Laparoscopic Truncal Vagotomy and Gatrojejunostomy for Pyloric Stenosis

PURPOSE: Peptic ulcer disease (PUD) remains one of the most prevalent gastrointestinal diseases and an important target for surgical treatment. Laparoscopy applies to most surgical procedures; however its use in elective peptic ulcer surgery, particularly in cases of pyloric stenosis, has not been popular. The aim of this study was to describe the role of laparoscopic surgery and an easily performed procedure for pyloric stenosis. We accordingly performed laparoscopic truncal vagotomy with gastrojejunostomy in 10 consecutive patients with pyloric stenosis. METHODS: Data were collected prospectively from all patients who underwent laparoscopic truncal vagotomy with gastrojejunostomy from August 2009 to May 2014 and reviewed retrospectively. RESULTS: A total of 10 patients underwent laparoscopic trucal vagotomy with gastrojejunostomy for peptic ulcer obstruction from August 2009 to May 2014 in oo university hospital. The mean age was 62.6 (+/-16.4) years old and mean BMI was 19.3 (+/-2.5) kg/m2. There were no conversions to open surgery and no occurrence of intra-operative complications. The mean operation time was 107 (90~130) minutes and blood loss was < 20 ml. Oral feeding was permitted for most patients on day 3 post operatively after upper gastrointestinal series to confirm no leakage or passage disturbance. The mean hospital stay was 7.3 days, the mean follow up duration was 19.8 (+/-17.2) months, and there was no mortality related to the operation. CONCLUSION: Laparoscopic truncal vagotomy and gastrojejunostomy was a good, easily performed surgical choice for patients with duodenal ulcer stricture.

Gastrojejuno-colic fistula after gastrojejunostomy / 대한외과학회지

Gastrojejunocolic fistula is a rare condition after gastrojejunostomy. It is severe complications of gastrojejunostomy, which results an inadequate resection or incomplete vagotomy during peptic ulcer surgery. The symptoms are diarrhea, upper abdominal pain, bleeding, vomiting and weight loss. A 55-year-old man with chronic diarrhea and weight loss for 6 months visited Dankook University Hospital. The patient had received a truncal vagotomy and gastrojejunostomy for duodenal ulcer obstruction 15 years previously. The patient underwent gastroscopy and upper gastrointestinal series evaluations, which detected the gastrojejunocolic fistula. After improving of malnutrition, an exploratory laparotomy was undertaken, which revealed that the gastrojejunostomy site and the T-colon formed adhesion and fistula. En block resection of the distal stomach and T-colon included the gastrojejunocolic fistula, and Roux-en-Y gastrojejunostomy was performed. Recovery was uneventful and the patient remained well at the follow-up. We report a gastrojejunocolic fistula, which is a rare case after gastrojejunostomy.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment / Derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular: uma nova proposta para o tratamento do diabetes melito tipo 2

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

OBJETIVO: Avaliar a eficácia da operação de derivação biliopancreática com exclusão duodeno-jejunal associada com vagotomia troncular em doentes com diabetes tipo 2 com sobrepeso ou obesidade classe I ou II. MÉTODOS: Foram estudados dez doentes com diabetes melito tipo 2 e sobrepeso ou obesidade grau I ou II submetidos à derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular. Os valores de glicemia no pré e no pós-operatório foram comparados pelo teste de Friedman. O nível de significância adotado foi de 5%. RESULTADOS: Houve diferença significante (p=0,01) nas glicemias pré e pós-operatórias de três meses, de seis meses (p=0,001) e de 12 meses (p=0,001). Houve diferença significante entre a glicemia pós-operatória de um mês e glicemia pós-operatória de seis meses (p=0,01). O nível de hemoglobina glicosilada reduziu-se em 80% dos doentes, houve melhora acentuada do perfil lipídico e a média da redução do IMC foi de 7,0±1,5 kg/m² após 12 meses da operação. CONCLUSÃO: No paciente com diabetes melito tipo 2 associado com sobrepeso ou obesidade grau I/II, a realização da derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular proporcionou controle glicêmico, redução do excesso de peso e melhora do perfil lipídico após 12 meses da operação.

Partial gastrectomy associated to anterior truncal vagotomy: alterations in metabolism of the calcium. experimental study in rats / Gastrectomia parcial e vagotomia troncular anterior: alterações no metabolismo de cálcio. estudo experimental em ratos

BACKGROUND: The calcium is not absorbed in the lack of hydrochloric acid and the osteomalacia and osteoporosis may occurs; it is well recognized in patients that had gastric resection. AIM: To evaluate the effects of the partial gastrectomy associated to anterior truncal vagotomy in the absorption and metabolism of calcium. METHODS: Eighteen adults male Wistar rats were submitted to partial gastrectomy associated to anterior truncal vagotomy (GXT, eight animals) and the sham operation (10 animals, control group). The diet consumption and the weight gains of the animals were measured three times during the week. The animals received formulated experimental diet orally (AIN-93M) by eight weeks. The serum calcium, urinary and fecal calcium, apparent absorption of the calcium, activity of the enzyme alkaline fosfatase and calcium in the bone were measured after 60 days. RESULTS: The sham operated animals showed higher diet consumption, weight gains, serum and urinary calcium, excretion of calcium in feces, apparent absorption of calcium and activity of the enzyme alkaline fosfatase (P<0,05) as compared to the animals of the gastrectomized group. However, the concentration of the bone calcium was increased in the animals of the gastrectomized group. CONCLUSION: Partial gastrectomy associated to anterior truncal vagotomy showed to be a good experimental model the study calcium metabolism, decreasing the calcium absorption, serum and urinary calcium and activity of the enzyme alkaline fosfatase. However, for alterations at bone level in rats suggests an experimental study in larger period.

RACIONAL: O cálcio não é absorvido na ausência de ácido clorídrico e a osteomalácia e osteoporose podem ocorrer; este fato é bem reconhecido em pacientes que se submeteram à gastrectomias. OBJETIVO: Avaliar os efeitos da gastrectomia parcial associada à vagotomia troncular anterior na absorção e metabolismo de cálcio. MÉTODOS: Dezoito ratos Wistar machos e adultos foram submetidos à gastrectomia parcial e vagotomia troncular anterior (oito animais) e à laparotomia simples como grupo controle (10 animais). O consumo de dieta e o peso dos animais foram monitorados três vezes por semana. Os animais receberam dieta oral formulada experimentalmente (AIN-93M), durante 8 semanas. O cálcio sérico, cálcio urinário e fecal, absorção aparente de cálcio, atividade da enzima fosfatase alcalina e cálcio ósseo foram mensurados após 60 dias de observação. RESULTADOS: Os animais controle apresentaram médias estatísticas maiores (P<0.05) para o consumo de dieta, ganho de peso, cálcio sérico, cálcio urinário, excreção de cálcio nas fezes, absorção aparente de cálcio e atividade da enzima fosfatase alcalina comparados aos animais do grupo gastrectomizado. Entretanto, a concentração de cálcio ósseo foi superior no grupo de animais gastrectomizados (P<0,05) quando comparado com o grupo controle. CONCLUSÃO: A gastrectomia parcial associada à vagotomia troncular anterior mostrou ser um bom modelo experimental para estudo com o metabolismo de cálcio, ocasionando diminuição da absorção de cálcio, cálcio sérico, cálcio urinário e fosfatase alcalina. No entanto, para alterações a nível ósseo em ratos, sugere-se um estudo experimental em período maior.

The Clinical Analysis of 12 Cases of Bezoars

PURPOSE: Bezoars are the uncommon result of ingestion of poorly digestible or indigestible substances. It is defined as retained concretions of animal or vegetable material in the gastrointestinal tract. The aim of this study was to review and analyze in these cases with reviewing literature. METHODS: The medical records of 12 cases, treated between May 1999 and April 2009, were reviewed. The clinical characteristics, as well as the diagnostic evaluations and results of medical and surgical treatment, were also analyzed retrospectively. RESULTS: Of the 12 cases, 6 men and 6 women, the bezoars were in the stomach, jejunum and ileum or in both stomach and jejunum in 1, 2, 7 and 2 cases, respectively. 4 patients (33.3%) had a history of gastric or duodenal ulcer following previously received gastric surgery such as subtotal gastrectomy or truncal vagotomy with pyloroplasty. In 3 cases, the bezoars were found in operative field under the impression of intestinal obstruction due to adhesive ileus, which could not be found by preoperative radiologic evaluation. Among the 12 cases, 11 cases were successfully treated by operative and endoscopic removal, but 1 case expired due to sepsis. CONCLUSION: A bezoar occurs mainly in patients who have previously undergone a gastric operation. Surgeons should keep in mind the possibility of bezoars in patients presenting an intestinal obstruction following a past gastric operation. The principle of treatment for bezoars used to be surgery, but recently gastric bezoars are often treated by gastrofiberscopy.

Validation of POSSUM-physiological Score as Predictors of Post-operative Morbidity and Mortality after Emergency Operation for Peptic Ulcer Complications

PURPOSE: The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity) score was developed to predict post-operative mortality and morbidity rates. The aim of this study was to validate the POSSUM physiologic score (POSSUM-P) in emergent operations for peptic ulcer complications. METHODS: We retrospectively collected data on patients who underwent emergent operation for peptic ulcer complications at Boramae Hospital between January 2003 and April 2009. The data included patients' characteristics (underlying disease, medication, duration of symptoms), operative characteristics (operation method, morbidity, and mortality) and the items for the POSSUM-P (basic information (age, sex, etc.), circulatory and respiratory signs, electrocardiogram, blood pressure, hemoglobin, white blood cell count, potassium level, sodium level, urea level and Glasgow coma scale). The POSSUM-P was calculated and compared according to the morbidity and mortality. RESULTS: One hundred and twelve patients were included. As for operation methods, primary repair (48.2%) was most common, followed by truncal vagotomy with pyloroplasty (27.7%). Thirty-seven patients had morbidities including wound infections (20), pneumonias (14), fluid collections (9), and so on. Eight patients died due to sepsis or pulmonary edema. The means of POSSUM-P were significantly different between patients with and without mortality (37.8 vs. 19.2, P<0.001) and between patients with and without morbidity (26.7 vs. 17.3, P<0.001). Those were different between patients with and without postoperative pneumonia and wound infection (P=0.002 and P=0.029, respectively). CONCLUSION: The POSSUM physiologic score could help to predict the mortality or morbidity after emergency operation for complications of peptic ulcer disease, especially postoperative pneumonia or wound infection.

Effects of the partial gastrectomy associated to anterior truncal vagotomy in the metabolism of the iron in rats / Efeitos da gastrectomia parcial e vagotomia troncular anterior no metabolismo de ferro de ratos

PURPOSE: To evaluate the effects of the partial gastrectomy associated to anterior truncal vagotomy in the absorption and metabolism of iron. METHODS: Eighteen adults male Wistar rats were submitted to the partial gastrectomy associated to anterior truncal vagotomy (eight animals) and the sham operation (10 animals, control group). The diet consumption and the weight gains of the animals were monitored three times during the week. The animals received supplements of vitamin B12, for the prevention of the megaloblastic anemia, and a formulated experimental diet orally and denominated AIN-93M by 8 weeks. The fecal iron, apparent absorption of the iron, haematocrit, haemoglobin and serum iron were measured after 60 days. RESULTS: The animals undergoing sham operation presented larger statistical averages (p<0.05) for the diet consumption, weight gains, apparent absorption of iron, haematocrit, haemoglobin and serum iron compared to the gastrectomized group. However, the excretion of iron in feces was larger in the gastrectomized group (+14.3 percent) (p<0.05) when compared to the control group. CONCLUSION: Partial gastrectomy associated to anterior truncal vagotomy showed to be a good experimental model the study of iron metabolism, decreasing the haematocrit, the haemoglobin and the iron absorption, consequently causing anemia.

OBJETIVO: Avaliar os efeitos da gastrectomia parcial associada a vagotomia troncular anterior na absorção e metabolismo do ferro. MÉTODOS: Dezoito ratos Wistar machos e adultos foram submetidos a gastrectomia parcial e vagotomia troncular anterior (oito animais) e à laparotomia simples como grupo controle (10 animais). O consumo de dieta e o peso dos animais foram monitorados três vezes por semana. Os animais receberam suplementos de vitamina B12 para prevenção de anemia megaloblástica, além de dieta oral formulada experimentalmente e denominada AIN-93M, durante 8 semanas. O ferro fecal, a absorção aparente de ferro, o hematócrito a hemoglobina e o ferro sérico foram mensurados, após 60 dias de observação. RESULTADOS: Os animais controles apresentaram médias estatísticas maiores (p <0.05) para o consumo de dieta, ganho de peso, absorção aparente de ferro, hematócrito, hemoglobina e ferro sérico comparados aos animais gastrectomizados. Entretanto, a excreção de ferro nas fezes foi superior no grupo de animais gastrectomizados (+14.3 por cento) (p<0.05) quando comparado com o grupo controle. CONCLUSÃO: A gastrectomia parcial associada a vagotomia troncular anterior mostrou ser um bom modelo experimental para o estudo do metabolismo do ferro, ocasionando diminuição do hematócrito, da hemoglobina e absorção de ferro, e conseqüentemente causando anemia.

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.

Laparoscopy-assisted truncal vagotomy with antecolic anterior gastrojejunostomy for cicatricial pyloric stenosis

Duodenal ulcer is a common disease in Egypt. The management of this disease has changed dramatically. Surgery is still indicated for the complications of duodenal ulcer. Pyloric stenosis is a common complication that may result from reluctance of the ulcer patient to seek medical advice or to receive adequate treatment. From 1992 to 2006, 175 patients with cicatricial pyloric stenosis were operated on [open truncal vagotomy with gastrojejunostomy] in our center. The aim of this work is to declare the role of minimally invasive surgery in the form of laparoscopic truncal vagotomy and extracorporeal gastrojejunostomy /or treatment of cicatricial pyloric stenosis. From December 2006 to December 2007, 14 cases of cicatricial pyloric stenosis underwent laparoscopic truncal vagotomy and extracorporeal antecolic gastrojejunostomy through a small 4 cm transverse incision in the left hypochondrium. The advantages of this procedure include reduction of pain, size of the wound and incidence of incisional hernia. The results are comparable to those of a totally laparoscopic truncal vagotomy and gastrojejunostomy. Cicatricial pyloric stenosis is an absolute indication for surgery. The standard surgical approach is truncal vagotomy and gastrojejunostomy. It could be performed totally laparoscopic using either endosteplers or intracorporeal suturing. Laparoscopy- assisted truncal vagotomy with gastrojejunostomy achieves the advantages of .minimally Invasive surgery, easy anastomosis and is cost effective. This procedure is relatively easy to perform as the anastomosis is done extracorporeally. It is less expensive than the use of endostaplers. It achieves the advantage of minimally invasive surgery in a cheap manner. This is very suitable for developing countries like Egypt

Does troncular vagotomy modify the proliferative gastric lesions induced in rats by duodenogastric reflux

PURPOSE: to investigate if combining VT to DGR through the pylorus can modulate the biological behavior of PL induced by DGR and to verify if TV alone can induce morphologic lesions in the gastric mucosa. METHODS: 62 male Wistar rats were assigned to four groups: 1 - Control (CT) gastrotomy; 2 - Troncular Vagotomy (TV) plus gastrotomy; 3 - Duodenogastric reflux through the pylorus (R) and 4 - Troncular vagotomy plus DGR (RTV). The animals were killed at the 54 week of the experiment. DGR was obtained by anastomosing a proximal jejunal loop to the anterior gastric wall. TV was performed through isolation and division of the vagal trunks. Gastrotomy consisted of 1 cm incision at the anterior gastric wall. PL were analyzed gross and histologically in the antral mucosa, at the gastrojejunal stoma and at the squamous portion of the gastric mucosa. RESULTS: Groups R and RTV developed exophytic lesions in the antral mucosa (R=90.9 percent; RTV=100 percent) and at the gastrojejunal stoma (R=54.54 percent; RTV=63.63 percent). Histologically they consisted of proliferative benign lesions, without cellular atypias, diagnosed as adenomatous hyperplasia. Both groups exposed to DGR presented squamous hyperplasia at the squamous portion of the gastric mucosa (R= 54.5 percent; RTV= 45.4 percent). TV, alone, did not induce gross or histological alterations in the gastric mucosa. TV did note change the morphologic pattern of the proliferative lesions induced by DGR. CONCLUSIONS: DGR induces the development of PL in the pyloric mucosa and at the gastrojejunal stoma. TV does not change the morphologic pattern of the proliferative lesions induced by DGR. TV alone is not able to induce morphologic lesions in the gastric mucosa.

OBJETIVO: investigar se a adição da VT ao RDG através do piloro, interfere no comportamento biológico das LP induzidas pelo RDG e observar se a VT isoladamente leva ao desenvolvimento de lesões morfológicas na mucosa gástrica. MÉTODOS: Foram utilizados 62 ratos Wistar machos, distribuídos em quatro grupos experimentais: 1- Controle (CT) Gastrotomia; 2- Vagotomia Troncular + gastrotomia (VT); 3-Refluxo duodeno-gástrico (R) e 4- RDG através do piloro e VT (RTV). Os animais foram sacrificados na 54ª semana do experimento. O RDG foi obtido através de anastomose do jejuno proximal com a parede gástrica anterior. A vagotomia troncular foi realizada através da dissecção e divisão dos troncos vagais. A gastrotomia consistiu de secção e síntese de um cm na parede gástrica anterior. As LP foram analisadas macroscopicamente e histologicamente na mucosa gástrica, na anastomose gastrojejunal e no estômago escamoso. RESULTADOS: Os grupos R e RVT desenvolveram lesões exofíticas na mucosa do antro gástrico (R=90,9 por cento e RVT=100 por cento) e na anastomose gastrojejunal (R=54,5 por cento e RVT=63,6 por cento) que se caracterizaram no exame histológico por lesões proliferativas epiteliais benignas, sem atipias celulares, diagnosticadas como hiperplasia adenomatosa. Na região do estômago escamoso, ambos os grupos expostos ao RDG apresentaram hiperplasia escamosa (R= 54,5 por cento e RVT= 45,4 por cento). A VT não modificou o padrão histopatológico das LP induzidas pelo RDG. Os grupos VT e CT não apresentaram alterações macroscópicas ou histológicas significativas. CONCLUSÕES: o RDG induz o desenvolvimento de lesões proliferativas (LP) benignas na mucosa do antro gástrico e na anastomose gastrojejunal. A VT isoladamente não induz alterações proliferativas na mucosa gástrica e não modifica as características morfológicas das LP induzidas pelo RDG através do piloro.

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.

Benign gastric outlet obstruction

The number of cases which had surgery for benign gastric outlet obstruction is 24 cases. Affected male with benign gastric outlet obstruction were much more than female and the percentage of them is 75%. The average of age which were more affected is 60-70 years. Blood group O wase the commonest blood group in patients of benign gastric outlet obstruction. Benign gastric outlet obstruction were treated with gastrojejunostomy and truncal vagotomy in 57.8% of patients. 4.1% of patients with benign gastric outlet obstruction were treated with pyloroplasty and truncal vagotomy

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.

The Clinical Analysis of 25 Cases of Bezoars

PURPOSE: Bezoars are defined as retained concretions of animal or vegetable material in the gastrointestinal tract, and can be classified as trichobezoar, phytobezoar, trichophytobezoar or concretion. The purpose of this study was to review and analyze 25 cases of bezoar. METHODS: The medical records of 25 patients, treated between February 1995 and November 2004, were reviewed. The clinical characteristics, as well as the diagnostic evaluations and results of surgical treatment, were also analyzed retrospectively. RESULTS: Of the 25 patients, 13 men and 12 women, the bezoars were in the stomach, ileum or in both the stomach and ileum in 17, 5 and 2 cases, respectively, with 1 case in the esophagus. Bezoars are usually caused by an altered gastric physiology, with impaired gastric emptying as a result of surgery, such as subtotal gastrectomy, antrectomy or truncal vagotomy with pyloroplasty. The treatment of bezoars depends on their composition and location. A gastric bezoar can be treated by endoscopic removal, although not all cases can be completely removed. Small bowel bezoars are usually discovered on exploration due to an intestinal obstruction, with surgical removal being the standard treatment method in such cases. CONCLUSION: A bezoar occurs mainly in patients who have previously undergone a gastric operation. Surgeons should keep in mind the possibility of bezoars in patients presentingan intestinal obstruction following a past gastric operation. The treatment principle for bezoars used to be surgery, but recently gastric bezoars are often treated by gastrofiberscopy.

Operaciones conservadoras de órganos en la úlcera péptica duodenal / Conserving-organ operations in duodenal peptic ulcer

Se realizó un estudio descriptivo de los resultados obtenidos del tratamiento quirúrgico electivo de la úlcera péptica duodenal en 107 pacientes durante el periodo de 1985 a 1995. Se utilizaron como procederes quirúrgicos la vagotomía altamente selectiva en 56 pacientes y la vagotomía altamente selectiva anterior con vagotomía troncular posterior en 51 pacientes. La indicación quirúrgica más frecuente fue la no respuesta al tratamiento médico en el 90,7 por ciento de los casos. De ambas técnicas, la vagotomía altamente selectiva anterior con vagotomía troncular posterior fue la de menor tiempo quirúrgico y menor estadía posoperatoria. El 32,7 por ciento de los pacientes tuvieron complicaciones posoperatorias. La disfagia (14 por ciento) y las diarreas (17 por ciento) fueron las más frecuentes. Hubo recidivas en el 4,6 por ciento de los casos. Se obtuvieron buenos resultados, según la clasificación de Visick, en el 92,6 por ciento de los pacientes y no hubo mortalidad posoperatoria

Long term results of truncal vagotomy and [uncut] roux gastrojejunostomy for management of chronic duodenal ulcer with reference to gastric emptying

In the previous reports, we described the surgical technique of truncal vagotomy and "uncut" Roux gastro-jejunostomy [TV+UCRGJ] in management of chronic duodenal ulcer [CDU]. Also, we demonstrated that it is not associated with significant increase in postoperative enterogastric reflux [EGR]. This work represents the long-term results of TV+UCRGJ, with assessment of gastric emptying using gastro-hydro-sonography. Fifty two patients, [mean age: 47.21+12.89 years], with CDU were managed by TV+UCRGJ and were followed-up for a mean duration of 54.71 +/- 9.21 months, for symptomatic outcome. Gastric emptying for semisolids was assessed ultrasonographically, by measuring the percent change of the post-prandial gastric antral area [AA] in patients, pre and at least 12 months post-operative. The results were compared to 50 matching controls. Excellent or fair symptomatic outcome was described by 47 patients [90.3%]. Four patients [7.7%] needed redo gastric surgery, two with ARG [one due to stapler line dehiscence] and two with severe gastric stasis. There was a significant drop in the mean preoperative symptomatic score, following surgery [2.98 +/- 0.92 Vs 0.827 +/- 1.279, p=0.000], to a figure matching the controls [0.827 +/- 1.279 Vs 0.667 +/- 1.046, p=0.514]. Ultrasonographic assessment of gastric emptying, showed insignificant difference in gatric emptying percent at 30 minutes between postoperative and controls values [66.73 +/- 11.75% Vs. 70.19 +/- 10.27%, P=0.810]. As well, there was insignificant difference between post and preoperative values [66.73 +/- 11.75% Vs. 69.85 +/- 11.88%, p=0.074]. Truncal vagotomy and "Uncut" Roux gastrojejunostomy carries good long-term symptomatic and functional outcome. Also, it is associated with normal gastric emptying. So, it can be included as an initial surgical option in the management of uncomplicated CDU

Clinical Review of Cholelithiasis after Gastric Resection in Gastric Cancer Patients

PURPOSE: An increased incidence of cholelithiasis has been widely reported following a truncal vagotomy and gastrectomy in benign peptic ulcer disease. However, there have been few studies on cholelithiasis following a gastrectomy in gastric cancer patients. Therefore, the incidence, influencing factors, natural course and whether a prophylactic cholecystectomy is required during a gastrectomy were investigated. METHODS: 1, 057 patients with gastric cancer, who received a gastrectomy at Chung-Ang University Hospital between January, 1992 and December, 2001, were reviewed. Of the 1, 057 patients, 591 were included in this study, with 420 and 46 patients excluded due to lack of follow-up after the gastrectomy and because they received a preoperative or concomitant cholecystectomy, respectively. Age, gender, extents of gastrectomy, anastomosis methods and cancer staging were investigated as factors for potential correlation with any incidence. Furthermore, the interval between the gastrectomy and the discovery of cholelithiasis and the number of patients receiving a cholecystectomy due to cholecystitis during the follow-up period were also studied. RESULTS: The preoperative prevalence of cholelithiasis was 7.22% (46/637). The incidence of cholelithiasis after a gastrectomy was 7.61% (45/591), with a mean duration of 32.13+/-28.18 months. There were no significant differences in the incidences of cholelithiasis according to age, gender, extents of gastrectomy or stage (P>0.05). 23 cases of cholelithiasis (50%) were detected within 24 months and 80% (36/45) of all cases developed within 48 months. Among the 45 gallstone patients, only 6 (13.33%) developed acute cholecy- stitis and received a cholecystectomy. CONCLUSION: The incidence of cholelithiasis after a gastrectomy was very low, and was independent of age, gender, and other influencing factors in our study. Therefore, close observation and follow-up evaluation would be helpful in the prevention and detection of cholelithiasis. Also further study will be needed on the relationship between the methods of anastomosis and the incidence of cholelithiasis. The clinical benefits of a prophylactic cholecystectomy during a gastrectomy should also be studied carefully.

A Clinical Analysis of Complicated Gastroduodenal Ulcer in Children

A total of 30 cases of the peptic ulcer in children, who underwent operations from January 1981 to December 1995 because of complications at Department of the Surgery, Chonbuk National University Medical School, is reviewed. Twenty-three were males (76.7%), 7 females (23.3%) and male was preponderant at 3.3:1. There were 25 cases (83.3%) age 10 to 15 years, 3 (10.0%) between 2 and 9 years, and 2 (6.7%) below 2. The ulcer was located at duodenum in 27 (90.0%), and at stomach in 3 cases (10.0%). Complications were perforation in 19 cases (63.3%), pyloric obstruction in 9 (30.0%) and bleeding in 2 (6.7%). For perforation, truncal vagotomy with pyloroplasty was done in 11 cases, truncal vagotomy with hemigastrectomy and gastrojejunostomy in 6, and simple closure in 2 cases. For obstruction, truncal vagotomy with hemigastrectomy and gastrojejunostomy was done in 5, and truncal vagotomy and pyloroplasty in 3 cases. For bleeding lesions, truncal vagotomy and pyloroplasty was performed in 2 cases. Ten postoperative complications developed in 9 patients; adhesive ileus in 5, recurrence in 2, pneumonia 2, and wound seroma 1 case. One patient developed a primary duodenal perforation and another a recurrent obstruction. Both of patients had symptoms for more than 3 years and were treated with truncal vagotomy and pyloroplasty for the primary operations. Hospital stay was 11.5 days for the patient with perforated ulcer, 11.0 days for the patient with pyloric obstruction, and 14.5 days for the child with bleeding. Average hospital period was 11.6 days. To reduce recurrences after operation, extensive procedure such as distal gastrectomy with vagotomy at the first operation should be considered in case with severe complication or with patients who have been symptomatic for long periods.

Cirugía del hiato esofágico. Abordaje videolaparoscópico / Surgery of esophageal hiatus. Videolaparoscopic approach

Desde comienzos de la década de los 90, la realización de la cirugía del hiato esofágico (tratamiento de la enfermedad por reflujo gastroesofágico, de la acalasia esofágica, cirugía denervativa gástrica en el tratamiento de la ulcera duodenal crónica) mediante un abordaje videolaparoscópico, ha logrado una gran difusión y aceptación a nivel mundial. La excelente exposición y visualización de una región anatómica, profundamente situada en el hemiabdomen superior, a lo que se suman las ventajas del abordaje mínimamente invasivo, logrando resultados a corto y mediano plazo comparables a la cirugía convencional explican este fenómeno. Los autores comunican su breve experiencia inicial en esta cirugía y realizan una revisión de la literatura, con especial énfasis en la técnica quirúrgica. Se operaron 23 pacientes: 14 funduplicaturas de Nissen Rossetti, 4 miotomías asociadas a funduplicaturas de diferente tipo y cinco cirugías denervativas gástricas por ulcera duodenal. Hubo 2 conversiones, ambas por perforación esofágica. No hubo complicaciones mayores postoperatorias y la mortalidad fue nula. Los resultados funcionales fueron buenos. Los resultados obtenidos, coincidentes con la bibliografía internacional apoyan la continuación de esta línea de trabajo.

Oximetria do estômago: estudo comparativo entre vagotomia gástrica proximal e seromiotomia da curvatura gástrica menor anterior com vagotomia troncular posterior na úlcera duodenal crônica / Oximetry of stomach: comparative study between proximal gastric vagotomy and anterior lesser curve seromyotomy with posterior truncal vagotomy in chronic duodenal ulcer

Retardo do esvaziamento gástrico de alimentos sólidos ocorre mais intensamente depois de vagotomia gástrica proximal (VGP) que após seromiotomia da curvatura gástrica menor anterior com vagotomia troncular posterior (SMAVTP), podendo estar relacionado à hipóxia da parede gástrica e, principalmente, do marcapasso gástrico. OBJETIVO: Determinar a repercussäo da desvascularizaçäo cirúrgica da curvatura menor e do fundo gástrico no estômago como um todo e, particularmente, na regiäo do marcapasso. MÉTODOS: Mediu-se a saturaçäo de oxigênio da hemoglobina (SpO2) intra-operatória, por oximetria de pulso, da parede gástrica anterior em 20 portadores de úlcera duodenal crônica, alocados casualmente em dois grupos de 10 pacientes para tratamento cirúrgico por VGP ou SMAVTP. RESULTADOS: As mediçöes, obtidas antes de fundoplicatura parcial, mostraram que o fundo gástrico e a curvatura menor proximal tiveram reduçäo significante da SpO2 quando comparados ao corpo gástrico (p < 0,05); que a SpO2, na regiäo do marcapasso gástrico, näo sofreu alteraçäo estatisticamente significante; que a associaçäo entre ligadura dos vasos gástricos curtos e VGP ou SMAVTP reduziu significantemente a SpO2 (p < 0,05); e que a técnica da VGP resultou em SpO2 significantemente menor que a SMAVTP (p < 0,05). CONCLUSÄO: A VGP, quando associada à ligadura dos vasos gástricos curtos, produz alteraçöes isquêmicas agudas da parede gástrica, na regiäo da curvatura menor proximal e do fundo gástrico, mais intensas que a SMAVTP. A regiäo do marcapasso gástrico näo sofre hipóxia imediatamente após os procedimentos operatórios