Nonoperative management without nasogastric tube decompression for adhesive small bowel obstruction.

BACKGROUND: Although nasogastric tube (NGT) decompression is widely used in nonoperative management for adhesive small bowel obstruction (SBO), robust evidence is lacking to support this routine practice. METHODS: Patients who received nonoperative management with a diagnosis of adhesive SBO were retrospectively reviewed. Those who received NGT or long-tube decompression at admission were categorized into the NGT group, while those who initially had no NGT placement were categorized into the non-NGT group. The incidence of vomiting after admission, pneumonia after admission, and the need for surgery were compared. RESULTS: Among 288 patients, 148 (51.3%) had non-NGT conservative treatment. There were no significant differences in the incidence of vomiting (NGT vs non-NGT: 12.9% vs 18.9%, p = 0.16), pneumonia (1.4% vs 0%, p = 0.235), or need for surgery (12.9% vs 7.4%, p = 0.126). CONCLUSIONS: While NGT decompression is a standard of care for adhesive SBO, selective NGT insertion for patients with persistent nausea or vomiting can become an option.

Internal hernia of the stomach through the lateral space of the colostomy: a case report.

An 81-year-old woman had undergone laparoscopic abdominoperineal resection for rectal cancer. A permanent colostomy was created through an intraperitoneal route. Three months after the surgery, the patient presented with lower abdominal pain and vomiting. Computed tomography showed gastric incarceration through the lateral space of the lifted sigmoid colostomy. Although the herniated stomach was reduced by nasogastric tube decompression, the patient experienced a recurrence of gastric hernia shortly thereafter. A laparoscopic operation was performed, and a new colostomy was constructed through an extraperitoneal route. The patient had no hernia recurrence during the 20 months of follow-up after the operation. Gastric internal hernia associated with colostomy can occur as a rare complication. Although reduction of the incarcerated stomach is possible by nasogastric tube decompression, surgical repair of the hernia may be the optimal management to prevent recurrence.

[Stage IV gastric cancer patient who underwent palliative gastrectomy showing complete response to induction therapy with methotrexate plus 5-fluorouracil and secondary treatment with oral TS-1].

We describe our experience with a patient who had undifferentiated gastric carcinoma with extensive lymph node metastasis, including para-aortic lymph-node metastasis, and had a complete response to induction therapy with methotrexate plus 5-fluorouracil (sequential therapy with MTX, 5-FU, and Leucovorin) and secondary treatment with oral TS-1. The patient was a 71-year-old woman with a massive gastric tumor (signet ring cell carcinoma), occupying most of the stomach. A computed tomographic (CT) scan revealed para-aortic, celiac, and common hepatic lymph-node metastases. Stage IV disease was diagnosed. Palliative total gastrectomy was performed to control bleeding and to improve oral intake of food. Two courses of induction therapy with MTX, 5-FU, and Leucovorin were started 3 weeks after surgery. A CT scan revealed residual lymph node metastasis. The response was assessed to be no change, but the levels of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 improved from 7,028 ng/ml and 726 U/ml 3 weeks after surgery to 2,832 ng/ml and 281 U/ml, respectively. Secondary treatment with oral TS-1 was begun, and a CT scan showed distinct shrinkage of lymph-node metastases. There was no serious toxicity. The levels of CEA and CA19-9 decreased markedly to 2.9 ng/ml and 16 U/ml, respectively, about 6 months after surgery and remained at 3.7 ng/ml and 16 U/ml, respectively, about 1 year after surgery.