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Gastric outlet obstruction caused by gastrostomy tube migration should not occur in patients who have gastrostomy buttons. This is the first reported case of gastric outlet obstruction caused by internal displacement of a gastrostomy button.
Gastric outlet obstruction due to a gallstone impacted in the duodenal bulb (Bouveret's syndrome) is a rare complication of gallstones. We report a 47-year-old man with this syndrome in whom the impacted stone migrated uneventfully.
Gastric outlet obstruction initiated by acute gastric volvulus is rare but potentially fatal. An unusual case of intrathoracic acute gastric volvulus complicated by distal stomach and transverse colon herniation into retrocardial space is reported. Prompt clinical diagnosis was followed by emergency laparoscopic de-rotation and gastropexy.
Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.
A newborn boy had junctional epidermolysis bullosa, duodenal obstruction, and gastric infarction, a newly described combination that extends the spectrum of gastrointestinal findings associated with junctional epidermolysis bullosa. The infant underwent feeding jejunostomy, but died 16 days after birth. This report emphasizes the need for gastrointestinal assessment in any neonate suspected of having epidermolysis bullosa, especially if the pregnancy was complicated by polyhydramnios.
BACKGROUND: Gastric bypass through laparotomy is required traditionally when gastric outlet obstruction occurs secondary to a disease process (e.g., unresectable cancer). The recent trend toward minimally invasive procedures has led us to apply laparoscopic bypass surgery for gastric obstruction caused by unresectable advanced gastric cancer. METHODS: From March 1998 to February 2000, 78 gastrojejunostomies (GJ) (45 open [OGJ] and 33 laparoscopic [LGJ] procedures) were performed for palliation of gastric outlet obstruction caused by advanced gastric, duodenal, papilla of vater, and pancreatic cancers at the Asan Medical Center. In 68 patients with advanced gastric cancer, OGJ (n = 38) and LGJ (n = 30) were performed. Of these, 10 OGJ patients were compared with 10 diagnosis-matched LGJ control subjects who underwent surgery during the same period in terms of age, gender, American Society of Anesthesiology (ASA) grading, previous abdominal surgery, operating time, time to oral food intake, pain-killer consumption, postoperative hospital stay, immune response, morbidity, and mortality. Immune parameters including serum white blood cells (WBC) count, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), cortisol, and erythrocyte sedimentation rate (ESR) levels were assessed preoperatively and on postoperative days 1 and 3 between the two groups. With the patients under the general endotracheal anesthesia, we applied an upper midline incision in OGJ and inserted four trocars in LGJ. Side-to-side gastrojejunostomy was performed in a standard fashion. In LGJ, intracorporeal suture using 2-0 vicryl was performed to repair the gastrotomy and jejunotomy site after gastrojejunostomy using a 30-mm or 45-mm Endo-GIA stapler. RESULTS: There were no significant differences between OGJ and LGJ in terms of gender, age, ASA grading, and previous abdominal surgery. In OGJ, antecolic isoperistaltic GJ was performed in 10 cases, but 8 antecolic and 2 retrocolic approaches were performed in LGJ with no conversion to open surgery. Operating time (113.5 +/- 11.2 vs 100.5 +/- 9.8 min), pain-killer consumption (540 +/- 123.2 vs 430 +/- 58.2 mg), and postoperative hospital stay (12.5 +/- 3.9 vs 8.5 +/- 2.9 days) were reported, respectively. Serum WBC and cortisol levels were slightly increased in both groups preoperatively and on postoperative days 1 and 3. Serum ESR, TNF-alpha, and IL-6 levels were significantly increased in the OGJ patients. Postoperative complications (9 with OGJ and 2 with LGJ) and postoperative death (1 in each group) occurred. During the follow-up period (3-23 months), there was one case of readmission in each group because of anemia and generalized pain. CONCLUSIONS: Laparoscopic GJ for the palliation of unresectable advanced gastric cancer can achieve excellent results with less suppression of immune function, lower morbidity, greater improvement of hemodynamic activities, and earlier recovery of bowel movements than OGJ.
Gastric outlet obstruction (GOO) presenting beyond the newborn period is a relatively rare condition, when infantile hypertrophic pyloric stenosis (IHPS) is excluded. This report describes the clinical features, evaluation and management of 18 patients with GOO which was not caused by IHPS. The sex, age, and main presenting features were recorded on admission. Hemoglobin estimation, serum chemistry and blood gas analysis were also assessed in these patients. The diagnosis was confirmed with gastrointestinal barium, B ultrasound, gastroscopy, or at surgery. Some of them underwent gastroscopy with biopsy sampling for rapid urease test or histologic examination with Giemsa stains for Helicobacter pylori. Thirteen patients had peptic ulcer disease, of which six were successfully treated with medications. While the other seven needed operative management which included Heineke-Mikulicz pyloroplasty, gastroduodenostomy or gastrojejunostomy, respectively. All the patients who had Heineke-Mikulicz pyloroplasty or gastrojejunostomy developed bile reflux gastritis that could be alleviated with omeprazol. None of the patients developed dumping syndrome, failing to thrive, or anemia. Three children with antral diaphragm recovered without any complications by diaphragm excision with Heineke-Mikulicz pyloroplasty. The pylorus was compressed by fibrotic band in one 30-month boy, and he recovered uneventfully with Heineke-Mikulicz pyloroplasty during 10-year follow-up. Gastric outlet obstruction secondary to ingestion of sulfuric acid was noted in one patient, and he was successfully treated with gastroduodenostomy. Our data suggests that the satisfactory results could be expected in children with GOO with different therapeutic modalities based on the specific cause and degree of obstruction.
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.
Gastric carcinoma is among the most common cancers worldwide. Surgery remains the mainstay of potentially curative treatments. Unfortunately, most patients have an advanced form of the disease. We evaluated our experience in palliating malignant gastric outlet obstruction caused by gastric cancer with expandable metal stents (Wallstent Enteral; Boston Scientific, Singapore). Six patients with a median age of 68 years (range, 45-88) underwent the procedure. Three had metastatic gastric cancer; two recurrent gastric cancer; and one locally advanced gastric cancer with poor comorbid status. After the procedure, five of the six patients were able to resume an oral feeding within 24 hours. One patient with gastric dysmotility caused by linitus plastica required nasogastric tube feeding. Three patients died during a median follow-up period of 4 weeks (range, 2-8). The other three patients were still well at a median follow-up period of 10 weeks (range, 5-12). There was no procedure-related mortality or morbidity, nor was there any stent migration or blockage in any of these patients. In conclusion, palliation of malignant gastric outlet strictures caused by gastric cancer with expandable metal stents is an effective and safe alternative to surgery, particularly in patients with postgastrectomy anastomotic recurrence and in those who are poor candidates for surgery. Patients who are not expected to survive beyond 1 month and those with linitus plastica and associated gastric dysmotility may not be appropriate candidates for such a procedure.
BACKGROUND: In patients with gastric outlet obstruction (GOO), palliative enteral stenting is a less invasive procedure compared with gastroenterostomy. Most diseases analyzed in previous studies of such stenting were pancreaticobiliary malignancies. METHODS: We reviewed the medical records of patients with GOO secondary to gastric cancer who were admitted to our institution between September 1994 and September 2004. The outcome of stent placement for GOO was compared with the outcome in patients who underwent palliative open gastrojejunostomy during the same period. Enrolled patients from both groups displayed symptomatic GOO. Patients with recurrent gastric cancer were excluded from this study. RESULTS: Twenty-two patients underwent palliative enteral stenting, and 22 patients were subjected to surgical gastrojejunostomy (bypass). There were no significant differences between the two groups regarding patient baseline characteristics. Technical success and clinical success were obtained in 100% and 77.3%, respectively, of both groups. The operating time was shorter in the stent group (30 vs 118 min; P<0.0001). The time from the procedure to the resumption of food intake was shorter in the stent group than in the bypass group (2 days vs 8 days; P<0.0001). An improvement in performance score after the procedure was observed in both groups (stent group; P=0.0264; bypass group; P=0.0235). No significant differences were observed regarding the possibility of discharge. In patients discharged, the median postoperative hospital stays were 19 days and 28 days (P=0.0558). The median survival periods were 65 days and 90 days. Minor complications were observed in 1 patient in the stent group and in 4 in the bypass group. No mortality or severe complications were observed for either group. CONCLUSIONS: Self-expandable metallic stent placement is a safe and efficacious procedure for palliation, with shorter operating time and more prompt restoration of oral intake, compared to surgical alternatives in patients with GOO caused by gastric cancer.
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Nonsteroidal antiinflammatory drug associated gastric ulcerations are often prepyloric and painless; when recurrent, such ulcers may lead to pyloric scarring and gastric outlet obstruction. We performed a retrospective case control study to seek an association between gastric outlet obstruction and nonsteroidal antiinflammatory drug use. The use of nonsteroidal antiinflammatory drugs in cases with gastric outlet obstruction was compared to an age- and sex-matched outpatient control group undergoing endoscopy. The proportion of drug use by patients with gastric outlet obstruction, seven of nine, was significantly higher than the proportion in controls, 29 of 90. The duration of nonsteroidal antiinflammatory drug use was also significantly longer in patients with gastric outlet obstruction than in control patients. Chronic nonsteroidal antiinflammatory drug use is associated with gastric outlet obstruction.
A case of gastric outlet obstruction diagnosed prenatally at 22 weeks' gestation is described. The differential diagnosis and the clinical management of this rare condition are discussed, and an updated literature review is presented.
BACKGROUND: Gastric outlet obstruction is occasionally reported to occur in advanced gall bladder malignancy and may require palliative surgery. A review of 39 patients who required gastroenterostomy for symptomatic or incipient gastric outlet obstruction in carcinoma gall bladder is presented. METHODS: This retrospective review included 24 women and 15 men over nine years who underwent gastrojejunostomy for locally advanced neoplasms of the gall bladder. RESULTS: Twenty two patients with carcinoma gall bladder had symptomatic gastric outlet obstruction whereas in 17 patients gastrojejunostomy had been performed for intraoperatively assessed impending obstruction. Thirty-four patients had concomitant jaundice. In most cases, there was obstruction of the first two parts of the duodenum, mostly by direct tumoral infiltration (64%). All patients underwent anterior gastrojejunostomy, with billoenteric bypass in 15 patients. There were two postoperative deaths. Eight patients developed postoperative delayed gastric emptying; all settled on conservative management, though two patients had recurrent refractory vomiting. Thirty patients had no vomiting till a follow up ranging from 36 days to 11 months. CONCLUSIONS: Gastric outlet obstruction may frequently complicate gall bladder cancer and a satisfactory palliation can be achieved in most patients by gastrojejunostomy.
Gastric outlet obstruction after esophagogastrectomy with a drainage procedure is unusual, but when encountered, its management can be formidable. A Rous-en-Y intrathoracic gastrojejunostomy was created in a 74-year-old woman 2 years after Ivor Lewis esophagogastrectomy for benign disease to treat severe gastric outlet obstruction at the native pylorus.
Although the combination of gastric outlet obstruction and esophageal atresia is rarely seen in neonates, it has been well described. We report the case of a 5-day-old newborn with esophageal atresia and tracheoesophageal fistula associated with complete gastric outlet obstruction due to a mucous plug. As the patient had intense gastric distention, severe respiratory distress requiring ventilatory therapy and complete pyloric obstruction in radiograms, emergency gastrostomy was performed before definitive operation. Definitive treatment consisted of tracheoesophageal fistula ligation and primary esophageal anastomosis. Exploratory laparotomy during the same session revealed a normal pyloric canal, completely obstructed by a firm mucous plug. The plug was removed by pylorotomy, and a pyloroplasty was performed to ease gastric evacuation. Postoperative feeding problems suggested gastric dysmotility as the possible cause for the mucous plug obstruction.
Treatment of inoperable gastric outlet obstruction caused by tumor compression is difficult and often unsatisfactory. The case of a 56-year-old female patient in whom self-expanding stents were implanted, successfully enabling oral nutrition, is reported.
We report a 45-year-old woman with chronic peptic ulcer disease and multiple episodes of bowel obstruction, who was admitted with gastric outlet obstruction. Because of gastric hypersecretion, a diagnosis of Zollinger-Ellison syndrome was suspected and an initial serum gastrin of 1,251 pg/ml supported this diagnosis. Subsequent evaluation failed to reveal a gastrinoma. A repeat serum gastrin level after 14 days of continuous nasogastric decompression was 43 pg/ml, suggesting that the initial hypergastrinemia was due to antral distention. It is important to consider the possibility of gastric outlet obstruction as a stimulus for serum gastrins in the range previously considered diagnostic for the Zollinger-Ellison syndrome.