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Resumen La intususcepción yeyunogástrica es una complicación rara, pero potencialmente fatal de acuerdo con el momento de su diagnóstico e intervención. Debido a su baja incidencia, se requiere de una alta sospecha diagnóstica, basada en la clínica y los antecedentes quirúrgicos. En el presente reporte se expone el caso de un paciente de 74 años, con historia de gastroyeyunostomía y cerclaje duodenal realizados como parte del manejo de úlcera duodenal 20 años atrás. Se presentó por urgencias luego de 7 días de inicio de los síntomas caracterizados por dolor, intolerancia a la vía oral y hematemesis. Su diagnóstico se realizó mediante endoscopia de vías digestivas altas y su manejo definitivo, mediante gastrectomía subtotal y reconstrucción en Y de Roux transmesocólica por laparotomía.
Abstract Retrograde jejunogastric intussusception is a rare but potentially fatal complication, according to the time of diagnosis and intervention. Due to its low incidence, a high diagnostic suspicion is required, based on the clinical and surgical history. This study presents the case of a patient of 74 years old with a history of gastrojejunostomy and duodenal cerclage performed as part of duodenal ulcer treatment 20 years ago. The patient was admitted to the emergency unit, after 7 days of having symptoms such as pain, intolerance to oral intake, and hematemesis. Diagnosis was performed by upper digestive tract endoscopy and the final treatment by subtotal gastrectomy and transmesocolic Roux-en-Y reconstruction by laparotomy.
Subject(s)
Humans , Male , Aged , Gastrectomy , Intussusception , Jejunum , Literature , Pain , Gastric Bypass , Hematemesis , Gastrointestinal Tract , Duodenal UlcerABSTRACT
Introdução: A prática do jejum pré-operatório se consolidou no século XX e prosseguiu praticamente inalterada até os anos 80, onde passou a ser reestruturada. Diante disso, o presente artigo tem o intuito de realizar uma revisão sobre o jejum pré operatório orientado na literatura comparando-o com o que é encontrado dentro da realidade brasileira. Metodologia: Trata-se de um estudo de revisão da literatura, de natureza exploratória, realizada por meio de pesquisa de artigos científicos, dissertações e teses disponíveis nas bases de dados online. Resultados: a American Society of Anesthesiologists desenvolveu a Task "Force on Preoperative Fasting" que estabelece para líquidos claros um jejum mínimo de 2 horas e para dieta leve de 6 horas. No Brasil, um estudo com 3.175 pacientes revelou que 46% deles jejuaram por um período superior a 12 horas. DiscussaÌo: Além de não aumentar a possibilidade de danos, observa-se que a redução do tempo de jejum pré-operatório está associada a benefícios no processo de recuperação do paciente. Dentre as causas para o jejum prolongado nas instituições de saúde do Brasil estão o atraso nas operações, a transferência de horário e de período ou o seu adiamento para o próximo dia. Conclusão: o aprimoramento do jejum pré-operatório é necessário, tendo como estratégia a melhor comunicação entre equipes médicas e de enfermagem e o paciente atendido nas instituições hospitalares. (AU)
Background: The practice of preoperative fasting was consolidated in the twentieth century and remained unchanged until the 1980s, when it was questioned. Therefore, the present article aims to review the preoperative fasting oriented in the literature comparing it with what is found in Brazilian reality. Methods: This is an exploratory literature review study, conducted through research of scientific articles, dissertations and theses available in online databases. Results: The American Society of Anesthesiologists has developed the Task Force on Preoperative Fasting, which establishes for clear liquids a minimum fasting of 2 hours and 6 hours for a light diet. In Brazil, a study with 3,175 patients revealed that 46% of them fasted for more than 12 hours. Discussion: In addition to not increasing the possibility of damage, it is observed that the reduction of preoperative fasting time is associated with benefits in patient's recovery process. Causes of prolonged fasting in Brazilian health institutions include delayed operations, changes on time and period, or postponement to the next day. Conclusions: the improvement of preoperative fasting is necessary, having as strategy a better communication between medical and nursing teams and the patients treated at hospitals. (AU)
Subject(s)
Humans , Fasting , Preoperative Period , Physician-Patient Relations , Postoperative Complications/prevention & control , Time Factors , Intraoperative Complications/prevention & control , Nurse-Patient RelationsABSTRACT
Objective To explore the clinical efficacy of modified totally laparoscopic intra-gastric surgery for the treatment of submucosal tumors adjacent to the cardia or pylorus.Methods The retrospective crosssectional study was conducted.The clinicopathological data of 48 patients with gastric submucosal tumors adjacent to the cardia or pylorus between September 2014 and March 2018 were collected.There were 22 males and 26 females,aged from 38 to 78 years,with an average age of 58 years.Patients were performed multi-port or singleport modified laparoscopic intra-gastric surgery.Observation indicators:(1) surgical treatments;(2) postoperative recovery;(3) results of postoperative pathological examination;(4) follow-up.Patients were followed up by outpatient examination and telephone interview to detect the postoperative complications and tumor metastasis and recurrence up to June 2018.Measurement data with normal distribution were expressed as Mean±SD and measurement data with skewed distribution were described as M (range).Count data were represented as absolute number or percentage.Results (1) Surgical treatments:48 patients underwent modified totally laparoscopic intra-gastric surgery successfully,including one patient combined with proximal gastrectomy,without conversion to open surgery.Of the 48 patients,43 underwent multi-port modified laparoscopic intra-gastric surgery and 5 underwent single-port modified laparoscopic intra-gastric surgery.The operation time and volume of intraoperative blood loss were 68 minutes (range,45-110 minutes) and 20 mL (range,5-100 mL).The oncologic evaluation of 48 patients:48 patients had complete resection of tumors,without tumor rupture.The tumor diameter and distance from margin to tumor were 32 mm (range,20-40 mm) and 6 mm (range,5-10 mm).(2) Postoperative recovery:the time for initial oral intake and duration of postoperative stay were 2.8 days (rang,1.0-5.0 days) and 5.3 days(range,3.0-11.0 days).There were 4,3,1 and 1 patients complicated with surgical infection,delayed gastric emptying,sub-phrenic hydrops and digestive leakage respectively in the 48 patients.(3) Results of postoperative pathological examination:the distance from tumor margin to gastric cardia or pylorus,tumor diameter,circumferential resection margin were 15 mm (range,0-30 mm),24 mm (range,10-65 mm),6 mm (range,5-10 mm),respectively.Growth patterns of cancer in the 48 patents included 27 of intraluminal type,12 of intermural type,9 of mixed type.Pathological types of 48 patients:there were 26 patients with leiomyoma,9 with gastrointestinal stromal tumor,4 with other rare tumors,2 with carcinoid,2 with mucosa associated lymphoma,2 with inflammatory fibrous polyps,2 with gastritis cystica profunda,1 with ectopic pancreas.(4) Follow-up:41 of the 48 patients were followed up for 3-48 months,with a median follow-up time of 22 months.No tumor recurrence was detected in 37 of 41 patients by 3 times of gastroscopy and no stenosis or dysfunction of cardia or pylorus was detected in 39 patients by 2 times of upper gastrointestinal imaging (one patient undergoing two examinations).During the follow-up,there was no surgery-related complication or tumorspecific death.Conclusion Modified totally laparoscopic intra-gastric surgery is safe and feasible for the treatment of gastric submucosal tumors adjacent to the cardia or pylorus.
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The data of evidence-based medicine clinicaltrials and large databases showed that anastomotic leakage,pancreatic leakage and abdominal abscess were the most common complications after gastrectomy,and the complication rate was about 20％ and mortality rate was about 1％.Postoperative complications criteria of gastric surgery is mainly used Clavien-Dindo classification of surgical complications,Common Terminology Criteria for Adverse Events (CTCAE v4.0) and Japanese Clinical Oncology Group (JCOG) as evaluative standard.The performance status,American Society of Anesthesiologists score,physiological operative severity score for enumeration of mortality and morbidity (POSSUM),E-PASS scoring system,acute physiology and chroaic health evaluation (APACHE Ⅱ),Charlson comorbidity index and frailty score were used in predicting postoperative mortality and morbidity in gastric cancer patients.Authors can objectively evaluate risk of surgery and reasonably use these scoring systems for perioperative management.
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Apresenta-se o caso de um homem, 57 anos, submetido a uma antrectomia com reconstrução a Billroth II devido a uma úlcera péptica sangrante, que evoluiu no quarto dia de pós-operatório com intuscepção anterógrada jejuno-jejunal, causando síndrome da alça aferente.
Its reported a case of a 57-year-old male, who underwent an antrectomy with Billroth II reconstruction because of an bleeding peptic ulcer, that evolved in the fourth day postoperatively with a anterograde jejunojejunal intussusception causing afferent loop syndrome.
Subject(s)
Humans , Male , Middle Aged , Gastroenterostomy , Gastroenterostomy/adverse effects , Afferent Loop Syndrome , Gastrectomy , IntussusceptionABSTRACT
BACKGROUND: Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. While gastrointestinal surgery is relatively common in Korea, few studies have evaluated SSI in the context of gastric surgery. Thus, we performed a prospective cohort study to determine the incidence and risk factors of SSI in Korean patients undergoing gastric surgery. MATERIALS AND METHODS: A prospective cohort study of 2,091 patients who underwent gastric surgery was performed in 10 hospitals with more than 500 beds (nine tertiary hospitals and one secondary hospital). Patients were recruited from an SSI surveillance program between June 1, 2010, and August 31, 2011 and followed up for 1 month after the operation. The criteria used to define SSI and a patient's risk index category were established according to the Centers for Disease Control and Prevention and the National Nosocomial Infection Surveillance System. We collected demographic data and potential perioperative risk factors including type and duration of the operation and physical status score in patients who developed SSIs based on a previous study protocol. RESULTS: A total of 71 SSIs (3.3%) were identified, with hospital rates varying from 0.0 - 15.7%. The results of multivariate analyses indicated that prolonged operation time (P = 0.002), use of a razor for preoperative hair removal (P = 0.010), and absence of laminar flow in the operating room (P = 0.024) were independent risk factors for SSI after gastric surgery. CONCLUSIONS: Longer operation times, razor use, and absence of laminar flow in operating rooms were independently associated with significant increased SSI risk after gastric surgery.
Subject(s)
Humans , Cohort Studies , Cross Infection , Hair Removal , Incidence , Korea , Multivariate Analysis , Operating Rooms , Prospective Studies , Risk Factors , Tertiary Care CentersABSTRACT
BACKGROUND: Surgical site infection (SSI) is prominent among the total incidence of healthcare-associated infections, and is a major contributing factor in the trend of increasing medical costs. There have been numerous efforts to analyze the conditions and causes of SSI for the purpose of prevention. In this study of SSI development after gastric surgery, we evaluated the prevalence of specific pathogens and compared the clinical characteristics observed between gram-positive (GPB) and gram-negative bacteria (GNB). MATERIALS AND METHODS: We conducted a retrospective study of patients who developed SSI within 30 days after gastric surgery at 13 clinics in Korea, between January 2007 and December 2008. Only those cases of SSI which included confirmed pathogen were included in this study. RESULTS: Among the 121 patients who developed SSI, GPB were observed in 32 patients and 36 cases, and GNB were isolated in 32 patients and 36 cases. Methicillin resistant Staphylococcus aureus (MRSA) was the most frequently isolated pathogen in this analysis. There were no differences observed between the GPB and GNB group in terms of baseline characteristics, patient or procedure related risk factors, or factors associated with prophylactic antibiotics. CONCLUSIONS: In the previous studies of the occurrence of SSI after gastric surgery, it was reported that the majority of observed pathogens were enteric GNB. Further studies of the incidence of SSI after gastric surgery, particularly those related to MRSA infection, are necessary.
Subject(s)
Humans , Gram-Negative Bacteria , Gram-Positive Bacteria , Incidence , Korea , Methicillin Resistance , Methicillin-Resistant Staphylococcus aureus , Prevalence , Retrospective Studies , Risk Factors , Staphylococcus aureusABSTRACT
Jejunogastric Intussusceptions is a rare but potentially life threatening complication of a previous gastrectomy or gastrojejunostomy. A 70 years old man presented with severe epigastric pain followed by haematemesis, 8 years after truncal vagotomy and gastrojejunostomy for pyloric stenosis. Ultrasonography revealed dilated stomach with a large intragastric mass which has minimal peristaltic movement. Endoscopy of upper GIT revealed prolapsed segment of jejunal loops through the gastrojejunostomy stoma. Laparotomy disclosed a retrograde type II jejunogastric intussusception and was managed by reduction of jejunogastric intussusception, resection of gangrenous segment and end to end anastomosis. Post operative recovery was uneventful. Retrograde jejunogastric intussusceptions is a rare condition and around 200 cases has been reported since its first description in 1914. Urgent recognition and surgical treatment is mandatory to reduce the mortality rate from this complication.
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Minimal invasive surgery (MIS) became popular after the success of laparoscopic cholecystectomy. Since then, the role of laparoscopy has expanded widely to accommodate different type of surgical procedures, both benign and malignant. Laparoscopy surgery has many benefits, including less postoperative pain, less hospital stay, faster recovery of bowel motility, and better cosmetic result. For gastric surgery include pepticulcer, benign tumors, early gastric cancer and advanced gastric cancer, laparoscopic surgery was not exceptional. In aspect of technique, almost open procedures are reproduced aparoscopically. However, in aspect of evidence based medicine, we have to wait some evidence. The purpose of this article is to review the recent current status with literature review and propose the future of laparoscopic gastric surgery.
Subject(s)
Cholecystectomy, Laparoscopic , Cosmetics , Evidence-Based Medicine , Laparoscopy , Length of Stay , Pain, Postoperative , Stomach , Stomach NeoplasmsABSTRACT
Laparoscopic gastric surgeries are routinely performed with use of a nasogastric tube to decompress the upper gastrointestinal tract. A distended upper gastrointestinal tract can complicate successful laparoscopic gastric surgery as the distention compromises not only the visual field but also the laparoscopic manipulation of the stomach. Since nasogastric intubation is not without risks, we have attempted laparoscopic-assisted gastric cancer surgeries without nasogastric tubes. In this article we describe a simple method of aspirating gastric contents using a 9 cm long 19-gauge needle inserted percutaneously during laparoscopic-assisted gastrectomy. First, a 9 cm long 19-gauge disposable needle was introduced through the abdominal wall. This needle was then introduced to the stomach through the anterior wall and the stomach gases and fluids were aspirated by connecting the needle to suction. Thus, a collapsed upper gastrointestinal tract was easily obtained. We performed this procedure instead of nasogastric decompression on twenty-two patients with gastric cancer who underwent laparoscopic-assisted distal subtotal gastrectomy with lymph node dissection. The results were good with only one patient experiencing wound infection (4.5%) and one patient with postoperative acalculus cholecystitis (4.5%). There were no patients with either intraabdominal infection or anastomotic leakage and none of the patients needed postoperative nasogastric decompression, except the patient who experienced acaculus cholecystitis. Percutaneous needle aspiration is a very simple and efficient technique with little risk of postoperative complications. It can be used as an alternative to nasogastric tube decompression of the gastrointestinal tract for laparoscopic-assisted gastrectomy.
Subject(s)
Middle Aged , Male , Humans , Female , Aged , Adult , Stomach Neoplasms/surgery , Laparoscopy/methods , Intubation, Gastrointestinal/methods , Intraoperative Period , Gastrectomy/methods , Decompression, Surgical/methodsABSTRACT
PUPOSE: The use of laparoscopic surgery for gastric disease has been gaining popularity. However, there has been the controversy over the indications and the standard techniques of laparoscopic gastric surgery in the early gastric cancer (EGC). The purposes of this study were to compare the clinical outcomes among a hand-assisted laparoscopic distal gastrectomy (HALDG), a laparoscopy-assisted distal gastrectomy (LADG), and an open distal gastrectomy (ODG) and to discuss the role of these procedures in the treatment of EGC. MATERIALS AND METHODS: Between August 2001 and July 2004, laparoscopic surgery was performed in our institution on 25 patients, LADG (n=7) and HALDG (n=18) with EGC. Analysis was performed on clinical data such as the operative time, the hospital stay, the start of oral intake, and the number of harvested lymph nodes. Patients were categorized into early and late groups by using the date of surgery and were also grouped by surgical procedure. To evaluate the feasibility and efficacy of laparoscopic surgery for EGC, we compared the clinical data with those for ODGs performed during the same period. RESULTS: There was no difference in the number of harvested lymph nodes between the laparoscopic group and the open group, but the operation time in the laparoscopic group was longer than that in the open group (P<0.05). Also, no significant differences in other clinical data were found between the two groups. Comparing the early and the late periods of the series, the number of harvested lymph nodes for a HALDS increased from 22.31 4.29 to 29.40 3.21 (P<0.05). CONCLUSION: Our early experience with laparoscopic gastric surgery shows that a wide range of possibilities exist for applying laparoscopic gastric surgery to selected gastric cancer patients. However, the surgical procedure should be standardized, and the outcomes of laparoscopic surgery, in comparison to those of open surgery, need to be confirmed based on a large randomized study.
Subject(s)
Humans , Gastrectomy , Laparoscopy , Length of Stay , Lymph Nodes , Operative Time , Stomach Diseases , Stomach NeoplasmsABSTRACT
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.
Subject(s)
Humans , Academic Medical Centers , Adhesives , Afferent Loop Syndrome , Constriction, Pathologic , Diagnosis , Duodenal Ulcer , Duodenostomy , Endoscopy , Enterostomy , Fever , Gastrectomy , Gastric Bypass , Gastritis , Gastroenterostomy , Hyperamylasemia , Intestinal Fistula , Intestinal Volvulus , Jejunostomy , Mortality , Nausea , Pancreaticoduodenectomy , Pleural Effusion , Postoperative Complications , Retrospective Studies , Stomach Neoplasms , Stomach Ulcer , Subphrenic Abscess , Tachycardia , Vagotomy, Truncal , Vomiting , Wound InfectionABSTRACT
BACKGROUND: Endoscopic mucosal resection (EMR) is now in clinical use for the management of mucosal and submucosal tumors of the stomach (including early gastric cancer), but its use is limited by the size, depth, and the location of the tumor. METHODS: After the introduction of a new concept of laparoscopic intra-gastric surgery (L.I.G.S.) in which all trocars and surgical instruments are inserted directly into the gastric cavity to perform the resection of mucosal or submucosal lesions of the stomach by Dr. Ohashi, sixteen patients with a mucosal or a submucosal tumor in the posterior wall of the stomach have been successfully treated by L.I.G.S. in our hospital since 1995. RESULTS: 2 patients with early gastric cancer, 9 with a leiomyoma, and 5 with polyps. Twelve (87.5%) of the tumors were located in the antrum and 4 (12.5%) in the body. L.I.G.S. was successfully done on 14 patients (93%) with conversion to a minilaparotomy in 1 patient. The leiomyoma located in the lesser curvature was treated by L.I.G.S. through an anterior gastrotomy using hand suturing. The operationg time was about 100-160 minutes for the L.I.G.S., 120 minutes in the conversion case, and 180 minutes in the L.I.G.S. through an anterior gastrotomy. Postoperative pain was negligible in all cases, and the patients were discharged uneventfully six to seven days after surgery. The follow-up period was 1 to 37 months, and there were no recurrences. The important points of this approach are confirmation of the location of the tumor by both gastrofiberscopy and laparoscopy, excluding the determination of regional lymph node metastasis by endoscopic ultrasonography, and proper selection of the trocar sites. CONCLUSION: We conclude that L.I.G.S. is technically feasible, safe, and useful for a mucosal or a submucosal tumor in the posterior wall of the stomach and that it should be considered as a viable alternative to endoscopic mucosal resection and conventional gastric resection.
Subject(s)
Humans , Endosonography , Follow-Up Studies , Hand , Laparoscopy , Laparotomy , Leiomyoma , Lymph Nodes , Neoplasm Metastasis , Pain, Postoperative , Polyps , Recurrence , Stomach , Stomach Neoplasms , Surgical InstrumentsABSTRACT
BACKGROUND : Prophylactic nasogastric decompression is used routinely after elective gastric surgery in spite of many disadvantages and complications - discomfort, pain, especially postoperative atelectasis. The aim of this study was to determine whether routine nasogastric decompression benefitted patients undergoing elective stomach operations. METHODS : Two hundreds forty patients were studied prospectively. All patients underwent elective gastric surgery from January 1994 to March 1996 by one surgeon at Gospel Hospital. In the intubated group, 120 consecutive patients were treated with a nasogastric tube (silastic, 16 French) just before or during the operation, it being removed on the 1st or the 2nd postoperative day. In the tubeless group, a nasogastric tube was not inserted at all in 120 consecutive patients. We compared the differences between two groups with respect to the mean duration of flatus passing, the incidence of postoperative pulmonary complication, leakage, reoperation, wound dehiscence, and operation mortality. RESULTS : The two groups showed no significant differences in age, sex and operation methods. Flatus passed earlier in the tubeless group, but the difference was statistically insignificant. The patients suffering from atelectasis were much larger in number in the intubated group (p<0.03). There were no significant differences in the incidence of anastomotic leakage, wound dehiscence, reoperation and operation mortality. CONCLUSIONS : The routine omission of nasogastric intubation was not associated with increased risks, such as leakage, wound dehiscence, reoperation, postoperative pulmonary complication, delayed flatus passing or diet intake, operative morbidity and motality. Conversely, the incidence of postoperative atelectasis was twice as high in the intubated group. We conclud that routine nasogastric intubation should be used only in specific cases and routine use of nasogastric intubation is not justified.