroth II type antrectomy (1.76%) than for other surgical procedures. The etiologic factors of afferent loop syndrome were an adhesive band (41.4%), volvulus (24.1%), retroanastomotic internal herniation (20.7%), and stomal stenosis (13.8%). The time interval from the first operation to the onset of symptoms was less than two weeks in 58.6% of the patient. Epigastric pain was the most common symptom (93.1%), followed by nausea and/or vomiting (51.7%), tachycardia (41.3%), and fever (27.5%). The diagnostic procedure mainly performed was an upper gastrointestinal series (69%). Hyperamylasemia was noted in 17 patients (65%). Theoperations performed included a bypass jejunojejunostomy in 17 patients (58.6%), a Roux-en-Y enterostomy in 6 patients (20.7%), a tube duodenostomy in 2 patients (6.9%), a bypass jejunostomy with tube duodenostomy in 2 patients, and a pancreaticoduodenectomy in 2 patients. The postoperative complications were wound infections (34.5%), pleural effusion (13.8%), enterocutaneous fistulas (17.2%), and subphrenic abscesses (13.8%). The operative mortality rate (within 2 months) was 13.8%. CONCLUSIONS: If afferent loop syndrome is suspected, it may be demonstrated by using an upper gastrointestinal contrast study. Endoscopy should be performed in all patients in whom the diagnosis of afferent loop obstruction is suspected. It's main value is to rule out other causes for the patient's complaints, especially in alkaline reflux gastritis. Once the diagnosis is made, surgical correction is indicated. The most satisfactory measure to prevent afferent loop syndrome is to avoid a long afferent loop. If a Billroth I or a Roux-en-Y pattern gastrointestinal anastomosis is difficult, this complication is best avoided by using a short afferent loop and by fashioning the anastomosis to prevent an obstruction at the stoma.

Clinical Analysis of Anatomical Snuffbox Arteriovenous Fistula

This study concerns 110 patients who were underwent anatomical snuffbox arteriovenous fistula at Department of Surgery, Holy Family Hospital, College of Medicine, The Catholic University of Korea, from January 1995 to December 1997. We analysed the overall and success patency rate between diabetic and non-diabetic patients. The results obtained are as follows: 1) 52 operations were performed on male patients and 58, on females. And mean age was 51 years. 2) Average follow-up period was 19 months. 3) Early failure rate of all cases was 17 cases (15%), 2 cases (6%) in diabetic patients and 15 cases (9.7%) in non-diabetic patients. 4) Overall patency rates of all patients were 76.6, 72.0, 68.8 and 64.9% at 6, 12, 18 and 24 months and success patency rates were 90.7, 85.2, 81.4 and 76.8% after creation of anatomical snuffbox arteriovenous fistulas. 5) Overall patency rates of diabetic patients were 78.8, 74.8, 74.8 and 59.8% at 6, 12, 18 and 24 months and success patency rate were 83.4, 79.4, 79.4 and 63.5%. 6) Overall patency rate of non-diabetic patients were 75.9, 71.0, 66.6 and 66.6% at 6, 12, 18 and 24 months and success patency rate were 94.5, 88.4, 83.0 and 83.0%.

A case of Late Occlusion of Femoro-Post Tibial PTFE Graft due to Ectopic Bone Formation

The ectopic bone formation is a condition in which mature lamellar bone is formed in tissues that do not normally ossify, which was first described by Riedel in 1883. It has been observed at sites of chronic infection, hemorrhage, fibrous scarring or contracture. The pathophysiology of ectopic bone formation is not clearly identified but has complex and multifaceted causes, which resulted to differentiate the non-circulating pluripotent mesenchymal cells to osteoblastic stem cells. The local environment conditions of trauma, disruption of soft tissues and periostium, bone debris, hematoma, damaged muscle, uncommitted fibroblasts are suspected to be one of the causes of this condition. Comparing to simple soft tissue calcification, the ectopic bone has all the morphologic and biochemical characteristics of orthotopic bone, which is subjected to turnover and even has the ability for bone marrow formation. A case of late occlusion in a femoro-post. tibial PTFE graft about 5 months after vascular reconstruction due to ectotopic bone formation, which is confirmed by pathology around the graft is presented. After excision of the ectopic bone around the inflow vascular anastomosis site with re-vascularization, the patient was free from the ischemic leg symptoms. We reported a case of occlusion of vascular anastomosis site by ectopic bone formation with review of literature.