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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1033_Библиотеки_им_академика_М_И_Перельмана

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M. T. Fastiggi and M. Abbas
Self-Expanding Metal Stents
Similar to benign disease, self-expanding metal stents can be used to stent across malignant obstructions. Differences include that fully covered metal stents are usually used to prevent tumor ingrowth and dysphagia or obstruction [28]. While surgical bypass or gastrojejunostomy provides better long-term resolution of obstructive symptoms from malignant gastric outlet obstruction, endoscopic stent placement is associated with a shorter time to return to food intake and is recommended for patients with a life expectancy <2months [29].
Surgical Bypass
In severe cases of malignant obstruction, surgical intervention may be necessary. In the setting of metastatic or unresectable locally advanced abdominal malignancies, surgical bypass via gastrojeju­nostomy may provide better long-term outcomes for reintervention and complications compared to enteral stent placement [29]. Therefore, depending on the specics related to the patient and his or her preferences, disease staging, and prognosis, a detailed discus­sion should be held to determine an informed individual decision.
Surgical bypass can be performed laparoscopically unless sig­nicant disease burden limits working space. A gastrojejunos­tomy should be performed distal to the area of obstruction. If the disease burden is locally advanced but has a focal area of obstruc­tion, palliative surgical resection can be considered. A decom­pressive gastrostomy tube may also be placed to vent proximal secretions if not fully drained via the surgical bypass.
Special Considerations
Esophagogastric Junction Outow Obstruction
Care must be taken not to confuse gastric outlet obstruction with the disease spectrum of esophagogastric junction outow obstruction (EGJOO). EGJOO is a motility disorder resulting in
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obstruction at the esophagogastric junction with preserved peri­stalsis [30]. While presenting symptoms can mimic some symp­toms of gastric outlet obstruction, especially postprandial nausea/vomiting, it is a different disease entirely. Diagnosis can be made via high resolution manometry, with further investiga­tion via endoscopy and contrast esophagrams to help delineate the etiology [30].
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Bariatric Surgery Complications
Several complications of bariatric surgical procedures can cause or mimic gastric outlet obstruction. Complications from Roux­en- Y gastric bypass, sleeve gastrectomy, and gastric banding will be discussed.
Roux-En-Y Gastric Bypass
The Roux-en-Y gastric bypass is a malabsorptive and restrictive procedure, during which a small gastric pouch is anastomosed to a limb of jejunum, while the gastric remnant, duodenum, and proximal jejunum are bypassed and anastomosed downstream of the gastrojejunal anastomosis. Rates of stomal stenosis at the gas­trojejunostomy range from 4% to 26% and is thought to be sec­ondary to tissue ischemia, marginal ulceration, tension, and the use of 21mm EEA staplers [31, 32]. Stomal stenosis occurs when luminal diameter falls below 10mm and clinically presents sev­eral weeks after surgery as progressively worsening nausea, vom­iting, dysphagia, and inability to tolerate diet [33]. Diagnosis can be made via endoscopy or contrast studies, and manometry may show impaired esophageal motility (Fig.23.2).
Management is usually successful with endoscopic dilation, usually over the course of several attempts [34]. Strictures refractory to attempts at dilation may ultimately require surgical revision.
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Complete Transit (Viscous: 10 swallows)
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M. T. Fastiggi and M. Abbas
Liquid Swallow 1
Findings LES
LESP (mid resp.) Total Length Median IRP EGJ Morphology
Lower Esophageal Body (Liquid: 10 swallows)
Chicago Classification Metrics
Normal DCI (450 - 8000) Mean DCI DCI Ratio *Ineffective Hypercontractile (DCI > 8000) Premature (DL < 4.5) Panesophageal **Pattern Classification
*Ineffective includes weak, failed, and fragmented swallows. **Pattern Classification does not constitute a diagnosis. It may be invalid if the patient has had prior related surgeries.
Impedance
Distal Baseline Impedance
Complete Transit (Liquid: 10 swallows)
Liquid Swallow 2Liquid Swallow 3Liquid Swallow 4Liquid Swallow 5
Normal
11 mmHg
2.4 cm 6 mmHg
Type III
80.0 % 1650 mmHg·s·cm
0.75
20.0 %
0.0 %
10.0 %
0.0 % Normal Esophageal Motility
1072 ohms
60.0 %
80.0 %
10-45
<= 20
>= 50.0
>0.85 < 50.0 < 20.0 < 20.0 <= 0.0
>= 80.0 >= 70.0
Fig. 23.2 Impaired esophageal motility following Roux-en-Y gastric bypass
Sleeve Gastrectomy
The sleeve gastrectomy involves creation of a restrictive “sleeve” of a stomach over a bougie, resecting the greater curvature. Narrowing can occur at the incisura angularis or gastroesophageal junction and is seen in 0.6–1% of sleeve gastrectomy patients [35].
Narrowing at the incisura angularis can mimic a gastric outlet obstruction as there is essentially a mechanical obstruction preventing passage of contents through the pyloric channel (Figs. 23.1 and 23.3). This most commonly occurs either from selection of a bougie that was too small, stapling too close to the pylorus, or narrowing after stapling secondary to oversewing of the staple line. Management can be performed initially with endo­scopic dilation or stenting, and if unsuccessful, may require con­version to Roux-en-Y gastric bypass.
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Fig. 23.3 Gastric outlet obstruction following sleeve gastrectomy, with two high pressure zones distal to the lower esophageal sphincter
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Gastric Banding
Gastric banding is a purely restrictive procedure that involves the placement of a restrictive band around the cardia of the stomach. The procedure has largely fallen out of favor due to disappointing long-term weight loss and relatively high morbidity with high revision rates [36]. Acute stomal obstruction is an early postop­erative complication that can mimic gastric outlet obstruction. The etiology can be secondary to edema or due to an error in technique. If due to edema, obstruction may resolve with nasogas­tric decompression. Obstruction secondary to technical error usu­ally requires band revision or removal [33].
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M. T. Fastiggi and M. Abbas
References
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2. Frederickson D, Gan SI, Howell DA, Travis AC.Gastric outlet obstruc­tion in adults. Waltham, MA: UpToDate; 2020. Accessed 14 Aug 2020.
3. Kreel L, Ellis H. Pyloric stenosis in adults: a clinical and radiological study of 100 consecutive patients. Gut. 1965;6(3):253.
4. Shone DN, Nikoomanesh P, Smith-Meek MM, Bender JS.Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers. Am J Gastroenterol. 1995;90(10):1769.
5. Tendler DA. Malignant gastric outlet obstruction: bridging another divide. Am J Gastroenterol. 2002;97(1):4.
6. Samad AB, Whanzada TW, Shoukat IM. Gastric outlet obstruction: change in etiology. Pak J Surg. 2007;23(1):29–32.
7. Arabi NA, Musaad AM, Ahmed EE, Ibnouf MM, Abdelaziz MS.Primary gastric tuberculosis presenting as gastric outlet obstruction: a case report and review of the literature. J Med Case Rep. 2015;9(1):265.
8. Lau JY, Chung SS, Sung JJ, Chan AC, Ng EK, Suen RC, Li AK.Through­the- scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc. 1996;43(2):98–101.
9. Awan A, Johnston DE, Jamal MM.Gastric outlet obstruction with benign endoscopic biopsy should be further explored for malignancy. Gastrointest Endosc. 1998;48(5):497–500.
10. Jaka H, Mchembe MD, Rambau PF, Chalya PL.Gastric outlet obstruc­tion at Bugando medical Centre in Northwestern Tanzania: a prospective review of 184 cases. BMC Surg. 2013;13(1):1–8.
11. Taskin V, Gurer I, Ozyilkan E, Sare M, Hilmioglu F. Effect of helico­bacter pylori eradication on peptic ulcer disease complicated with outlet obstruction. Helicobacter. 2000;5(1):38–40.
12. Brandimarte G, Tursi A, Gasbarrini G.Antimicrobial treatment for peptic stenosis: a prospective study. Eur J Gastroenterol Hepatol. 1999;11(7):731–4.
13. Storm AC, Ryou M.Advances in the endoscopic management of gastric outow disorders. Curr Opin Gastroenterol. 2017;33(6):455–60.
14. Kozarek RA, Botoman VA, Patterson DJ.Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction. Gastrointest Endosc. 1990;36(6):558–61.
15. Kochhar R, Kochhar S.Endoscopic balloon dilation for benign gastric outlet obstruction in adults. World J Gastrointest Endosc. 2010;2(1):29.
16. Sonntag CC, Pauli EM.Medical and endoscopic management of gastric outlet obstruction. In: The SAGES manual of foregut surgery. Cham: Springer; 2019. p.749–78.
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17. Rana SS, Bhasin DK, Chandail VS, Gupta R, Nada R, Kang M, Nagi B, Singh R, Singh K.Endoscopic balloon dilatation without uoroscopy for treating gastric outlet obstruction because of benign etiologies. Surg Endosc. 2011;25(5):1579–84.
18. Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Tokar JL.Tools for endo­scopic stricture dilation. Gastrointest Endosc. 2013;78(3):391–404.
19. Cherian PT, Cherian S, Singh P. Long-term follow-up of patients with gastric outlet obstruction related to peptic ulcer disease treated with endo­scopic balloon dilatation and drug therapy. Gastrointest Endosc. 2007;66(3):491–7.
20. DiSario JA, Fennerty MB, Tietze CC, Hutson WR, Burt RW.Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction. Am J Gastroenterol. 1994;89(6):868.
21. Kim JH, Shin JH, Song HY.Benign strictures of the esophagus and gas­tric outlet: interventional management. Korean J Radiol. 2010;11(5):497–
506.
22. Ramage JI Jr, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murray JA, Norton ID, Diehl N, Romero Y.A prospective, randomized, double- blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol. 2005;100(11):2419–25.
23. Kochhar R, Poornachandra KS.Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc. 2010;2(2):61.
24. Kim KY, Tsauo J, Song HY, Kim PH, Park JH.Self-expandable metallic stent placement for the palliation of esophageal cancer. J Korean Med Sci. 2017;32(7):1062–71.
25. Heo J, Jung MK.Safety and efcacy of a partially covered self- expandable metal stent in benign pyloric obstruction. World J Gastroenterol: WJG. 2014;20(44):16721.
26. Boylan JJ, Gradzka MI.Long-term results of endoscopic balloon dilata­tion for gastric outlet obstruction. Dig Dis Sci. 1999;44(9):1883–6.
27. Csendes A, Maluenda F, Braghetto I, Schutte H, Burdiles P, Diaz JC. Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Am J Surg. 1993;166(1):45–9.
28. Wang C, Wei H, Li Y.Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis. BMC Cancer. 2020;20(1):73.
29. Jeurnink SM, Steyerberg EW, van Hooft JE, van Eijck CH, Schwartz MP, Vleggaar FP, Kuipers EJ, Siersema PD, Dutch SUSTENT Study Group. Surgical gastrojejunostomy or endoscopic stent placement for the pallia-
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tion of malignant gastric outlet obstruction (SUSTENT study): a multi­center randomized trial. Gastrointest Endosc. 2010;71(3):490–9.
30. Samo S, Qayed E.Esophagogastric junction outow obstruction: where are we now in diagnosis and management? World J Gastroenterol. 2019;25(4):411.
31. Schneider BE, Villegas L, Blackburn GL, Mun EC, Critchlow JF, Jones DB.Laparoscopic gastric bypass surgery: outcomes. J Laparoendosc Adv Surg Tech. 2003;13(4):247–55.
32. Qureshi A, Podolsky D, Cumella L, Abbas M, Choi J, Vemulapalli P, Camacho D.Comparison of stricture rates using three different gastroje­junostomy anastomotic techniques in laparoscopic roux-en-Y gastric bypass. Surg Endosc. 2015;29(7):1737–40.
33. Ellsmere J, Jones D, Chen W. Late complications of bariatric surgical operations. Waltham, MA: UpToDate; 2020. Accessed 14 Aug 2020.
34. Barba CA, Butensky MS, Lorenzo M, Newman R.Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Surg Endosc Other Interv Tech. 2003;17(3):416–20.
35. Burgos AM, Csendes A, Braghetto I.Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013;23(9):1481–6.
36. DeMaria EJ, Sugerman HJ, Meador JG, Doty JM, Kellum JM, Wolfe L, Szucs RA, Turner MA.High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid obesity. Ann Surg. 2001;233(6):809.
M. T. Fastiggi and M. Abbas
Gastroparesis
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24
BoraKahramangil, EmanueleLo Menzo, SamuelSzomstein, andRaulRosenthal
Introduction
Gastrointestinal motility is a complex process resulting from an interplay between sympathetic and parasympathetic nervous sys­tems, interstitial cells of Cajal, and intestinal smooth muscle cells. Abnormality in any of these components can lead to delayed gas­tric emptying [1]. Gastroparesis is a pathology of gastrointestinal motility characterized by objectively delayed gastric emptying, absence of mechanical obstruction, and a combination of clinical symptoms including upper abdominal pain, nausea, vomiting, early satiety, and belching [2].
Epidemiology andEtiology
Gastroparesis is a rare disorder with a prevalence of 38 per 100,000in females and 9.6 per 100,000in males [3]. Most cases are idiopathic with up to 1/3 of gastroparesis patients having no
B. Kahramangil · E. Lo Menzo (*) · S. Szomstein · R. Rosenthal Cleveland Clinic Florida, Department of General Surgery, Bariatric and Metabolic Institute, Weston, FL, USA e-mail: lomenze@ccf.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2023 A. D. Patel et al. (eds.), The SAGES Manual of Physiologic Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_24
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identiable underlying cause [4]. The most common form of non- idiopathic gastroparesis is diabetes mellitus [4]. Main hypotheses explaining diabetic gastroparesis include diabetic neuropathy- related changes in gastric emptying [5], decrease in interstitial cells of Cajal [6], and hyperglycemic oxidative stress [7]. Another well-recognized form of gastroparesis is postsurgi­cal. Any abdominal or thoracic surgical procedure causing injury to the vagus nerve can result in delayed gastric emptying [8]. Surgical procedures noted to be commonly associated with gas­troparesis include fundoplication, distal gastrectomy, and Roux­en-Y gastric reconstruction. Other rare causes of gastroparesis include viral infections [9], autoimmune gastric dysmotility [10], and Parkinson’s disease [11]. Finally, several medications includ­ing narcotics [12], anticholinergics, antidopaminergics [13], and tricyclic antidepressants [14] can trigger gastroparesis-like symptoms.
B. Kahramangil et al.
Clinical Presentation
Gastroparesis typically presents with a combination of symptoms including nausea, vomiting, abdominal pain, early satiety, post­prandial fullness, and abdominal distension. Severe gastroparesis can cause weight loss [13]. When present, emesis typically occurs several hours after a meal and contains undigested food particles. Gastroparesis-related abdominal pain is typically epigastric and may be exacerbated by eating. Patients may describe a cramping, vague, or burning pain. Physical examination may reveal epigas­tric tenderness, but rebound or guarding is not typical. In non­idiopathic cases, there may be additional signs and symptoms related to the underlying pathologic condition.
Diagnosis
Gastroparesis should be suspected in patients presenting with a combination of the above symptoms. However, diagnosis can only be made after exclusion of mechanical obstruction and
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objective demonstration of delayed gastric emptying. Radiologic imaging and/or endoscopy can be used to rule out mechanical obstruction. Delayed gastric emptying is typically demonstrated by gastric scintigraphy.
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Clinical Evaluation andDiagnostic Modalities
Clinical evaluation starts with a thorough history and physical exam. In patients with signs and symptoms consistent with gas­troparesis, exclusion of mechanical obstruction and objective demonstration of delayed gastric emptying are needed.
• Exclusion of mechanical obstruction: The work-up in patients suspected to have gastroparesis should start with an upper endoscopy to rule out other causes. Following a normal upper endoscopy, computed tomography (CT) enterography or magnetic resonance (MR) enterography may be obtained to rule out distal obstruction.
• Demonstration of delayed gastric emptying: Gastric empty­ing scintigraphy is the mainstay for the evaluation of gastric emptying. When possible, a solid meal with radioisotopes should be utilized for optimal test results [13]. In patients too sick to tolerate solids, a liquid meal can also be utilized [15]. All medications that can potentially alter gastric motility need to be stopped 48h prior to scintigraphy. Adequate glycemic control with glucose <180mg/dL has to be achieved in dia­betic patients. Typically, a meal consisting of (99m)Tc labeled egg whites or egg white substitutes is used [16, 17]. Scintigraphic imaging is obtained immediately after ingestion as well as at 1-, 2-, and 4- h marks. Normal values with a low­fat meal are 37–90% gastric retention at 1h, 30–60% retention at 2h, and<10% retention at 4h. Delayed gastric emptying is diagnosed if there is >60% food retention at 2 h or > 10% retention at 4hours [17]. Based on the degree of retention at 4h, gastroparesis can be categorized as mild (10–15%), mod­erate (15–35%), or severe (>35%).
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