Primary gastric rhabdomyosarcoma. Case report

Rhabdomyosarcomas are rare and malignant tumors. There have been reported two histological types of gastric rhabdomyosarcomas, the pleomorphic and embryonal cell types. We report the case of a 53-year-old male with endoscopic diagnosis of a Bormann type III ulcer which revealed a gastric primary rhabdomyosarcoma. Ultrasound showed two liver lesions, two hepatic pedicle lymph nodes and a huge primary gastric tumor. CT scan revealed a primary gastric tumor. The patient is submitted to a distal gastrectomy with a Billroth II reconstruction and a resection of the distal liver metastases at segment IV The patient was discharged uneventfully on the eighth postoperative day. The gold standard for a final diagnoses is the immuno-histochemical staining of the endoscopic biopsy. There is very little information on the results of chemotherapy and the surgical treatment is the best choice.     

Short-term results of gastrectomy with Roux-en-Y or Billroth II anastomosis for peptic ulcer. A prospective comparative study.

Since the Roux-en-Y anastomosis prevents the sequela of postoperative enterogastric reflux after gastrectomy, this approach has been advocated as the primary procedure in patients undergoing gastrectomy for peptic ulcer. We have prospectively followed for 2 years 22 patients, in whom gastrectomy was performed with, at random, either Roux-en-Y (n = 11) or Billroth II (n = 11) anastomosis. Two of the 11 patients who had received the Roux-en-Y procedure had anastomotic ulcers, leading to reresection in one of them. These two patients were found to have the highest values for basal and pentagastrin stimulated gastric acid output. After the Billroth II procedure a single patient had a small anastomotic ulcerative lesion. Apart from differences in intragastric bile acids (p less than 0.0001) and the gastritis activity score (p less than 0.01), no significant differences were found between the patients with Roux-en-Y and Billroth II anastomosis with respect to basal and pentagastrin-stimulated gastric acid secretion, basal, postprandial and bombesin-stimulated serum gastrin secretion, serum pepsinogen A and C concentrations, the serum pepsinogen A/C ratio, postprandial glucose, and for a modified Visick grading. From this small series we conclude that, as compared with the Billroth II-anastomosis, the Roux-en-Y procedure effectively prevents enterogastric reflux, and is associated with a higher gastritis activity score, but not with differences in gastric acid, gastrin, pepsinogens, or Visick grading. Furthermore, inadequate reduction of acid secretion in some patients after the Roux-en-Y procedure may lead to recurrent peptic ulcers.     

Delayed duodenal stump fistula after laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer: A case report

Duodenal stump fistula (DSF) is one of the most serious complications of gastrectomy. The mean time to diagnosis of DSF is approximately 9 days after operation. Our report describes an extremely rare case of delayed DSF 144 days after a laparoscopic distal gastrectomy.A 58-year-old man with drug-induced liver cirrhosis (Child-Pugh class A) underwent laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer. On postoperative day 1, he underwent reoperation because of intra-abdominal bleeding. Ongoing bleeding was observed in the stapler line of the duodenal stump and was controlled using metallic surgical clips. The patient was discharged on postoperative day 14, without complications. After 144 days following the first operation, he visited the emergency room with right flank pain and high fever. Computed tomography revealed free air and abscess near the duodenal stump site.Emergency laparotomy, abscess unlooping, and drain insertion were performed. After surgery, bile was drained by intra-abdominal drainage, and fistulography showed a duodenal fistula.The patient was discharged 55 days after his third surgery.This is an extremely rare case of DSF, which may be caused by the metallic surgical clips used for hemostasis of the duodenal stump stapler line. We believe that the use of metallic surgical clips for hemostasis of the duodenal stump after Billroth-II reconstruction should be avoided.     

Malnutrition after partial gastrectomy

Summary The late sequelae of partial gastrectomy in an unselected consecutive series of 109 patients included atrophic gastritis (78%), hypochlorhydria (76%), anemia (26%), low serum Vitamin B₁₂ (45%), hypoferremia (33%), hypoalbuminemia (29%), raised serum alkaline phosphatase (35%), and loss of weight (47%). The 109 cases were divided into 4 groups: duodenal ulcer with Billroth I anastomosis, duodenal ulcer with Billroth II anastomosis, gastric ulcer with Billroth I anastomosis, and gastric ulcer with Billroth II anastomosis. Statistical analysis of results in these groups showed significantly more sequelae after Billroth II gastrectomy and in patients with gastric ulcer. The gradient from duodenal ulcer with Billroth I to gastric ulcer with Billroth II was exemplified by the incidence of gastritis, 55% and 100%, anemia, 11% and 86%, low serum Vitamin B₁₂, 19% and 86%, hypoferremia, 9% and 57%, and weight loss, 28% and 86%. The incidence of gastritis rose from 2% in cases of duodenal ulcer and 32% in gastric ulcer preoperatively, to 95% and 100% respectively after Billroth II gastrectomy. Thus gastritis occurred frequently after gastrectomy, and itself may be an important determinant of the late sequelae of partial gastrectomy.Supported by a grant from the National Health and Medical Research Council of Australia.Publication No. 1152 from The Walter and Eliza Hall Institute of Medical Research.     

Helicobacter pylori infection in patients with ulcer recurrence after partial gastrectomy

BACKGROUND/AIMS: Recurrent ulceration of the stomach occurs in some patients after surgery for peptic ulcer disease. The aim of this study is to evaluate the association of Helicobacter pylori infection with ulcer recurrence in patients after partial gastrectomy due to peptic ulcer disease. METHODOLOGY: A total of 186 patients after partial gastrectomy with Billroth I or Billroth II anastomosis presenting with dyspepsia or bleeding were included. An ulcer recurrence was documented by endoscopic examination. Biopsy specimens were taken from the remnant gastric bodies in all patients. H. pylori infection was diagnosed by either a positive biopsy urease test or the presence of the microorganism on histology. RESULTS: Eighty-three (44.6%) patients among the 186 patients had recurrent ulcers. H. pylori infection was found in 29 (36%) patients in the ulcer group and 42 (41%) patients in the non-ulcer group. The incidence of H. pylori infection did not differ significantly between the two groups (P>0.05). CONCLUSIONS: H. pylori infection may not play an important role in the pathogenesis of recurrent ulcer after partial gastrectomy. Other factors should be studied further.     

Effect of partial gastrectomy on serum anti-Helicobacter pylori immunoglobulins in peptic ulcer patients

Since biliary enterogastric reflux is suggested to eradicate gastric infection withHelicobacter pylori (HP), we have investigated in a prospective randomized study the effect of partial gastrectomy with either Billroth II or Roux-en-Y anastomosis on infection with HP as assessed by the titers of IgG and IgA antibodies against HP in serum. These antibodies were measured by ELISA in serum of 22 patients before and at 10 days and 6, 15, and 24 months after either Billroth II (N=11) or Roux-en-Y (N=11) gastrectomy for peptic ulcer. All patients had HP demonstrated in their preoperative endoscopic gastric biopsies. The preoperative serum IgA antibodies against HP (anti-HP IgA) were increased in 20 of the 22 patients (range 0.21–1.69) while the IgG antibodies (anti-HP IgG) were increased in all 22 patients (range 0.38–1.31). Four of the Billroth II patients had clearance of HP from gastric biopsies accompanied by rapid and pronounced decrease of anti-HP IgA. In contrast, the patients with Roux-en-Y gastrectomy and the Billroth II patients with persistent HP infection had no change in anti-HP IgA after surgery. Anti-HP IgG showed variable results in the four patients without gastric HP infection and was not affected by gastrectomy in the patients with persistent HP infection. We concluded that serum anti-HP IgA, but not anti-HP IgG, is helpful in identifying those patients in whom HP is no longer demonstrable after Billroth II gastrectomy. Gastrectomy with Roux-en-Y anastomosis had no effect on gastric HP infection.     

Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature

Acute upper gastrointestinal bleeding is a rare, but serious complication of gastric bypass surgery. The inaccessibility of the excluded stomach restrains postoperative examination and treatment of the gastric remnant and duodenum, and represents a major challenge, especially in the emergency setting. A 59-year-old patient with previous history of peptic ulcer disease had an upper gastrointestinal bleeding from a duodenal ulcer two years after having a gastric bypass procedure for morbid obesity. After negative upper endoscopy finding, he was urgently evaluated for gastrointestinal bleeding. At emergency laparotomy, the bleeding duodenal ulcer was identified by intraoperative endoscopy through gastrotomy. The patient recovered well after surgical hemostasis, excision of the duodenal ulcer and completion of the remnant gastrectomy. Every general practitioner, gastroenterologist and general surgeon should be aware of growing incidence of bariatric operations and coherently possible complications after such procedures, which modify patient’s anatomy and physiology.     

Late follow-up of gastrectomized patients for peptic ulcer: clinical, endoscopic and histopathological aspects

BACKGROUND: The gastrectomy is an uncommon procedure because the proton bomb inhibitors associated to the antibiotic outlines used to eradicate the Helicobacter pylori changed the focus of the peptic ulcer treatment. AIMS: Later evaluation on those patients who underwent partial gastrectomy as a treatment for peptic ulcer, at that time when any drug to eradicate the Helicobacter pylori was not used. The clinical evaluation included the late postoperative symptoms and postgastrectomy syndromes like dumping, diarrhea, alkaline gastritis and nutritional aspects. The upper digestive endoscopy analysed the surgery reconstruction and the gastric stump, the duodenum and the jejunum mucosa aspects. The histopathological evaluation included looking for Helicobacter pylori by using two different methods: histology and urease test. CASUISTIC AND METHODS: Fifty-nine patients, 44 (74.6%) male, median age 55.5 years old (range from 31 to 77 years old), who underwent a clinical interview and an upper digestive endoscopy. Paraffin blocks from the surgical specimen were reviewed in order to find out if the patients did have or did not have Helicobacter pylori before surgery. RESULTS: The final results show that most of the patients had very good and good clinical evolution (Visick I e II) in 96%. The most common symptoms on late postoperative are mild dyspepsia with or without Helicobacter pylori, and diarrhea, anemia and dumping occurred in, respectively, 11 (18.6%), 2 (3.4%) and 2 (3.4%) cases. The Billroth I reconstruction had the best clinical results on statistical rate. The endoscopic finding showed normal results in the most number of cases, and reflux alkaline gastritis or erosive gastritis in a few cases. Ulcer recurrences were diagnosed in two patients (3.4%), and both had positive Helicobacter pylori. Most of the patients had Helicobacter pylori (86%) before surgery and also in the postoperative time (89.9%). CONCLUSIONS: The patients had a very good clinical evolution after the gastrectomy. The Billroth I reconstruction had the best clinical results. The Helicobacter pylori is still present on gastric stump in late postoperative time, and we believe that it does not bring any negative influence to surgical results.     

Endoscopic treatment of efferent loop syndrome with insertion of double pigtail stent

Efferent loop syndrome is a very rare postgastrectomy syndrome that can occur following Billroth-Ⅱor Rouxen-Y reconstruction.The most common loop syndrome after gastric surgery is afferent loop syndrome;however,efferent loop syndrome has been reported in rare cases.Here,we report a case of efferent loop obstruction that occurred after postoperative adhesiolysis of a small-bowel obstruction.The patient had undergone a partial gastrectomy with BillrothⅡanastomosis and gastric ulcer perforation 30 years prior.The efferent loop obstruction was successfully resolved by the insertion of a double pigtail stent.To the best of our knowledge,this is the first case in the literature describing the treatment of efferent loop obstruction.     

Acid secretion and gastric surgery

It was long believed that there were major differences in the pathophysiology between the three major categories of peptic ulcers. The unifying feature was that all peptic ulcers occurred in a mucosal compartment exposed to acid-pepsin secretions. All ulcers tended to heal more rapidly when acid secretion was more readily neutralized or inhibited. Decreased local resistance was considered to be present in primarily acute and chronic gastric ulcer. Surgery for peptic ulcer intended to reduce acid secretion, which also resulted in a diminished pepsin enzyme activity. The corresponding reduction could be accomplished either by gastric resection, different vagotomies or a combination of resections and vagotomies. Most of the procedures were basically abandoned at the time of introduction of modern medical therapeutic strategies. For duodenal ulcer and prepyloric ulcer diseases, various vagotomies were generally recommended or combined with antrectomy. Partial gastrectomy or antrectomy with gastroduodenostomy was the standard procedure for treatment of type 1 gastric ulcer. The great caveat associated with surgical procedures for elective treatment of uncomplicated peptic ulcer disease is confined to operative mortality, postoperative morbidity, and late postoperative metabolic sequelae. The only remaining indication today of remedial gastric surgery for peptic ulcer disease is when there is a defined risk for gastric cancer in an unhealed gastric ulcer and very seldom in a case with recurrent or therapy-resistant peripyloric ulcer.     

Gastric mucosa after partial gastrectomy.

A partial gastrectomy of Billroth I or II type was performed in a series of 146 patients with peptic ulcer. Gastric biopsy was carried out two years later and the histology of the specimens compared with that of the body mucosa at the time of operation. In 138 patients without body atrophic gastritis (AG) before operation this condition was found in 74 (54%) two years after (46% of DU patients and 73% of GU patients). Those with antral or pyloric canal ulcers were particularly liable to develop AG (81%). Apart from site of ulcer various other factors possibly associated with the development of AG were examined: no positive correlations were found with the possible exception of anaemia. Gastric parietal cell antibodies were not found in any patient with AG tested. The cause of gastritis after partial gastrectomy and its possible relationship with gastric carcinoma are discussed.     

Hydrogen (H2) breath test and gastric bacteria in acid-secreting subjects and in achlorhydric and postgastrectomy patients before and after antimicrobial treatment

Sixteen patients with pentagastrin-fast achlorhydria and 12 patients who had undergone Billroth II gastrectomy (at least 3 years previously) were compared with 10 acid-secreting volunteers and 13 patients with endoscopically proven peptic disease. The concentration and type of gastric bacteria were analysed in achlorhydrics, Billroth II patients, and patients with peptic disease. A 6-h hydrogen (H2) breath test after a standardized meal was performed in all subjects. The mean concentration of gastric bacteria was significantly higher in achlorhydrics and Billroth II patients than in patients with peptic disease. End-expiratory H2 excretion was elevated in achlorhydrics and Billroth II patients to levels significantly exceeding those of acid-secreting volunteers and patients with peptic disease. In achlorhydrics, total bacterial concentration in gastric juice was correlated to H2 excretion between 60 and 180 min after the meal. Treatment of achlorhydric and postgastrectomy patients with trimethoprim/sulphamethoxazole lowered H2 breath concentrations in both groups and reduced symptoms in achlorhydrics. Elevated end-expiratory H2 levels after a test meal indicate upper gastrointestinal bacterial overgrowth in achlorhydrics and in postgastrectomy patients.     

Modified Operation to Treat Types II and III Adenocarcinoma of the Esophagogastric Junction

Background/Aims: To study the effects of a gastric tube anastomosis in the intraperitoneal operation for types II and III adenocarcinoma of the esophagogastric junction (AEG). Methodology: Thirty-one patients with types II and III AEG were selected for proximal gastrectomy. After the proximal gastrectomy by the abdominal approach, the gastric remnant was cut into a tubular shape. The esophagus was then anastomosed to the gastric tube. Results: The surgical technique was performed on all 31 patients with types II or III AEG. The operation time was 279.52±34.99min, average surgery blood loss was 209.68±185.82mL, the number of hospital postoperative days was 10.48±2.01. All cases were followed-up for 2-12 months. One (3.2%) patient had postoperative anastomotic bleeding and another case had intractable hiccups. Only 3 (9.7%) patients felt heartburn after the operation. One (3.2%) patient was found to be suffering from reflux esophagitis through endoscopic examination. In addition, 1 (3.4%) patient had tumor recurrence. Conclusions: Using gastric tubes is a safe surgical technique and is followed by only a small number of complications at the early postoperative stage.     

Postoperative Complications and Functional Results After Subtotal Gastrectomy with Billroth II Reconstruction for Primary Gastric Cancer

Subtotal gastrectomy is considered the preferred treatment for gastric cancer with antral location. The aim of this study was to assess the incidence of early postoperative complications and late functional results in patients who underwent subtotal gastrectomy with Billroth II reconstruction for primary gastric adenocarcinoma. The results of 310 patients were analyzed with regard to postoperative complications and death rates. Functional results as they relate to the gastric resection were evaluated in 195 disease-free patients. Of the 310 patients, 77 developed postoperative general and surgical complications (24.8%) and 13 consequently died (in-hospital mortality: 4.2%). Although infrequent (6 cases, 1.9%), anastomotic leak was the most serious complication (4 cases died during the postoperative phase). Considering functional results, weight loss continued for the first trimester after surgery, after which it stabilized. Loss of appetite was rarely observed; early after the operation the majority of patients were consuming a normal diet and regularly consumed less than five meals per day (83.6%). Dumping syndrome was uncommon and usually resolved within one year (12.3% at three months, 9.5% after one year, 5.2% after two years). On the other hand, postprandial abdominal fullness was frequently observed (43.1% at three months, 36.1% after one year, 21.3% after three years, and 16.5% after five years). Billroth II reconstruction after subtotal gastrectomy is associated with a limited risk of anastomotic complications. Anastomotic leak, although infrequent, is a life-threatening complaint and requires prompt recognition and aggressive surgical treatment. The incidence of late complications was low and the majority of patients recovered from them within one year after surgery, although the occurrence of postprandial abdominal fullness was not completely irrelevant.     

A case of afferent loop syndrome with acute cholangitis developed after percutaneous transhepatic cholangioscopic lithotripsy for treatment of choledocholithiasis in a patient who underwent Billroth II gastrectomy

Afferent loop syndrome is a rare complication which can occur in patients with Billroth II gastrectomy. Bile and pancreatic juice is congested at afferent loop in the syndrome. This syndrome can progress rapidly to necrosis, perforation, or severe sepsis, and therefore early diagnosis and swift surgical intervention is important. But, cases of endoscopic or percutaneous transhepatic drainage have been reported when surgical management was inappropriate to proceed. We report a case of afferent loop syndrome accompanying acute cholangitis developed after percutaneous transhepatic cholangioscopic lithotripsy for the retrieval of common bile duct stone in a patient who underwent Billroth II gastrectomy due to early gastric cancer. There was no other organic cause. We treated afferent loop syndrome successfully by performing balloon dilation of afferent loop outlet.     

Laparoscopy-assisted distal gastrectomy for advanced gastric cancer with situs inversus totalis:A case report

Situs inversus totalis(SIT) is a rare anomaly in which the abdominal and thoracic cavity structures are located opposite to their usual positions. Occasionally,patients with this condition are diagnosed with malignant tumors. We report a case of a 60-yearold woman with gastric cancer and SIT. Laparoscopyassisted distal gastrectomy(LADG) with D2 lymph node dissection and Billroth Ⅱ anastomosis were performed successfully on the patient by careful consideration of the mirror-image anatomy. The operation required 230 min, and no intraoperative complications occurred. The final pathological report was p T4 a N0M0,according to the American Joint Committee on Cancer 7th edition staging guidelines. The postoperative course was favorable, and the patient was discharged on postoperative day 8. We believe that this is the first case of LADG with D2 lymphadenectomy reported in a SIT patient with advanced gastric cancer.     

Excluded gastric mucosa presenting as a polypoid tumor in the duodenal stump after B II resection

We present endoscopic findings of a polypoid tumor in the duodenal stump after Billroth II partial gastric resection in a 61-year-old male. Histologic examination of the tumor revealed gastric mucosa of antral type. Accordingly, Congo red dyeing test failed to show acid secretion. The excluded antral mucosa did not gain any clinical significance in this patient since there was no history of peptic ulcer relapse within the 25 years after gastric operation.     

Ulcer surgery - what remains?

Ulcer surgery today concentrates on the complications of chronic ulcer disease, especially ulcer perforation and endoscopically uncontrollable ulcer bleeding. In this case the laparoscopic or open closure of the gastroduodenal defect or local hemostasis of the bleeding ulcer by laparotomy are the main aims of surgery. Elective operations due to recurrent gastric or duodenal ulcers have become rare. An indication for gastric ulcer resistant to conservative therapy could be persisting suspicion of malignancy whereas in duodenal ulcer gastric outlet obstruction represents a reason for surgery. If these indications are confirmed the classic procedures of gastric resection like Billroth I and Billroth II are performed whereas vagotomy is no longer used. Altogether ulcer surgery has become very safe although it is practiced quite rarely.     

Ulkuschirurgie – was bleibt?

Ulcer surgery today concentrates on the complications of chronic ulcer disease, especially ulcer perforation and endoscopically uncontrollable ulcer bleeding. In this case the laparoscopic or open closure of the gastroduodenal defect or local hemostasis of the bleeding ulcer by laparotomy are the main aims of surgery. Elective operations due to recurrent gastric or duodenal ulcers have become rare. An indication for gastric ulcer resistant to conservative therapy could be persisting suspicion of malignancy whereas in duodenal ulcer gastric outlet obstruction represents a reason for surgery. If these indications are confirmed the classic procedures of gastric resection like Billroth I and Billroth II are performed whereas vagotomy is no longer used. Altogether ulcer surgery has become very safe although it is practiced quite rarely.     

Esophageal stricture with Barrett’s esophagus due to alkaline reflux after total gastrectomy successfully managed by duodenal diversion

A case of esophageal stricture with Barrett’s esophagus after total gastrectomy is reported herein. A 72-year-old woman was referred to our hospital because of dysphagia due to a stricture in the esophagus for 5 years. She had earlier undergone total gastrectomy followed by Billroth II reconstruction consequent to a gastric ulcer at the age of 49 years. She was diagnosed as having an esophageal stricture with Barrett’s esophagus. The 24-h pH monitoring indicated significant reflux of alkaline duodenal contents into the esophagus. The patient underwent duodenal diversion with Roux-en-Y reconstruction. The postoperative course has been uneventful, with no dysphagia and no dilatation. No change in the extent of Barrett’s esophagus has been observed to date at 7 years postoperatively. This case presented with development of Barrett’s esophagus and subsequently of esophageal stricture solely by duodenal reflux. Duodenal diversion was concluded to have been effective for esophageal stricture with Barrett’s esophagus after total gastrectomy.