Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_857_Библиотеки_им_академика_М_И_Перельмана
.pdf
26 How toManage Conditions oftheStomach inLow- andMiddle-Income Countries
https://t.me/medicina_free
307
The common complications of ulcers are
bleeding, perforation, stulation, and gastric
outlet obstruction when an ulcer is unattended
to. Perforations are usually anteriorly placed
and are cataclysmic events necessitating emergent surgical intervention. The incidence of perforations [7] is described as being anywhere
between 2% to 10%; this has decreased with
liberal use of H2 blockers and proton pump
inhibitors which usually are not readily available in LMICs. Haemorrhage, if posterior, is a
profuse life-threatening event mandating emergent intervention. Less profuse bleeding also
necessitates endoscopic examination and nonoperative intervention if possible.
The diagnosis of ulcer disease is primarily
endoscopic. All ulcers should be four quadrant
biopsied if they have the following features
suspicious of malignancy; raised edges, ulcers
more than 1cm in diameter, and friable mass
lesions, with altered morphology of the adjoining mucosa are features that must alert the
endoscopist to a malignancy. Only in areas
with a low prevalence of gastric cancer is there
a role of not taking biopsies from an innocuous ulcer that does not have suspicious features. H. pylori testing should be routine in all
patients with ulcer disease. A “test and treat”
policy may be more cost-effective, but in areas
of high incidence of H. pylori with symptoms,
the reverse “treat and test” policy may be
justified.
Perforation
The typical “air under the diaphragm” is found in
only15% of all duodenal perforations. Late presentations may seal off the perforation and permit
absorption of the air, whereas very early perforations may not permit visualization on radiography. The rare posterior perforation may permit
air to outline the right heart border or highlight
the medial cardiophrenic angle. CT scan ndings
may show a mucosal discontinuity or demonstrate a mucosal outpouching of an ulcer crater
extending through variable thickness of the gastric wall [8].
Fistulation
Fistulation into a perivisceral abscess cavity,
including the lesser sac, or into adjacent coelomic cavities can result in biliary enteric stulae
that present with chronic symptoms [9] or with
acute life-threatening symptoms if blood vessels
are breached [10], such as the pancreatico- or
gastroduodenal artery.
The treatment of ulcer disease, unless complicated, is primarily medical. Eradication of H.
pylori yields higher healing rates [11] and lower
recurrence rates [12]. Discontinuing NSAIDS,
continuing proton pump inhibitors for 2 weeks
for uncomplicated ulcers and up to 12weeks for
complications usually permits healing and prevents recurrences. Continuation of NSAID use, if
mandated, is to be considered with concurrent
use of proton pump inhibitors to prevent
recurrences.
Bleeding
Patients who present with upper gastrointestinal
haemorrhage are best managed algorithmically
(see Fig. 26.1). All patients who present with
bleeding whether profuse and fresh, or altered
blood with melena per rectum, are rst resuscitated with two large bore IV cannulae, nasogastric tube in situ, and Foley catheter in situ and
admitted to a high dependency or intensive care
unit. Labs are procured for haematocrit and for
cross matching blood wherever the facilities
exist. Using matched family donors urgently is an
option that should be exercised if necessary. A
good history and examination can differentiate
the probability of the aetiology of haemorrhage
being either variceal or non-variceal. If non variceal, all patients who remain tachycardic and
unstable require endoscopy. The patients who
stabilize with intravenous proton pump inhibitor
therapy may be endoscoped electively.
On endoscopy the stigmata of recent haemorrhage and the Forrest classication [13] which
straties severity of upper GI bleeding according to the endoscopic ndings and thus permits
decisions to intervene or follow up [14]. Actively
308
https://t.me/medicina_free
P. V. Alexander and M. Jacob
ab
Fig. 26.1 (a, b) Gastric carcinoma: (a) CT view with large defect; (b) gross pathologic specimen
bleeding or oozing ulcers, or those with a visible
vessel or clot, need intervention to control bleeding and prevent a rebleed while those with at pigmented spot or clean ulcer base do not. Intravenous
proton pump inhibitors and tranemexic acid prior
to endoscopic intervention and adequate preparation for the endoscopy are vital in remote locations
distant from tertiary help in LMICs.
The endoscopic intervention of bleeding ulcers
should not be undertaken lightly. It is best conducted in the main operating theatre and not in an
adjacent endoscopic suite, with the patient intubated to protect the airway and avoid aspiration of
blood. A good working endoscope with clear air
and water channels is mandatory and so is a team
practised and well versed in the steps of intervention since the procedure is dependent on multiple
operators, one to manoeuver the endoscope and
another to man the injection cannula. Banding is
the procedure of choice, but not many peripheral
centres may possess the technology or expertise
to permit banding. Injection sclerotherapy is the
next best alternative, using a sclerosant agent, or
absolute alcohol. The injection of cyanoacrylate
glue will require disposable cannulae and practised assistants to permit execution without the
glue solidifying in the cannula itself. Intralesional
or perilesional techniques may be used depending
on the choice of the endoscopist and ndings at
the time of endoscopy. A relay of pre-loaded
syringes with saline permits quick ushing of
blood and visualization of the source of bleeding
in an otherwise bloody eld. Post sclerotherapy
observation in a high dependency unit with blood
cross matched and at hand is ideal for the next
72hours prior to discharge. Large (>1cm) ulcers
in the stomach are best biopsied to rule out malignancy or biopsied at a later elective sitting.
Bleeding from posterior ulcers involving the gastroduodenal artery can be torrential and difcult
to control endoscopically. Advanced centres can
use the thermal gold electrode coagulation or
clips to attain haemostasis, but these measures are
not available easily in LMICs in remote regions.
When the arterial bleeding cannot be controlled,
the procedure can be converted into an open procedure, and the artery approached with an anterior
duodenotomy and controlled with a horizontal
mattress stitch, being careful not to take sutures
too deep to involve the common bile duct.
Other common causes of non-variceal bleeds
are outlined in Table26.2.
Stress ulcerations can be very troublesome in
patients who are admitted to the intensive care
unit and be hypotensive as a result of multiple
ulcerations in the stomach, extending into the GI
tract. The treatment is primarily medical and supportive. Less severe stress ulcerations may not be
diagnosed, and endoscopy is challenging with the
patient on multiple inotropic supports and on
assisted ventilation.
Mallory-Weiss tears occur at the gastroesophageal junction as a result of violent retching, usually in alcoholics. While this bleeding is
usually self-limiting, it could result in massive
haemorrhage needing endoscopic intervention.
26 How toManage Conditions oftheStomach inLow- andMiddle-Income Countries
https://t.me/medicina_free
309
Table 26.2 Causes of non-variceal upper GI
haemorrhage
•Gastric and/or duodenal ulcers
•Severe or erosive gastritis/duodenitis
•Severe or erosive oesophagitis
•Stress ulceration
•Portal hypertensive gastropathy
•Angiodysplasia (also known as vascular ectasia)
•Mallory-Weiss syndrome
•Mass lesions (polyps/cancers)
•No lesion identied (10–15% of patients).
•Dieulafoy lesion
•Gastric antral vascular ectasia
•Haemobilia
•Hemosuccus pancreaticus
•Aortoenteric stula
•Cameron lesions
•Ectopic varices
•Iatrogenic bleeding after endoscopic interventions
Vascular ectasias and Dieulafoy lesions are
sinister causes that may be difcult to diagnose,
presenting with massive haemorrhage causing
hypotension. Endoscopy during an active bleeding episode is the best chance at nding them
because the vessel retracts when the patient is
stable or the bleeding is quiescent. Dieulafoy
lesions are usually in the territory of the left gastric artery, and recurrent and troublesome bleeding without visualization of the culprit vessel
may validate the role of prophylactic ligation of
the left gastric artery to prevent further rebleeds.
Large (>1 cm) bleeding gastric ulcers especially in an elderly patient will need wide excision of the ulcer at the least and an antrectomy or
subtotal gastrectomy at best, due to the possibility of a malignancy. Endoscopic control of the
bleeding and biopsy followed by subsequent
denitive management is the safer alternative,
decreasing the morbidity and mortality of
attempting resection emergently in an unstable
patient.
upper abdominal pain “like a bolt from the blue”,
it is still a contender in the causes of the acute
surgical abdomen in LMICs. Duodenal perforations are more common than gastric perforations,
and large gastric ulcer perforations, especially in
the elderly, may be manifestations of a malignancy lurking in the ulcer, thus requiring denitive management rather than just a closure of the
perforation. The Modied Roscoe Graham
omental patch technique is the time tested procedure of choice for the perforated duodenal ulcer,
where a strip of vascularized omentum is used to
seal the perforation with three retaining sutures
of silk, followed by subsequent H. pylori eradication therapy on follow-up. Large perforations
may still permit this technique to be used by rst
tying the suture to permit approximation and then
applying the omentum over it.
A chronic scarred and deformed duodenum or
a very large perforation may be better served by
converting the perforation into a pyloroplasty,
with or without a vagotomy. Posterior duodenal
perforations are rare and difcult to diagnose
with the absence of free air under the diaphragm.
Suggestion of this perforation may be found by
noticing air outlining the right border of the heart
or when the left cardiophrenic angle is outlined
by air. Intraoperative injection of sparkling water
may be done to note the air bubbles (better than
methylene blue which discolours the whole eld.
Kocherization of the duodenum, and closure of
the perforation with or without an omental patch,
is the treatment of choice. Posterior ulcers are
more prone to bleed than perforate. Follow-up
endoscopy to document healing of the ulcer is
rarely indicated, but measures to avoid reinfection with Helicobacter such as boiling the drinking water and avoidance of smoking are simple
measures to prevent recurrence [16].
Perforation
Gastric and duodenal perforations are very common presentations in LMICs, though literature
has reported decrease in incidence with the wide
use of proton pump inhibitors [15]. Presenting
with the classic history of the sudden onset of
Bezoars
Bezoars are an uncommon cause of gastric outlet
obstruction when patients who are mentally challenged compulsively swallow foreign bodies,
hair, or vegetable matter that conglomerates in
the stomach into a bezoar. Vegetable matter
310
https://t.me/medicina_free
P. V. Alexander and M. Jacob
bezoars (phytobezoars) and hair bezoars (trichobezoars) often have long tails that may enter and
populate the proximal jejunum. A variety of other
swallowed objects may constitute foreign body
bezoars. Endoscopic diagnosis and surgical
removal via an anterior gastrotomy is the treatment of choice. Psychiatric and psychologic
assistance postoperatively is mandatory to
address the root cause of the problem.
Gastric Cancer
Epidemiology andDemographics
Gastric cancer is a sleeper. Investigations after
the onset of symptoms usually reveal widespread
disease. Screening programs in high-risk countries permit early detection and treatment. Highrisk areas may condense into geographical
regions even within countries. The ubiquitous
banner of “gastritis” camouages and permits
insidious growth of the carcinoma till it presents
itself as unresectable or metastatic. 25% of these
patients would have had a history of ulcer disease
in the past, and the relationship with H. pylori
infection charts a pathway from gastritis to transformation into carcinoma.
Gastric cancer is the fth most common cancer and the third leading cause of cancer-related
mortality after lung and colorectal cancers, contributing to more than one million cases per year
[17]. Gastric cancer incidence rates increase with
increasing age and are twofold to threefold higher
for men than women [18]. Gastroesophageal
junctional and proximal gastric cancers have
greatly increased while distal lesions have
decreased. Early diagnosis of gastric cancer is
difcult because most patients are asymptomatic
in the early stage. Adenocarcinoma is the most
common malignancy affecting the stomach. It
accounts for 90% of malignant tumours found
within the stomach; and the rest include lymphomas, carcinoids, and gastrointestinal stromal
tumours.
Distal gastric cancers are more common in
developing countries and in the lower socioeconomic groups. Environmental factors like
chronic infection with H. pylori are the main
cause of gastric cancer, accounting for approximately 90% of distal gastric cancer cases worldwide [19]. Dietary substances such as nitrates and
nitrites and, in particular, N-nitrosodimethylamine
(NDMA) have increased the risk of gastric cancer.
NDMA occurs in dietary foods as a food additive
often used in processed meats and is a potential
carcinogen [20]. Proximal tumours are predominating in developed countries, among whites, and
in higher socio-economic classes; the major risk
factors for proximal cancers are gastroesophageal
reux disease and obesity [21]. Smoking increased
the risk of gastric cancer, especially for proximal
gastric cancers, and the magnitude of risk linearly
increases with number of cigarettes per day and
duration of smoking [22]. An excess body mass
index (over 25 kg/m2) has a 1.13 odds ratio of
developing cancer [23]. The strength of the association increased with increasing BMI. There is
also an increased risk of gastric cancer with high
alcohol consumption. Risk of gastric cancer is up
to tenfold higher in persons with a family history
of gastric cancer [24] and in those who have had
previous gastric resection or duodenal bypass
with reux of bile or pancreatic secretions [25].
Chronic atrophic gastritis with pernicious anaemia and adenomatous polyps, but not hyperplastic, have signicant malignant potential.
History
A signicant number of patients with gastric cancer have a history of gastric ulcer.
Overt or occult gastrointestinal bleeding, with
haematemesis or melaena, is seen in one fth of
the patients who may present to the hospital with
anaemia. Abdominal mass is the most common
physical nding in advanced disease. Many of the
patients may present with signs or symptoms of
distant metastatic disease. The most common
sites of metastatic disease are the liver, the
peritoneal surfaces, and para-aortic lymph nodes
and less commonly, ovaries in female patients, the
brain, bone, lungs, and soft tissue. Common presenting symptoms, besides gastritis, are weight
loss, anaemia, and epigastric pain. Melaena is
26 How toManage Conditions oftheStomach inLow- andMiddle-Income Countries
https://t.me/medicina_free
311
often noticed but ignored. Dysphagia occurs in
proximal and oesophagogastric junction carcinoma. Early satiety and nausea are also symptoms
that lurk for a while prior to presentation.
Physical Examination
A palpable mass is indicative of disease that has
already spread locally or systemically. Distant
spread to ovaries, liver, or to distant organs may
also be the primary presentation of gastric carcinoma. Metastases to the left supraclavicular node
(Virchow’s node), umbilicus (Sister Mary
Joseph’s nodule), or the axilla (Irish node) may
be detectable signs on general physical examination. Jaundice from the liver metastases, ascites,
and gastric outlet obstruction are also late presenting features. Jaundice is occasionally seen
with locally advanced distal tumours with periportal lymph nodes causing biliary obstruction.
Very rarely, direct inltration of gastric cancer to
the transverse colon resulting in gastrocolic stula, patient presents with feculent vomiting or
passage of recently ingested material in the stool.
Often, inltration into the pancreas causes severe
back pain. More subtle presentations of a coincident paraneoplastic process may be with acanthosis nigricans pigmentation in skin folds,
polyarteritis nodosa or microangiopathic haemolytic anaemia, membranous nephropathy, diffuse
seborrheic keratosis (Leser Trelat sign), or hypercoagulability (Trousseau syndrome). Peritoneal
spread can present with an enlarged ovary
(Krukenberg tumour) or a mass in the cul-de-sac
on rectal examination (Blumer’s shelf). Presence
of ascites can also be the rst indication of peritoneal carcinomatosis.
Investigations
A patient with suspected gastric malignancy warrants the following investigations.
Liver function tests, creatinine, chest X-ray,
and upper GI endoscopy which is the primary
modality of investigation of any suspected gastric
cancer is an upper GI endoscopy (OGD), which
allows the direct visualisation and identify the
location of lesion and biopsies can be taken as
required. Gastroscopy is recommended for any
patient with new-onset dysphagia or aged
>55 years with signicant unintentional weight
loss, epigastric pain, or reux.
The traditional barium meal with follow
through has now largely been replaced by endoscopy and the CT scan, both of which are able to
provide diagnosis, histopathologic evidence, and
capability of staging the extent of the disease at
presentation [26]. Barium studies have a limited
role in identifying the gastric lesions; sensitivity
is as low as 14% in identifying early gastric cancers. Linitis plastica is the only variety of carcinoma best diagnosed by barium meal examination,
which is capable of demonstrating the “leather
bottle” stomach.
Contrast-enhanced computed tomography
(CECT): CT scan of the abdomen and pelvis provides information about the primary tumour,
local extent of the lesion, and distal metastatic
ndings such as ascites, peritoneal metastases,
liver metastases, and peri-gastric and distant
nodal disease. However, CT imaging cannot reliably detect subcentimetre lymph nodes, solitary
liver, and lung metastasis smaller than 5mm and
depth of tumour invasion.
MRI scans should be reserved to conrm liver
metastasis.
18-uorodeoxyglucose positron emission
tomography scan (PET scan): It is reserved for
patients with equivocal ndings of possible
metastasis on CECT scan. However, diffuse or
mucinous gastric tumours are not FDG avid. The
sensitivity of PET scanning for peritoneal carcinomatosis is only approximately 50 percent [27].
Gastric carcinoma may present in a variety of
morphologies at endoscopy. The characteristic
large friable ulcer with overhanging ulcer edge
margins is easily biopsied for conformation. Any
large gastric ulcer merits a biopsy since the wide
based at ulcer or mucosal thickening may also
bely the insidious growth of gastric carcinoma.
The biopsy technique of taking multiple (as many
as 7) biopsies increases the yield of diagnosis
rather than relying on a few samples of seemingly representative specimen.
312
https://t.me/medicina_free
P. V. Alexander and M. Jacob
Staging andTreatment
The Japanese classication has gradually given
way to the universal AJCC/IUCC TNM classication system, as the treatment of this disease has
now changed to incorporate neoadjuvant chemotherapy. The treatment of this disease can be
divided into the treatment of early disease,
locoregional disease, or systemic disease as
described below. The details of adjuvant therapy
are not discussed here since these require patient
management in a centre where specialized cancer
is practised. We focus in this chapter primarily on
urgent care of patients with gastric cancer.
Staging Laparoscopy
Staging laparoscopy is performed to detect occult
peritoneal dissemination in physically t patients
who appear to have locoregional disease in staging investigations, who are considered for neoadjuvant chemotherapy followed by curative
resection. If staging indicates need for neoadjuvant chemotherapy, patient should be transferred
to an oncology center.
Peri-Operative Chemotherapy/NeoAdjuvant Chemotherapy
Peri-operative chemotherapy further treatment of
localized gastric cancer has been the standard of
care in many countries after the signicant major
clinical trials (MAGIC, FNCLOC, EORCC)
which showed statistically signicant improvement in terms of 5-year and overall survival as
compared to the surgery alone patients [28]. The
two main benets of peri-operative chemotherapy are down staging of disease for surgical
resection and to prevent micro metastasis.
Detailed discussion of the types of pre- and postoperative chemotherapy for gastric cancer is
beyond the scope of this book, and the reader is
advised to consult recent standard textbooks and
the literature on this subject.
Adjuvant chemotherapy in patients with
locally advanced disease without any metastasis
who underwent radical gastrectomy with D2
lymphadenectomy, adjuvant chemotherapy had
signicant benet disease-free survival and overall survival [29].
Staging
• TNM staging of gastric cancer AJCC eighth
Edition: Table26.1.
• Initial preoperative staging work up enables
patients to be classied into three clinical
stage groups:
1. Localized cancer (stages cTis or cT1a).
2. Locoregional cancer (stages cT1b–cT4a;
cM0).
3. Metastatic cancer (stage cT4b; cM1).
• Carcinoma stomach treatment ow chart:
Image 1.
Role ofPerioperative Nutrition
In patients with proximal gastric cancers who
have dysphagia should have preoperative nasogastric feeding and distal tumours with gastric
outlet obstruction should have nasojejunal feeding till the time of surgery. There is no role of
perioperative total parenteral nutrition (TPN).
Immune nutrition may be useful in reducing the
postoperative morbidity but has no impact on
mortality.
Surgery
Peri-operative chemotherapy has made signicant disease regression inlocally advanced gastric adenocarcinoma. En block resection of
primary tumour along with regional lymph node
resection remains the cornerstone of therapy. The
decision of total or subtotal gastrectomy depends
on the location, extent, and histology of the
tumour with lymphadenopathy. Surgical resection
includes resection of primary tumour with the
tumour-free margins of at least 4cm with adequate lymphadenectomy (minimum 16 nodes) to
ensure optimum curative resection.
Tumour located in the antrum and lower 2/3
of the stomach can be treated with subtotal gastrectomy, while tumours located in the proximal
or upper third of the stomach and type III
Siewert gastroesophageal junction tumour and
gastric tumour with linitis plastica will require
more extensive resection, including total
gastrectomy.
26 How toManage Conditions oftheStomach inLow- andMiddle-Income Countries
https://t.me/medicina_free
313
Lymphadenectomy
Although there is no worldwide consensus on the
extent of lymphadenectomy, traditionally in East
Asia and Japan, D2 lymphadenectomy is practised, and this is an extensive and aggressive
lymphadenectomy. However, D1+ lymphadenectomy which includes peri-gastric lymph nodes
and nodes along coeliac artery and its branches,
is generally recommended in the West and is
associated with low postoperative morbidity and
mortality.
Reconstruction
After subtotal or total gastrectomy, reconstructive procedure is determined based on the surgeon’s individual experience. There is a lack of
evidence for the best optimal reconstruction
procedure in the available literature. Roux-en-Y
jejunal reconstruction with gastrojejunostomy
and jejunojejunostomy, 40 to 60cm below the
GJ to avoid bile reux, is the most frequently
performed procedure worldwide (Fig.26.2).
Follow-Up
At present, the National Comprehensive Cancer
Network (NCCN) guidelines on follow-up and
surveillance of gastric cancer recommends a history and physical every 3–6months for 1–2years,
followed by every 6–12months for 3–5 years,
and then annually. Investigations including complete blood count (CBC), creatinine, liver func-
tion tests, and radiological imaging are
recommended; in addition, the NCCN also recommends monitoring for nutritional deciency
(e.g. B12, calcium, and iron) in surgically
resected patients. Upper GI endoscopy surveillance at least every 2years is recommended in
higher-risk populations, inpatients with other
underlying disorders that increase risk, like intestinal metaplasia or dysplasia, and in patients with
closed resection after total or subtotal gastrectomy [30].
Palliation
Best Supportive Care
The main focus for patients who are too frail to
have chemotherapy or surgical excision, or those
who have unresectable disease and/or metastatic
disease, is to relieve their symptoms and support
them and their families through a terminal illness.
Nausea and vomiting is treated with anti- emetics
such as granisetron and ondansetron. Poor appetite
may respond to steroids such as dexamethasone.
In locally unresectable, metastatic gastric cancers with obstruction, bleeding, perforation, and
pain, a palliative resection or a gastrojejunostomy
is advised if it can be tolerated. There is no role
for lymphadenectomy or multiorgan resection,
liver resection, or peritoneal cytoreduction for
metastatic disease. There is no survival benet
Fig. 26.2 Reconstruction
after subtotal gastrectomy
and total gastrectomy
314
https://t.me/medicina_free
P. V. Alexander and M. Jacob
related to palliative gastrectomy. Patients with
gastric outlet obstruction who have persistent
vomiting may benet from the endoscopic placement of a self-expanding metallic stent, although
the results are unpredictable. Palliative chemotherapy is recommended in t patients with metastatic and unresectable disease. Bleeding from
advanced gastric tumours can be troublesome
and can be greatly reduced by a short course of
external beam radiation.
Prognosis
Overall 5- year survival rates for stomach cancer
are 32%; if the tumour hasn’t spread outside the
stomach (localized), 70%; and if tumours have
spread to nearby lymph nodes or structures outside the stomach (regional), 32%. In metastatic
disease, 5-year survival is as low as 6% [31].
Treatment ofRecurrent Disease
Patients with recurrent disease should be evaluated to distinguish isolated locoregional recurrence should be evaluated for disease control
using surgery, chemotherapy, radiotherapy, or a
combination of the above. Patients who are not
suitable or unt for denitive treatment and with
distant metastases should be treated
symptomatically.
References
1. Dent J, El-Serag HB, Wallander MA, Johansson
S. Epidemiology of gastro-oesophageal reux disease: a systematic review. Gut. 2005;54(5):710.
2. Dan YY, So JB, Yeoh KG. Endoscopic screening for gastric cancer. Clin Gastroenterol Hepatol.
2006;4(6):709.
3. Lu CL, Chang SS, Wang SS, Chang FY, Lee
SD. Silent peptic ulcer disease: frequency, factors
leading to "silence," and implications regarding the
pathogenesis of visceral symptoms. Gastrointest
Endosc. 2004;60(1):34.
4. Wilcox CM, Clark WS. Features associated with
painless peptic ulcer bleeding. Am J Gastroenterol.
1997;92(8):1289.
5. Barkun A, Leontiadis G. Systematic review of the
symptom burden, quality of life impairment and
costs associated with peptic ulcer disease. Am J Med.
2010;123(4):358.
6. Kang JY, Yap I, Guan R, Tay HH.Acid perfusion of
duodenal ulcer craters and ulcer pain: a controlled
double blind study. Gut. 1986;27(8):942.
7. Chung KT, Shelat VG. Perforated peptic ulcer—an
update. World J Gastrointest Surg. 2017;9(1):1.
8. Tonolini M, Ierardi AM, Bracchi E, Magistrelli P, Vella
A, Carraello G.Non-perforated peptic ulcer disease:
multidetector CT ndings, complications, and differential diagnosis. Insights Imaging. 2017;8(5):455.
Epub 2017 Jul 4
9. Van Steenbergen W, Ponette E, Marchal G, Fevery J,
De Groote J. Distal common bile duct stenosis secondary to benign duodenal ulceration: report of a
case. Gastrointest Radiol. 1990;15(3):215.
10. Odze RD, Bégin LR. Peptic-ulcer-induced aortoenteric stula. Report of a case and review of the literature. J Clin Gastroenterol. 1991;13(6):682.
11. Leodolter A, Kulig M, Brasch H, Meyer-Sabellek
W, Willich SN, Malfertheiner P. A meta-analysis
comparing eradication, healing and relapse rates in
patients with Helicobacter pylori-associated gastric or duodenal ulcer. Aliment Pharmacol Ther.
2001;15(12):1949–58.
12. Ford AC, Delaney BC, Forman D, Moayyedi
P.Eradication therapy in Helicobacter pylori positive
peptic ulcer disease: systematic review and economic
analysis. Am J Gastroenterol. 2004;99(9):1833–55.
13. Forrest JA, Finlayson ND, Shearman DJ.Endoscopy in
gastrointestinal bleeding. Lancet. 1974;2(7877):394.
14. Katschinski B, Logan R, Davies J, Faulkner G, Pearson
J, Langman M.Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci. 1994;39(4):706.
15. Bashinskaya B, Nahed BV, Redjal N, Kahle KT,
Walcott BP. Trends in peptic ulcer disease and the
identication of helicobacter pylori as a causative
organism: population-based estimates from the US
Nationwide inpatient sample. J Glob Infect Dis.
2011;3(4):366–70.
16. Bellack NR, Koehoorn MW, MacNab YC, Morshed
MG.A conceptual model of water's role as a reservoir
in helicobacter pylori transmission: a review of the
evidence. Epidemiol Infect. 2006;134(3):439. Epub
2006 Mar 2
17. Bray F, Ferlay J, Soerjomataram I, Siegel RL,
Torre LA, Jemal A. Global cancer statistics 2018:
GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA
Cancer J Clin 2018;68(6):394–424. doi:https://doi.
org/10.3322/caac.21492.
18. Gastric cancer: overview. Gastroenterol Clin N Am.
2013;42:211–7.
19. Correa P.Helicobacter pylori and gastric carcinogenesis. Am J Surg Pathol. 1995;19(Suppl 1):S37–43.
20. Tricker AR, Preussmann R. Carcinogenic
N-nitrosamines in the diet: occurrence, formation,
mechanisms and carcinogenic potential. Mutat Res.
1991;259:277–89.
26 How toManage Conditions oftheStomach inLow- andMiddle-Income Countries
https://t.me/medicina_free
315
21. Catalano V, Labianca R, Beretta GD, Gatta G, de
Braud F, Van Cutsem E. Gastric cancer. Crit Rev
Oncol Hematol. 2009;71:127–64.
22. Praud D, Rota M, Peluchi C, et al. Cigarette smoking and gastric cancer in the Stomach Cancer Pooling
(StoP) Project. Eur J Cancer Prev. 2018;27:124–33.
23. Bae J-M.Body mass index and risk of gastric cancer
in Asian adults: a meta-epidemiological meta-analysis
of population-based cohort studies. Cancer Res Treat.
2020;52:369–73.
24. Han X, Xiao L, Yu Y, etal. Alcohol consumption and
gastric cancer risk: a meta-analysis of prospective
cohort studies. Oncotarget. 2017;8:83237–45.
25. Namikawa T, Kitagawa H, Iwabu J, Okabayashi T,
Kobayashi M, Hanazaki K. Tumors arising at previous anastomotic site may have poor prognosis in
patients with gastric stump cancer following gastrectomy. J Gastrointest Surg. 2010;14:1923–30. https://
doi.org/10.1007/s11605- 010- 1298- 4. [PubMed]
26. Dooley CP, Larson AW, Stace NH, et al. Doublecontrast barium meal and upper gastrointestinal
endoscopy. A comparative study. Ann Intern Med.
1984;101:538.
27. Gertsen EC, Brenkman HJF, van Hillegersberg R,
etal. 18F-Fludeoxyglucose-positron emission tomography/computed tomography and laparoscopy for
staging of locally advanced gastric cancer: a multicentre prospective Dutch Cohort Study (PLASTIC).
JAMA Surg. 2021;156:e215340.
28. Yang Y, Yin X, Sheng L, Xu S, Dong L, Liu
L. Perioperative chemotherapy more of a benet
for overall survival than adjuvant chemotherapy for
operable gastric cancer: an updated meta-analysis.
Sci Rep. 2015;5:12850. https://doi.org/10.1038/
srep12850.
29. Paoletti X, Oba K, Burzykowski T, et al. For the
GASTRIC (Global Advanced/Adjuvant Stomach
Tumor Research International Collaboration) group.
Benet of adjuvant chemotherapy for resectable gastric
cancer: a meta-analysis. JAMA. 2010;303:1729–37.
30. NCCN Clinical practice guidelines in oncology
(NCCN guidelines): gastric cancer. Natl Comp
Cancer Netw Available at: http://NCCN.org.
31. Gastric Cancer, Version 2.2022. NCCN clinical practice guidelines in oncology. J Natl Compr Cancer
Netw. 2022;20:2. (jnccn.org)
How toDiagnose andManage
https://t.me/medicina_free
Acute Abdomen and
Intra-Abdominal Infections inLowandMiddle-Income Countries
MarkA.Hardy andChristineYang
The man who asks a question is a fool for a minute, the man who does not ask is a fool
for life.
– Confucius
27
Abbreviations
AA Acute appendicitis
ADA Adenosine deaminase
ATT Anti-tuberculosis therapy
CT Computerized tomography
DEC Diethylcarbamazine
GITB Gastrointestinal tuberculosis
HICs High-income countries
IAI Intra-abdominal infection
ICU Intensive care unit
ID Infectious disease
LMICs Low- and middle-income countries
MDA Mass drug administration
MDR Multidrug resistant
PPD Puried protein derivative skin test
SES Socio-economic status
SOFA Sequential (sepsis-related) Organ
Failure Assessment
USG Ultrasonography
M. A. Hardy (*) · C. Yang
Department of Surgery, Columbia University Vagelos
College of Physicians and Surgeons,
New York, NY, USA
e-mail: mah1@cumc.columbia.edu; cy2634@cumc.
columbia.edu
Introduction andBackground
Acute abdomen and intra-abdominal infections
(IAI) are surgical emergencies commonly
encountered in both HICs and LMICs, and a
major cause of non-traumatic deaths in LMICs.
Several studies have shown that operations for
IAIs account for approximately 11–12% of surgeries in LMICs. In a recent review, Sartelli etal.
reported that of 989 operations at one LMIC hospital, 299 (30.2%) were explorations for acute
abdomen. In that group, the male to female ratio
was 4.1:1, and patient ages ranged from 15 to
95 years [1]. In another series of 3114 surgical
patients in Ghana [2], (male-female ratio 2:1 and
similar age range to that in Sartelli’s series), the
most common indications for surgery were acute
appendicitis (22.4%), typhoid ileal perforations
(16.2%), acute intestinal obstruction (12.6%),
gastroduodenal perforations (11.0%), nonspecic abdominal pain (9.8%), abdominal injuries (8.3%), and acute cholecystitis 102 (3.2%),
with a surprisingly similar incidence of sigmoid
volvulus and small bowel obstruction (whereas
HICs encounter small bowel obstruction far more
frequently than sigmoid volvulus), and a relative
paucity of diverticular and neoplastic indications
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_27
317
Соседние файлы в папке Библиотека им академика М.И. Перельмана