Tratamiento endoscópico de la obstrucción del tracto de salida gástrico de origen péptico-cicatricial en un niño de 4 años / Endoscopic treatment of cicatricial pyloric stenosis of peptic origin in a 4-year-old boy

La obstrucción de la salida gástrica es una afección infrecuente en la edad pediátrica. Tradicionalmente, la cirugía ha sido el modo de tratamiento estándar, pero está asociada a mayor morbimortalidad. El tratamiento endoscópico ha surgido como una alternativa al tratamiento convencional. Presentamos el caso de un paciente de 4 años con estenosis prepilórica secundaria a enfermedad ulceropéptica. El cuadro clínico empezó con vómitos y dolor abdominal de 2 meses de evolución. Frente a la falta de respuesta al tratamiento médico y a la dilatación endoscópica con balón, se realizaron incisiones radiadas con electrocauterio e inyecciones de esteroides. La terapéutica endoscópica con balón debería ser el primer gesto terapéutico en este tipo de estenosis refractarias al tratamiento médico

Gastric outlet obstruction is an uncommon condition in children. Traditionally, surgery has been the standard mode of treatment, but it is associated with higher morbidity and mortality. Endoscopic treatment has emerged as an alternative to conventional treatment. We present the case of a 4-year-old patient with refractory prepyloric stenosis secondary to peptic ulcer disease. The picture begins with vomiting and abdominal pain of 2 months of evolution. Pre-pyloric stenosis was confirmed. Faced with the lack of response to medical treatment and balloon dilation, radiated incisions were made with electrocautery and steroid injections. When medical treatment is not sufficient, endoscopic balloon therapy should be the first therapeutic gesture in this type of stenosis; given its refractoriness, we believe it is important to highlight the usefulness of endoscopic treatment, which could prevent surgery and associated morbidity and mortality.

Obstrução gástrica por bezoar / Gastric obstruction due to bezoar

A obstrução por bezoar é um acúmulo de material parcialmente ou não digerido no estômago. Bezoares gástricos são raros e ocorrem com mais frequência em pacientes com transtornos de comportamento, esvaziamento gástrico anormal ou após cirurgia gástrica. Podem ser assintomáticos ou apresentar sintomas como dor abdominal e vômitos incoercíveis. Podem ainda ter composições diversas e ocorrer em todas as faixas etárias. O objetivo deste relato foi demonstrar um caso de bezoar gástrico em paciente previamente submetido à cirurgia bariátrica e internado com quadro de vômitos incoercíveis e hemorragia digestiva alta, com a demonstração de que sua resolução completa ocorreu na realização da segunda endoscopia.

Bezoar obstruction is an accumulation of partially digested or undigested material in the stomach. Gastric bezoars are rare and occur more frequently in patients with behavioral disorders, abnormal gastric emptying, or after gastric surgery. They may be asymptomatic or present with symptoms such as abdominal pain and incoercible vomiting. They can have diverse compositions and occur in all age groups. The aim of this report was to demonstrate a case of gastric bezoar in a patient who previously underwent a bariatric surgery and was hospitalized with incoercible vomiting and upper gastrointestinal hemorrhage, with the demonstration that its complete resolution occurred during the second endoscopy.

EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center

SUMMARY INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

RESUMO INTRODUÇÃO: A gastroenterostomia ecoguiada é um novo procedimento para paliação da obstrução maligna gastroduodenal. Nosso objetivo foi avaliar os resultados dessa técnica em nossa experiência inicial. MÉTODOS: Foram incluídos pacientes com obstrução maligna gastroduodenal de nossa instituição. O sucesso técnico foi definido como a realização adequada de uma gastroenterostomia. O sucesso clínico foi definido como boa aceitação de dieta pastosa durante a internação. Os eventos adversos e a aceitação alimentar foram avaliados um mês após o procedimento. RESULTADOS: Três pacientes foram incluídos. Os sucessos técnico e clínico foram alcançados em todos os casos. Não houve eventos adversos e a aceitação alimentar permaneceu adequada um mês após o procedimento nos pacientes incluídos. CONCLUSÃO: O EUS-GE é um tratamento promissor para pacientes com obstrução maligna gastroduodenal.

Atresia de píloro: comunicación de 3 casos / Pyloric atresia: a report of 3 cases

La atresia de píloro es una malformación digestiva infrecuente. La ecografía prenatal mostrará polihidramnios y dilatación gástrica fetal. En el 20% de los casos, la atresia de píloro se asocia con epidermólisis bullosa, una anomalía cutáneo-mucosa de alta morbimortalidad. En la ecografía prenatal, se podrá ver el signo de los "copos de nieve" en el líquido amniótico y alteraciones auriculares en el feto. Por biopsia corial, se determinan mutaciones genéticas asociadas con epidermólisis bullosa, que confirman la asociación y permiten asesorar a los padres portadores. La herencia es autosómica recesiva y 25% de los hijos pueden manifestarla. El recién nacido con atresia de píloro tendrá vómitos no biliosos y la radiografía abdominal mostrará dilatación gástrica y ausencia de aire intestinal. La atresia de píloro es una malformación corregible quirúrgicamente, con buen resultado. Se presentan tres neonatos con atresia pilórica.

Pyloric atresia is a rare malformation of the alimentary tract. Fetal gastric dilatation and polihydramnios are the main prenatal sonographic findings. In 20% of the cases epidermolysis bullosa is associated. This is a group of genetic anomalies affecting the skin and mucous membranes, which appear fragile and easily blistering. Therefore, this association should be investigated as soon as pyloric atresia is prenatally suspected. The "snow flake" sonographic sign in the amniotic fluid and some irregularities in the fetal's ears could be found and should motivate the investigation of those gene mutations known to be related to epidermolysis bullosa, in order to accomplish an appropriate familial counseling. The parents would be carriers of certain mutation and 25% of the siblings will be affected. A newborn with pyloric atresia will soon exhibit non-bilious vomiting and distention of the upper abdomen. A huge gastric dilatation and a gasless intestine will be apparent in the abdominal plain x-ray. Pyloric atresia is a surgically resolvable malformation. We present herein three patients with this infrequent anomaly.

Can the duration of vomiting predict postoperative outcomes in hypertrophic pyloric stenosis?

Hypertrophic pyloric stenosis [HPS] is a common cause of gastric outlet obstruction [GOO] in infants. Prolonged GOO is believed to result in acid and electrolyte disturbances, gastric atony, and delayed postoperative recovery. We studied the impact of prolonged vomiting as an indicator of GOO symptoms on the post-operative outcomes in HPS. A retrospective chart review of all patients who underwent pyloromyotomy at a tertiary care center between February 1997 and February 2009. The duration of pre-operative vomiting was correlated with presenting electrolytes and acid-base balances, postoperative time to full feed, postoperative morbidity and duration of hospitalization. Forty-seven patients were identified. At presentation, the median [range] for duration of symptoms was 14 [3-60] days, and surgeries were performed at 2 [0-6] days after admission. Apart from one case of postoperative wound infection, all patients had an unremarkable recovery. The unusually prolonged duration of vomiting in our cohort did not correlate with the mean [SD] preoperative chloride level of 93.9 [8.8] mEq/L, mean [SD] pH level of 7.5 [0.9], mean postoperative time to full feeding of 31 [15.1] hours, or mean duration of hospitalization of 5.1 [2.2] days. Duration of vomiting in HPS at presentation does not seem to have a significant impact on the postoperative outcomes

Obstrucción intestinal causada por tricobezoar: Síndrome de Rapunzel / Intestinal obstruction due to a tríchobezoar or Rapunzel Syndrome: report of one case

Rapunzel syndrome or gastrointestinal trichobezoar is caused by hair ingestion. The diagnosis may be suspected in young females with important weight loss, who deny hair eating. We report a 16 year-old female consulting in the emergency room for abdominal pain. She was subjected to an exploratory laparotomy and a big mass was palpated in the stomach. A gastrostomy and enterostomy were performed and a 17x6x5 cm trichobezoar was extracted. The patient had an uneventful postoperative outcome and was derived to Psychiatry.

Effect of early enteral feeding after upper gastrointestinal surgery.

BACKGROUND AND AIMS: The impact of early enteral nutrition in elective upper gastrointestinal surgery was the focus of this study, with particular reference to its feasibility and benefits. METHOD: This prospective study was carried out over 2 years. The study group included 30 patients and the control group had 31patients. Twenty-two patients in each group underwent truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer and gastric outlet obstruction. Eight patients in the study group and nine in the control group underwent gastrectomy for carcinoma stomach. A standard milk-based diet was initiated 12 hours after surgery through a nasojejunal tube. The patients were monitored for side effects of enteral feeding and postoperative infective complications. Nitrogen balance and nutritional parameters like the body weight, serum albumin, and serum transferrin were measured pre and postoperatively. RESULTS: The groups were comparable with respect to age, sex, and preoperative nutritional factors like body weight, serum albumin, and serum transferrin. The return of bowel sounds and passage of flatus took place significantly earlier in the study group (1.43 vs. 2.81 days). Diarrhoea and abdominal cramps were the significant complications noted in the study group in relation to early enteral feeding. No patient required withdrawal of enteral feeds. They showed a positive nitrogen balance on the fourth postoperative day. The patients in the study group showed significant increase in the serum transferrin level compared with the preoperative level but the serum albumin level was not significantly altered. CONCLUSION: Early enteral feeding through the nasojejunal tube following elective upper gastrointestinal surgery is feasible, safe and improves the nutritional status.

Laparoscopic jejuno-jejunostomy for afferent loop stasis following truncal vagotomy with posterior gastro-jejunostomy for pyloric stenosis.

A 47-year-old man presented with epigastric pain relieved by bilious vomiting since one month. He had undergone truncal vagotomy with posterior gastrojejunostomy for benign gastric outlet obstruction 2 years ago. Endoscopy showed distension and stasis in the afferent loop, bile gastritis and esophagitis. Laparoscopic Braun jejunojejunostomy relieved his symptoms.

Gastrojejunostomy for gastric outlet obstruction in patients with gastric carcinoma : general surgery

Objective. To investigate the utility of gastrojejunostomy for the palliation of gastric outlet obstruction in irresectable or incurable gastric carcinoma. Methods. This is a retrospective review of 67 patients who underwent a gastrojejunostomy for gastric outlet obstruction caused by gastric carcinoma between 1 January 1996 and 31 May 2003. Results. There were 19 complications after surgery; including 4 patients with unsatisfactory gastrojejunostomy drainage. Sixty patients were discharged from hospital having resumed normal eating. Their median survival after surgery was 9 months. Conclusion. Gastrojejunostomy offers worthwhile palliation and may prolong survival in a significant group of patients with irresectable gastric carcinoma and gastric outlet obstruction

Effect on gallbladder function subsequent to truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer.

The effect of truncal vagotomy on gallbladder function and on the incidence of lithogenesis has remained controversial. A prospective and retrospective investigational study was undertaken to evaluate the effect of truncal vagotomy and gastrojejunostomy on gallbladder function. The study included a total of 76 patients and 77 controls. In Group I (Prospective group), 32 consecutive patients with chronic duodenal ulcer and gastric outlet obstruction undergoing truncal vagotomy and gastrojejunostomy were included. Group II included 25 age and gender matched controls (prospective group). Group III included 44 patients who had undergone truncal vagotomy and gastrojejunostomy 3 years or more prior to presentation (Retrospective group) and Group IV included 52 age and gender matched controls for the retrospective group. The patients in the prospective groups were followed up for a period of 1 year. An alkaline tide test was done in the prospective and retrospective group to assess for the completeness of vagotomy. Gallbladder contractile response to fatty meal and the presence of stones and sludge were noted in all the four groups by ultrasonography. There were 30 patients in the prospective group and 40 in the retrospective group after excluding patients with incomplete vagotomy. On ultrasound examination, there was no significant difference in the gallbladder volume and contractility of the study group when compared with the controls. Gallbladder sludge was found in 16 to 25% of patients in the prospective group (group I) during follow up, where as similar finding was documented in 8% of the matched control (group II (P>0.1). However, in the retrospective (group III) 10% (4 out of 40) had calculi and 20% of patients demonstrated sludge which was significantly higher when compared with the controls (p = 0.001). Truncal vagotomy and gastrojejunostomy did not affect gallbladder contractility, but it might predispose to the formation of sludge and subsequent calculi in a proportion of patients in long term.

Tricobezoares gastroduodenales: una causa poco frecuente de obstrucción del tracto de salida / Gastro-duodenal Trichobezoars: a rare cause of obstruction of the gastrointestinal tract

Antecedentes: el tricobezoar representa el 55% de los bezoares en el hombre. El 90% de los casos son mujeres y el 40% presentan trastornos psiquiátricos. Objetivo: evaluar el motivo de consulta y la metodología diagnóstica y terapéutica realizada en pacientes con tricobezoares. Diseño: análisis retrospectivo de historias clínicas y reporte de casos. Método: se incluyeron 4 pacientes, desde enero de 2000 hasta marzo de 2004, 3 mujeres y 1 varón, con una edad media de 32.3 años (rango 22 a 37 años). Resultados: todos los pacientes presentaron tumoración epigástrica no dolorosa, dispepsia, vómitos biliosos y pérdida de peso de 5 a 25 kg. En 3 se realizó una seriada esófago-gastroduodenal (SEGD) y en todos ecografía, tomografía computada (TAC) y videoendoscopía alta (VEDA). Todos recibieron tratamientos endoscópicos con intención de remoción, sin lograr el objetivo. Todos negaron tricofagia y tenían patología psiquiátrica. El tratamiento quirúrgico fue gastrotomía con exéresis del tricobezoar. El peso medio fue de 1.100 g (rango 700 a1.500 g). Conclusiones: el tricobezoar es una rara causa de obstrucción del tracto de salida. El diagnóstico debe ser sospechado por clínica y SEGD, y confirmado por VEDA y TAC. El tratamiento de elección es el quirúrgico. No obstante se han descripto otros tratamientos como la fragmentación endoscópica, la litotripsia extracorpórea y, recientemente, el abordaje laparoscópico.

Anterior or posterior gastro-jejunostomy with truncal vagotomy for duodenal ulcer--are they functionally different?

Truncal vagotomy with gastrojejunostomy (GJ) is the standard treatment for chronic cicatrizing duodenal ulcer with gastric outlet obstruction. We tried to determine if a significant functional difference exists in the early and late outcomes following anterior and posterior types of GJ to treat this condition. The case records of 106 patients who underwent truncal vagotomy and GJ at our institute from 1 January 1995 to 31 December 1999 were studied retrospectively. Patients were followed up with a personal interview. Perioperative and long-term parameters were compared in the anterior and posterior G.I. groups. Sixty-five patients (61.32%) were followed up; 31 in the anterior group and 34 in the posterior group. The median follow-up was 5 years (range 2.5-7.5 years). Except for a significant difference in length of afferent loop (p < 0.0001), there were no significant differences in the duration of hospital stay, nasogastric aspirates on postoperative days 1, 2, 3 and 4 and the day the nasogastric tube was removed. Early postoperative complications were uncommon and not different in the two groups and long-term outcomes were similar. The Anterior GJ, being technically easier and needing less operative time, may be advocated in all cases of chronic duodenal ulcer, with gastric outlet obstruction requiring truncal vagotomy and drainage.

Mercedes-Benz pyloroplasty: a new technique.

Closure of large duodeno-pyloro-gastrotomy can be difficult. The resulting 'pyloroplasty' may lead to major deformity at the gastric outlet. We describe a technique that combines features of the Heineke-Mikulicz pyloroplasty and V-Y plasty. The technique is simple and is not associated with any new post-operative problem.

What happens to Helicobacter pylori after vagotomy and drainage?

H. pylori is currently identified as the dominant risk factor for chronic duodenal ulcer. The effect of surgery in the form of truncal vagotomy and drainage on the H. pylori status is not well known. Forty three patients with obstructed duodenal ulcer who were positive for H. pylori preoperatively by the urease test on the antral mucosal biopsy specimens were recalled for repeat endoscopy and urease test from the same site at 1 month, 3 months, 6 months and more than 1 year after surgery. The H. pylori positivity declined from 100% preoperatively to 69%, 71%, 73% and 80% at these intervals postoperatively respectively. The fall in H. pylori status after surgery was significant at all intervals. Since surgery for duodenal ulcer in the form of truncal vagotomy and drainage is curative for duodenal ulcer in over 90% of patients whereas H. pylori is suppressed in approximately 20% of patients only, it appears that its effect is independent of H. pylori status. Further studies are required to confirm whether a fall in H. pylori positivity in the antrum is absolute or is due to proximal migration of the organism.

Tribezoar gigante associado a maus-tratos na infância: relato de um caso / Giant trychobezoar associated to child abuse and neglect: a case report

Relata-se o caso de uma paciente de 9 anos portadora de tricotilomania que desenvolveu um tricobezoar gigante e a associaçäo deste com maus-tratos. Säo revisados os principais tipos de bezoar, bem como suas apresentaçöes clínicas, diagnósticos e terapêuticas. Ressalta-se a importância do diagnóstico diferencial de patologias gástricas em crianças, a necessidade do tratamento dos estressores psicológicos que levam à tricotilomania e o papel da endoscopia digestiva associada à cirurgia no manejo destes casos