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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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2
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Kamada T, Satoh K, Itoh T, Ito M, Iwamoto J, Okimoto T, Kanno T, Sugimoto M, Chiba T, Nomura S, Mieda M, Hiraishi H, Yoshino J, Takagi A, Watanabe S, Koike K. Evidence-based clinical practice guidelines for peptic ulcer disease 2020. J Gastroenterol 2021; 56:303-322. [PMID: 33620586 PMCID: PMC8005399 DOI: 10.1007/s00535-021-01769-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/03/2021] [Indexed: 02/05/2023]
Abstract
The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an English version. The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs). Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers. Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence.
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Affiliation(s)
- Tomoari Kamada
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, 2-6-1, Nakasange, Kita-ku, Okayama, 700-8505, Japan.
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
| | - Kiichi Satoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiyuki Itoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masanori Ito
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junichi Iwamoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tadayoshi Okimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takeshi Kanno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsushige Sugimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshimi Chiba
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sachiyo Nomura
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsuyo Mieda
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hideyuki Hiraishi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junji Yoshino
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Atsushi Takagi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sumio Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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3
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Natarajan SK, Chua D, Anbalakan K, Shelat VG. Marginal ulcer perforation: a single center experience. Eur J Trauma Emerg Surg 2017; 43:717-722. [PMID: 27619359 DOI: 10.1007/s00068-016-0723-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/06/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP. METHODS Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5 years. RESULTS Nine patients (2.7 %) presented with MUP. GJ was previously done for either complicated peptic ulcer (n = 4) or for suspected gastric malignancy (n = 5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10 mm. Four patients (44.4 %) had omental patch repair, three (33.3 %) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies. CONCLUSION MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.
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Affiliation(s)
- S K Natarajan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
- , 481 Yio Chu Kang Road, #03-01, Castle Green, Singapore, 787056, Singapore.
| | - D Chua
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - K Anbalakan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - V G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Antroduodenectomy with Gastroduodenal Anastomosis: Salvage Emergency Surgery for Complicated Peptic Ulcer Disease--Results of a Double Institution Study of 35 Patients. J Gastrointest Surg 2016; 20:539-45. [PMID: 26643299 DOI: 10.1007/s11605-015-3050-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/29/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic and interventional techniques are currently the mainstay of management of bleeding duodenal ulcer. As well, for patients with perforated duodenal ulcer, laparoscopic simple closure is nowadays usually performed. Although indications for emergency antroduodenectomy have declined, this procedure is still necessary as a salvage option when conservative management has failed or is not practicable. Our study aimed to evaluate indications and results of antroduodenectomy with gastroduodenal anastomosis in current practice and to examine the factors that predict operative outcomes. METHODS All patients who underwent emergency antroduodenectomy with gastroduodenal anastomosis in two surgical care departments specialized in emergency digestive surgery were studied from 2000 to 2015. RESULTS Thirty-five patients (27 males, 77 %) with a median age of 68 years (20-90) underwent emergency antroduodenectomy with gastroduodenal anastomosis. Indications were bleeding and perforated duodenal ulcer in 24 and 11 patients, respectively. The overall complication rate was 69 %, especially because of a high rate of medical complications (57 %). Only two patients (6 %) required reoperation for anastomotic leakage. The overall mortality rate was 40 % (n = 14). According to the univariate analysis, age >70, >3 comorbidities, ASA score >2, and postoperative medical complications were associated with an increased risk of in-hospital mortality. In the multivariate analysis, age and ASA score remained independent risk factors. No recurrence of complicated duodenal disease was observed. CONCLUSION Antroduodenectomy with gastroduodenal anastomosis is a safe and effective long-term strategy, with a low and acceptable rate of surgical complications, for complicated duodenal ulcer not responding to conservative measures.
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5
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Araaya GH, Desta KG, Gebremeskel WW, Wasihun AG. Gastrojejunocolic fistula after gastrojejunostomy in Ayder referral hospital Northern Ethiopia: A report of two cases. Ann Med Surg (Lond) 2015; 4:448-51. [PMID: 26693276 PMCID: PMC4660275 DOI: 10.1016/j.amsu.2015.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 10/03/2015] [Accepted: 10/22/2015] [Indexed: 11/30/2022] Open
Abstract
Background Gastrojejunocolic fistula (GJCF) is a late and severe complication of a stomal ulcer after gastrojejunostomy, which develops as a result of inadequate resection of stomach or incomplete vagotomy. The occurrence of perforation in a GJCF is even more a rare complication because long evolution time or latent period is required for its appearance. Patients with this condition usually present with diarrhea, weight loss, feculent vomiting, under-nutrition and features of peritonitis that require immediate surgical intervention. Case presentation We described two cases of gastrojejunocolic fistula in men aged 60 and 40, first cases of gastrojejunocolic fistula seen in our referral hospital and in the whole region following more than a decade after gastrojejunostomy. Both patients initially presented with watery diarrhea, vomiting of fecal materials, poor appetite and weight loss. Upper GI series or barium enema studies allowed a conclusive diagnosis to be made. Both patients underwent one-stage en bloc resection, and their postoperative course and outcome was one cure and one death. Conclusion As it is rare phenomenon, high clinical suspicion is very important in the diagnosis of GJCF on patients who manifest with chronic diarrhea, vomiting of fecal matter, abdominal pain and features of malnutrition. Careful preoperative preparation is mandatory before any type of surgical procedure is carried out. Pre-operative nutritional status should be evaluated in patients undergoing corrective surgery. Adequate resection of the stomach after Gastrojejunostomy and complete vagotomy is important to prevention development of GJCF. High Nasal carriage of Staphylococcus aureus. Vancomycin, Gentamicin and Ceftriaxone were 100% effective. Isolated bacteria showed high resistance to penicillin and Ampicillin. Low MRSA prevalence arte. Food handlers should train on personal hygiene.
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Affiliation(s)
- Girmay Hagos Araaya
- Department of Surgery, School of Medicine, College of Health Sciences, Ayder Referral Hospital, Mekelle University, Ethiopia
| | - Kibrom Gebresilasie Desta
- Department of Surgery, School of Medicine, College of Health Sciences, Ayder Referral Hospital, Mekelle University, Ethiopia
| | - Weldehawaria Weldu Gebremeskel
- Department of Surgery, School of Medicine, College of Health Sciences, Ayder Referral Hospital, Mekelle University, Ethiopia
| | - Araya Gebreyesus Wasihun
- Department of Medical Microbiology and Immunology, Biomedical Institute, College of Health Sciences, Mekelle University, Ethiopia
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6
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Abstract
The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.
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Affiliation(s)
- John S Bolton
- Department of Surgery Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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7
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Keren D, Matter I, Rainis T, Goldstein O, Stermer E, Lavy A. Sleeve gastrectomy leads to Helicobacter pylori eradication. Obes Surg 2008; 19:751-6. [PMID: 18830786 DOI: 10.1007/s11695-008-9694-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 09/05/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of Helicobacter pylori (HP) in patients scheduled and undergoing laparoscopic sleeve gastrectomy (LSG) has not been previously evaluated. METHODS Included were obese patients presenting to our institution for LSG over 24 months. All patients had presurgical HP breath test, and the symptomatic ones received triple therapy with symptom follow-up. Post surgery, all excluded stomachs were evaluated for HP, and those that were positive performed a second 13C-urea breath test (UBT) 3 months later. RESULTS Forty patients underwent LSG. Male to female sex ratio was 1:3; mean age-42 years; mean weight-122 kg; and mean BMI of 43.4 kg/m2. Presurgical HP was positive in 15 (37.5%) patients (11 symptomatic and four asymptomatic). Only these 11 patients were given HP eradication therapy and all experienced complete subsequent symptom resolution. HP was detected in 17 out of the 40 (42.5%) cases of excluded stomachs. All performed a 13C-UBT 3 months post operation and only three (17.6%) tested positive. CONCLUSIONS HP infection is frequent in biopsies from patients with previous LSG and the majority of follow-up 13C-UBT were negative. In our small initial sample, we treated only symptomatic patients preoperatively. Routine screening for HP for all LSG patients and/or treatment for all positive ones would subject patients to expensive and unnecessary investigations. We propose that this stomach-reducing, pylorus-preserving surgery might even lead to HP eradication. The clinical implications of HP and this gastrectomy for a non-neoplastic, non-peptic indication deserve further study.
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Affiliation(s)
- Dean Keren
- Gastroenterology Unit, Surgery Department, Bnai Zion Medical Center, Technion-Institute of Technology, Haifa, Israel.
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8
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Aydinli B, Yilmaz O, Ozturk G, Yildigan MI, Gursan N, Basoglu M. Is perforated marginal ulcer after the surgery of gastroduodenal ulcer associated with inadequate treatment for Helicobacter pylori eradication? Langenbecks Arch Surg 2007; 392:593-9. [PMID: 17370084 DOI: 10.1007/s00423-007-0167-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 02/01/2007] [Indexed: 01/17/2023]
Abstract
BACKGROUND A marginal ulcer developing after an initial operation for gastroduodenal ulcer is a serious threat to the patient, and a challenge to surgeons. Helicobacter pylori is the primary cause of peptic ulcer disease. However, its role in ulcer recurrence, especially of marginal ulcer (MU), after peptic ulcer surgery is unclear. This study aimed to determine any association between H. pylori infection and perforated MU by comparing the prevalence of H. pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) use in patients with perforated (PMU) and in those with nonperforated MU (NPMU). STUDY DESIGN The study retrospectively evaluated the records of 16 patients with PMU who underwent surgical treatment and 24 patients with NPMU who underwent medical treatment in Atatürk University, School of Medicine, Department of General Surgery and Gastroenterology, between January 1995 and December 2004. RESULTS The rate of H. pylori in the PMU group was significantly higher than that of the NPMU group (P < 0.01). There was a significant relationship between NSAID consumption and PMU compared with NPMU patients (P < 0.01). There was also a significant relationship between NSAID consumption and H. pylori and PMU (P < 0.01). CONCLUSION Eradication of H. pylori after the first PMU operation especially in cases with impaired hemodynamics, severe peritoneal contamination, and/or a diameter smaller than 1 cm and avoiding the use of NSAIDs will surely reduce the risk of relapsing ulcers.
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Affiliation(s)
- Bulent Aydinli
- Department of General Surgery, Medical Faculty, School of Medicine, Atatürk University, 25070, Erzurum, Turkey.
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9
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St Jean MR, Dunkle-Blatter SE, Petrick AT. Laparoscopic management of perforated marginal ulcer after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007; 2:668. [PMID: 17138240 DOI: 10.1016/j.soard.2006.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 09/20/2006] [Accepted: 09/21/2006] [Indexed: 11/25/2022]
Affiliation(s)
- Michael R St Jean
- Section of Minimally Invasive and Bariatric Surgery, Womack Army Medical Center, Fort Bragg, North Carolina 28310-7301, USA.
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10
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Abstract
The facts that H pylori infection is commoner in duodenal ulcer (DU) patients than in the normal population, and that eradication results in most cases being cured, have led to the belief that it causes DU. However, early cases of DU are less likely than established ones to be infected. H pylori-negative cases are usually ascribed to specific associated factors such as non-steroidal anti-inflammatory drugs (NSAIDs), Crohn’s disease, and hypergastrinaemia, but even after excluding these, several H pylori-negative cases remain and are particularly common in areas of low prevalence of H pylori infection. Moreover, this incidence of H pylori negative DU is not associated with a fall in overall DU prevalence when compared with countries with a higher H pylori prevalence. In countries with a high H pylori prevalence there are regional differences in DU prevalence, but no evidence of an overall higher prevalence of DU than in countries with a low H pylori prevalence. There is no evidence that virulence factors are predictive of clinical outcome. After healing following eradication of H pylori infection DU can still recur. Medical or surgical measures to reduce acid output can lead to long-term healing despite persistence of H pylori infection. Up to half of cases of acute DU perforation are H pylori negative. These findings lead to the conclusion that H pylori infection does not itself cause DU, but leads to resistance to healing, i.e., chronicity. This conclusion is shown not to be incompatible with the universally high prevalence of DU compared with controls.
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Affiliation(s)
- Michael Hobsley
- Department of Surgery, Royal Free and University College Medical School, London, United Kingdom.
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Lipof T, Shapiro D, Kozol RA. Surgical perspectives in peptic ulcer disease and gastritis. World J Gastroenterol 2006; 12:3248-52. [PMID: 16718847 PMCID: PMC4087970 DOI: 10.3748/wjg.v12.i20.3248] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Revised: 04/06/2006] [Accepted: 04/16/2006] [Indexed: 02/06/2023] Open
Abstract
For much of the twentieth century, surgery was frequently the solution for peptic ulcer disease. Our understanding of the pathophysiology of ulcers paralleled the development of potent pharmaceutical therapy. As the surgical world developed parietal cell vagotomy which would minimize the complications of surgery, patients failing medical therapy became rare. Emergent surgery for complicated peptic ulcers has not declined however. The development of proton pump inhibitors and the full understanding of the impact of H pylori has led to a trend towards minimalism in surgical therapy for complicated peptic ulcer disease. In addition to the changes in patient care, these developments have had an impact on the training of surgeons. This article outlines these trends and developments.
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Affiliation(s)
- Tamar Lipof
- Department of Surgery, University of Connecticut School of Medicine, 263 Farmington Avenue, MC 3955 Farmington, CT 06030-3955, USA
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12
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Demertzis K, Polymeros D, Emmanuel T, Triantafyllou K, Tassios P, Ladas SD. Omeprazole maintenance therapy prevents recurrent ulcer bleeding after surgery for duodenal ulcer. World J Gastroenterol 2006; 12:791-5. [PMID: 16521197 PMCID: PMC4066134 DOI: 10.3748/wjg.v12.i5.791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the omeprazole maintenance therapy in patients with recurrent ulcer bleeding after surgery for duodenal ulcer.
METHODS: We studied 15 consecutive patients with recurrent ulcer bleeding after surgery for duodenal ulcer. Omeprazole (20 mg/d) maintenance therapy was given after ulcer healing. In addition to clinical follow-up, ambulatory 24-h gastric pH assay was performed before and during omeprazole therapy in those patients and controls with previous duodenal ulcer surgery but no ulcer recurrence.
RESULTS: All the 15 ulcers were healed after being treated with omeprazole (40 mg/d) for 2 mo. Eleven patients with two (1-9) episodes of recurrent ulcer bleeding completed the follow-up (43, 12-72 mo). None of them had a bleeding episode while on omeprazole. One patient discontinued the therapy and had recurrent bleeding. The median 24-h fraction time of gastric pH <4 in patients was 80, 46-95%, and was reduced to 32, 13-70% by omeprazole (P = 0.002).
CONCLUSION: Long-term maintenance therapy with omeprazole (20 mg/day) is effective in preventing recurrent ulcer bleeding.
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Affiliation(s)
- Konstantinos Demertzis
- Hepatogastroenterology Unit, 2nd Department of Internal Medicine, Attikon University General Hospital, 23 Sisini Street, 11528 Athens, Greece
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13
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Lublin M, McCoy M, Waldrep DJ. Perforating marginal ulcers after laparoscopic gastric bypass. Surg Endosc 2005; 20:51-4. [PMID: 16333541 DOI: 10.1007/s00464-005-0325-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Accepted: 09/07/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LGB) can be performed with minimal morbidity and mortality. This article describes the first presentation of a known disease entity after LGB: perforating marginal ulcers of the jejunum immediately distal to the gastrojejunal anastomosis. METHODS A chart review of 902 LGB procedures performed by a single surgeon between April 2000 and September 2004 identified eight patients with perforating marginal ulcers. RESULTS The patients presented an average of 157 days (range, 53-374 days) after LGB. All the patients were treated using laparoscopic primary closure followed by medical therapy. Morbidity, in one patient only, consisted of two abdominal fluid collections requiring separate drainage procedures. There was no mortality. The average follow-up period was 13 months (range, 2-18 months). No patient experienced recurrent ulceration. CONCLUSIONS Although the etiology is unclear, marginal ulcers, a known complication of gastrojejunostomy, may present as perforating ulcers after LGB in a characteristic fashion and can be managed laparoscopically.
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Affiliation(s)
- M Lublin
- Department of Surgery, Sutter Roseville Medical Center, One Medical Plaza, Roseville, CA 95661, USA
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14
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Coelho-Neto JDS, Andreollo NA, Lopes LR, Nishimura NF, Brandalise NA, Leonardi LS. [Late follow-up of gastrectomized patients for peptic ulcer: clinical, endoscopic and histopathological aspects]. ARQUIVOS DE GASTROENTEROLOGIA 2005; 42:146-52. [PMID: 16200249 DOI: 10.1590/s0004-28032005000300004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- João de Souza Coelho-Neto
- Departamento de Cirurgia, Centro de Diagnóstico de Doenças do Aparelho Digestivo-GASTROCENTRO, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP
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Affiliation(s)
- Sean P Harbison
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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Kirsch C, Madisch A, Piehler P, Bayerdorffer E, Stolte M, Miehlke S. Helicobacter pylori in gastric corpus of patients 20 years after partial gastric resection. World J Gastroenterol 2004; 10:2557-9. [PMID: 15300905 PMCID: PMC4572162 DOI: 10.3748/wjg.v10.i17.2557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 04/04/2004] [Accepted: 04/29/2004] [Indexed: 12/15/2022] Open
Abstract
AIM To determine the long-term prevalence of Helicobacter pylori (H pylori) gastritis in patients after partial gastric resection due to peptic ulcer, and to compare the severity of H pylori-positive gastritis in the corpus mucosa between partial gastrectomy patients and matched controls. METHODS Endoscopic biopsies were obtained from 57 patients after partial gastric resection for histological examination using hematoxylin/eosin and Warthin-Starry staining. Gastritis was graded according to the updated Sydney system. Severity of corpus gastritis was compared between H pylori-positive partial gastrectomy patients and H pylori-positive duodenal ulcer patients matched for age and gender. RESULTS In partial gastrectomy patients, surgery was performed 20 years (median) prior to evaluation. In 25 patients (43.8%) H pylori was detected histologically in the gastric remnant. Gastric atrophy was more common in H pylori-positive compared to H pylori-negative partial gastrectomy patients (P<0.05). The severity of corpus gastritis was significantly lower in H pylori-positive partial gastrectomy patients compared to duodenal ulcer patients (P<0.01). There were no significant differences in the activity of gastritis, atrophy and intestinal metaplasia between the two groups. CONCLUSION The long-term prevalence of H pylori gastritis in the gastric corpus of patients who underwent partial gastric resection due to peptic ulcer disease is comparable to the general population. The expression of H pylori gastritis in the gastric remnant does not resemble the gastric cancer phenotype.
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Affiliation(s)
- Christian Kirsch
- Medical Department I, Technical University Hospital Carl Gustav Carus, Fetscherstrabe 74, D-01307 Dresden, Germany
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Gilliam AD, Speake WJ, Lobo DN, Beckingham IJ. Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom. Br J Surg 2003; 90:88-90. [PMID: 12520581 DOI: 10.1002/bjs.4003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. METHODS A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. RESULTS Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). CONCLUSION Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.
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Affiliation(s)
- A D Gilliam
- Section of Surgery, E Floor, West Block, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
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MacDonald WC, Owen DA. Gastric carcinoma after surgical treatment of peptic ulcer: an analysis of morphologic features and a comparison with cancer in the nonoperated stomach. Cancer 2001; 91:1732-8. [PMID: 11335898 DOI: 10.1002/1097-0142(20010501)91:9<1732::aid-cncr1191>3.0.co;2-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery for peptic ulcer is associated with an increased risk of later development of gastric carcinoma. This risk applies to cancer occurring in the distal stomach, not at the cardia. Mucosal alterations occurring in the nonneoplastic mucosa, adjacent to postgastrectomy carcinomas, are currently poorly defined. METHODS Between 1975 and 1995, the authors collected records of 76 patients with gastric carcinoma developing after previous ulcer surgery. Thirty-three gastrectomy specimens were available for study and were compared with a control series of gastric carcinomas occurring in the intact stomach. Morphologic features studied were macroscopic findings, tumor type, extent of inflammation, atrophy, intestinal metaplasia, reactive gastropathy, and presence of Helicobacter pylori. When possible, a semiquantitative grading system (Sydney system) was used. RESULTS The 33 patients with resected carcinoma after ulcer surgery were representative of the total 76 patients. There were no differences between the seven postulcer surgery cardia carcinomas and the control cardia carcinomas. The 18 distal carcinomas occurring after prior gastrectomy had significantly less intestinal metaplasia and Helicobacter pylori in the nonneoplastic mucosa than did the controls. Eight distal carcinomas occurring after a vagotomy and pyloroplasty had adjacent mucosa with findings intermediate between the gastrectomy carcinomas and the controls. CONCLUSIONS The differences shown suggest that for distally located postgastrectomy carcinomas Helicobacter pylori infection with extensive intestinal metaplasia may be relatively less important in pathogenesis and that intestinal reflux with reactive gastropathy more important. There was no evidence to support a different mechanism of pathogenesis for postsurgical carcinomas occurring at the cardia from that of control cardia carcinomas.
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Affiliation(s)
- W C MacDonald
- Division of Medical Oncology, University of British Columbia, Vancouver, British Columbia, Canada
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Morgenstern S, Koren R, Fraser G, Okon E, Niv Y. Gastric corpus mucin expression after partial gastrectomy, in relation to colonization with Helicobacter pylori. J Clin Gastroenterol 2001; 32:218-21. [PMID: 11246347 DOI: 10.1097/00004836-200103000-00007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Twelve different genes for mucin have been described. MUC5AC and MUC6 encode the secreted apomucins of the stomach. A gradient from the surface epithelium (foveola) to the glands is typical for MUC5AC synthesis, whereas a gradient in the opposite direction was found for MUC6. Our goal was to determine the distribution of MUC5AC and MUC6 in the postoperative stomach, with relation to the H. pylori status. Gastric corpus biopsy specimens from patients who underwent partial gastrectomy were examined by immunohistochemistry for mucin gene (MUC5AC and MUC6) apoproteins. We used polyclonal antibodies for amino acid tandem repeats of both proteins. A scoring system (0-3) was used to assess staining intensity at four sites: the lumen, the foveola, the mucous neck cells, and the glands. Helicobacter pylori status was determined by histology and rapid urease test and was considered positive or negative when both tests were positive or negative, respectively. We studied 19 H. pylori-positive and 32 H. pylori-negative patients. No significant change in MUC5AC or MUC6 synthesis and secretion was demonstrated between H. pylori-positive or -negative patients. A gradient similar to that shown for the intact stomach (from the surface epithelium to the glands) for MUC5AC protein and an increase of MUC6 protein presentation from the mucous neck cell to the glands were demonstrated. The pattern of MUC5AC protein synthesis was not different between H. pylori-positive and -negative patients in the postoperative stomach. MUC6 expression was higher in the foveola in H. pylori-positive patients, whereas there was no difference in the other cell layers.
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Affiliation(s)
- S Morgenstern
- Department of Pathology, Rabin Medical Center, Tel-Aviv University, Israel
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Abstract
OBJECTIVE Research on ulcer psychosomatics has plummeted since the early 1970s, to the applause of many who argue that ulcer is simply an infectious disease. The purpose of this article is to discuss the relevance of ulcer psychogenesis in the age of Helicobacter pylori. METHODS A critical literature review was conducted. RESULTS There is a substantial and methodologically sound body of prospective studies linking stress with the onset and course of peptic ulcer. Psychosocial factors can be estimated to contribute to 30% to 65% of ulcers, whether related to nonsteroidal antiinflammatory drugs, H. pylori, or neither. The observed association between stress and ulcer is accounted for, in part, by recall bias, misreported diagnoses, and confounding by low socioeconomic status (a source of stress and of ulcer risk factors, such as H. pylori and on-the-job exertion) and by distressing medical conditions (which lead to use of nonsteroidal antiinflammatory drugs). Of the residual, true association, a substantial proportion is accounted for by mediation by health risk behaviors, such as smoking, sleeplessness, irregular meals, heavy drinking, and, again, nonsteroidal antiinflammatory drugs. The remainder results from psychophysiologic mechanisms that probably include increased duodenal acid load, the effects of hypothalamic-pituitary-adrenal axis activation on healing, altered blood flow, and impairment of gastroduodenal mucosal defenses. CONCLUSIONS Peptic ulcer is a valuable model for understanding the interactions among psychosocial, socioeconomic, behavioral, and infectious factors in causing disease. The discovery of H. pylori may serve, paradoxically, as a stimulus to researchers for whom the concepts of psychology and infection are not necessarily a contradiction in terms.
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Affiliation(s)
- S Levenstein
- Gastroenterology Department, San Camillo-Forlanini Hospital, Rome, Italy.
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Lee YT, Chan FK, Sung JJ. Treating Helicobacter pylori infection after surgery is unnecessary. BMJ (CLINICAL RESEARCH ED.) 1998; 316:1904-5. [PMID: 9632426 PMCID: PMC1113377 DOI: 10.1136/bmj.316.7148.1904a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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