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Surgery_Schwartz_7602 | Surgery_Schwartz | GI series may suggest slow gastric emptying and relative atony, 9or it may be normal. EGD may show bezoars or retained food but is frequently normal. Gastric emptying scintigraphy shows delayed solid emptying, and often delayed liquid emptying. Gastroparesis can be a manifestation of a variety of problems (Table 26-22). Medical treatment includes promotility agents, antiemetics, and, perhaps, botulinum injection into the pylorus.If the diabetic gastroparetic patient is not a candidate for pancreas transplant, both gastrostomy (for decompression) and jejunostomy tubes (for feeding and prevention of hypo-glycemia) can be helpful in managing these patients. Other surgical options include implantation of a gastric pacemaker, pyloroplasty or peroral endoscopic pyloromyotmy (particularly in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper | Surgery_Schwartz. GI series may suggest slow gastric emptying and relative atony, 9or it may be normal. EGD may show bezoars or retained food but is frequently normal. Gastric emptying scintigraphy shows delayed solid emptying, and often delayed liquid emptying. Gastroparesis can be a manifestation of a variety of problems (Table 26-22). Medical treatment includes promotility agents, antiemetics, and, perhaps, botulinum injection into the pylorus.If the diabetic gastroparetic patient is not a candidate for pancreas transplant, both gastrostomy (for decompression) and jejunostomy tubes (for feeding and prevention of hypo-glycemia) can be helpful in managing these patients. Other surgical options include implantation of a gastric pacemaker, pyloroplasty or peroral endoscopic pyloromyotmy (particularly in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper |
Surgery_Schwartz_7603 | Surgery_Schwartz | in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper Gastrointestinal BleedingAlthough there are arbitrary definitions of “massive” upper GI bleeding put forth, perhaps the most practical definition in the current era would be acute GI bleeding proximal to the ligament of Treitz, which requires blood transfusion. In multiple series, the stomach and proximal duodenum are by far the most com-mon sources of pathology associated with this diagnosis.109,198 Table 26-22Etiology of gastroparesisIdiopathicEndocrine or metabolic Diabetes mellitus Thyroid disease Renal insufficiencyAfter gastric surgery After resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue | Surgery_Schwartz. in patients responsive to pyloric Botox injection), and gastric resection.197 Generally, gastric resection should be done only after other therapeutic options have been exhausted.Massive Upper Gastrointestinal BleedingAlthough there are arbitrary definitions of “massive” upper GI bleeding put forth, perhaps the most practical definition in the current era would be acute GI bleeding proximal to the ligament of Treitz, which requires blood transfusion. In multiple series, the stomach and proximal duodenum are by far the most com-mon sources of pathology associated with this diagnosis.109,198 Table 26-22Etiology of gastroparesisIdiopathicEndocrine or metabolic Diabetes mellitus Thyroid disease Renal insufficiencyAfter gastric surgery After resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue |
Surgery_Schwartz_7604 | Surgery_Schwartz | resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue disorders Scleroderma Polymyositis/dermatomyositisInfiltrative disorders Lymphoma AmyloidosisDiffuse gastrointestinal motility disorder Chronic intestinal pseudo-obstructionMedication-inducedElectrolyte imbalance Potassium, calcium, magnesiumMiscellaneous conditions Infections (especially viral) Paraneoplastic syndrome Ischemic conditions Gastric ulcerReproduced with permission from Parkman HP, Harris AD, Krevsky B, et al: Gastroduodenal motility and dysmotility: an update on techniques available for evaluation, Am J Gastroenterol. 1995 Jun;90(6):869-892.Brunicardi_Ch26_p1099-p1166.indd 115201/03/19 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and | Surgery_Schwartz. resection After vagotomyCentral nervous system disorders Brain stem lesions Parkinson’s diseasePeripheral neuromuscular disorders Myotonia dystrophica Duchenne muscular dystrophyConnective tissue disorders Scleroderma Polymyositis/dermatomyositisInfiltrative disorders Lymphoma AmyloidosisDiffuse gastrointestinal motility disorder Chronic intestinal pseudo-obstructionMedication-inducedElectrolyte imbalance Potassium, calcium, magnesiumMiscellaneous conditions Infections (especially viral) Paraneoplastic syndrome Ischemic conditions Gastric ulcerReproduced with permission from Parkman HP, Harris AD, Krevsky B, et al: Gastroduodenal motility and dysmotility: an update on techniques available for evaluation, Am J Gastroenterol. 1995 Jun;90(6):869-892.Brunicardi_Ch26_p1099-p1166.indd 115201/03/19 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and |
Surgery_Schwartz_7605 | Surgery_Schwartz | 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and esophagogastric varices. Less common causes include benign or malignant neoplasm, angio-dysplasia, Dieulafoy’s lesion, portal gastropathy, Ménétrier’s disease, and watermelon stomach. Arterioenteric fistula should always be considered in the patient who has an aortic graft or who has undergone repair of a visceral artery aneurysm.The most important issues in the early hospital manage-ment of patients with acute upper GI bleeding are resuscita-tion and risk stratification. Large-bore IV access and Foley catheterization is accomplished, and nasogastric intubation is considered. Risk stratification is essentially accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or | Surgery_Schwartz. 7:13 PM 1153STOMACHCHAPTER 26The most common causes of acute upper GI bleeding in emer-gency department or hospitalized patients are peptic ulcer, gastri-tis, Mallory-Weiss syndrome, and esophagogastric varices. Less common causes include benign or malignant neoplasm, angio-dysplasia, Dieulafoy’s lesion, portal gastropathy, Ménétrier’s disease, and watermelon stomach. Arterioenteric fistula should always be considered in the patient who has an aortic graft or who has undergone repair of a visceral artery aneurysm.The most important issues in the early hospital manage-ment of patients with acute upper GI bleeding are resuscita-tion and risk stratification. Large-bore IV access and Foley catheterization is accomplished, and nasogastric intubation is considered. Risk stratification is essentially accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or |
Surgery_Schwartz_7606 | Surgery_Schwartz | accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or hematemesis suggest a large blood loss that has occurred over a short period of time. This is a high-risk situation.b. Does the patient have significant chronic disease, particu-larly lung, liver, kidney, and/or heart disease, which com-promises physiologic reserve? If yes, this is a high-risk situation.c. Is the patient anticoagulated, or immunosuppressed? If yes, this is a high-risk situation.d. On endoscopy, is the patient bleeding from varices, or is there active bleeding, or is there a visible vessel, or is there a deep ulcer overlying a large vessel (e.g., posterior duode-nal ulcer overlying the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with | Surgery_Schwartz. accomplished by answering the following questions:a. What is the magnitude and acuity of the hemorrhage? Hy-potension, tachycardia, oliguria, low hematocrit, pallor, al-tered mentation, and/or hematemesis suggest a large blood loss that has occurred over a short period of time. This is a high-risk situation.b. Does the patient have significant chronic disease, particu-larly lung, liver, kidney, and/or heart disease, which com-promises physiologic reserve? If yes, this is a high-risk situation.c. Is the patient anticoagulated, or immunosuppressed? If yes, this is a high-risk situation.d. On endoscopy, is the patient bleeding from varices, or is there active bleeding, or is there a visible vessel, or is there a deep ulcer overlying a large vessel (e.g., posterior duode-nal ulcer overlying the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with |
Surgery_Schwartz_7607 | Surgery_Schwartz | the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with supportive treatment and IV PPI. Selected patients may be discharged from the emergency department and managed on an outpatient basis.If the patient is deemed to be high risk based on one or more of the aforementioned questions, then the following should be done immediately:1. Type and cross-match for transfusion of blood products.2. Admit to ICU or monitored bed in specialized unit.3. Consult surgeon.4. Consult gastroenterologist.5. Start intravenous PPI.6. Perform upper endoscopy within 12 hours, after resuscita-tion and correction of coagulopathy. Endoscopic hemosta-sis should be considered in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these | Surgery_Schwartz. the gastroduodenal artery)? Could the patient be bleeding from an arterio-enteric fistula? If yes, this is a high-risk situation.When judged to be low risk, most patients will stop bleed-ing with supportive treatment and IV PPI. Selected patients may be discharged from the emergency department and managed on an outpatient basis.If the patient is deemed to be high risk based on one or more of the aforementioned questions, then the following should be done immediately:1. Type and cross-match for transfusion of blood products.2. Admit to ICU or monitored bed in specialized unit.3. Consult surgeon.4. Consult gastroenterologist.5. Start intravenous PPI.6. Perform upper endoscopy within 12 hours, after resuscita-tion and correction of coagulopathy. Endoscopic hemosta-sis should be considered in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these |
Surgery_Schwartz_7608 | Surgery_Schwartz | in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these patients will be adequately managed without operation. Mucosal lesions can usually be controlled with endo-scopic hemotherapy and medical management. Occasionally, arteriography can be helpful.199 Operation for bleeding ulcer is discussed previously (see “Operation for Bleeding Peptic Ulcer” and Fig. 26-43).Isolated Gastric VaricesIsolated gastric varices are those that occur in the absence of esophageal varices and are classified as type I (fundic) or type II (distal to fundus including proximal duodenum).200 The presence of isolated gastric varices is usually associated with portal hyper-tension or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic | Surgery_Schwartz. in most high-risk patients with acute upper GI bleeding.Although the surgeon should be involved early in the hos-pital course of all high-risk patients with acute upper GI bleed-ing, most of these patients will be adequately managed without operation. Mucosal lesions can usually be controlled with endo-scopic hemotherapy and medical management. Occasionally, arteriography can be helpful.199 Operation for bleeding ulcer is discussed previously (see “Operation for Bleeding Peptic Ulcer” and Fig. 26-43).Isolated Gastric VaricesIsolated gastric varices are those that occur in the absence of esophageal varices and are classified as type I (fundic) or type II (distal to fundus including proximal duodenum).200 The presence of isolated gastric varices is usually associated with portal hyper-tension or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic |
Surgery_Schwartz_7609 | Surgery_Schwartz | or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic measures.Patients with acute upper GI bleeding from isolated gas-tric varices should be considered high risk. Although data are limited, octreotide and/or vasopressin infusion may decease bleeding, if tolerated. Balloon tamponade with a Sengstaken-Blakemore tube may provide temporary control of exsanguinat-ing hemorrhage from type isolated gastric varices, but if this is used, endotracheal intubation for airway protection is prudent. Endoscopic treatment with sclerotherapy or varix ligation is less successful than in esophageal varices but should be con-sidered. Interventional radiology should be consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If | Surgery_Schwartz. or splenic vein thrombosis. Although there is a significant bleeding risk from isolated gastric varices on long-term follow-up, there is no indication for the routine application of prophylactic measures.Patients with acute upper GI bleeding from isolated gas-tric varices should be considered high risk. Although data are limited, octreotide and/or vasopressin infusion may decease bleeding, if tolerated. Balloon tamponade with a Sengstaken-Blakemore tube may provide temporary control of exsanguinat-ing hemorrhage from type isolated gastric varices, but if this is used, endotracheal intubation for airway protection is prudent. Endoscopic treatment with sclerotherapy or varix ligation is less successful than in esophageal varices but should be con-sidered. Interventional radiology should be consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If |
Surgery_Schwartz_7610 | Surgery_Schwartz | consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If the patient has splenic vein thrombosis and left-sided (sinistral) or segmental portal hypertension, splenectomy is quite effective in controlling bleeding from isolated gastric varices. The operative mortality is 5%. Liver transplantation should always be consid-ered in the cirrhotic patient.Hypertrophic Gastropathy (Ménétrier’s Disease)There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Ménétrier’s dis-ease. The latter is characteristically associated with protein-losing gastropathy and hypochlorhydria. There are large rugal folds in the proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently | Surgery_Schwartz. consulted and bal-loon-occluded retrograde transvenous obliteration considered. A transjugular intrahepatic portosystemic shunt (TIPSS) may be useful if there is nonsegmental portal hypertension. If the patient has splenic vein thrombosis and left-sided (sinistral) or segmental portal hypertension, splenectomy is quite effective in controlling bleeding from isolated gastric varices. The operative mortality is 5%. Liver transplantation should always be consid-ered in the cirrhotic patient.Hypertrophic Gastropathy (Ménétrier’s Disease)There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Ménétrier’s dis-ease. The latter is characteristically associated with protein-losing gastropathy and hypochlorhydria. There are large rugal folds in the proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently |
Surgery_Schwartz_7611 | Surgery_Schwartz | proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently been suggested that Méné-trier’s disease is caused by local overexpression of transform-ing growth factor-α in the gastric mucosa, which stimulates the epidermal growth factor receptor, a receptor tyrosine kinase, on gastric SECs. This results in the selective expan-sion of surface mucous cells in the gastric body and fundus. A few patients with this unusual disease have been successfully Figure 26-60. Mucosal biopsy in Ménétrier’s disease. (Repro-duced with permission from Ming S-C, Goldman H: Pathology of the Gastrointestinal Tract, 2nd ed. Baltimore, MD: Williams & Wilkins; 1998.)Brunicardi_Ch26_p1099-p1166.indd 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with | Surgery_Schwartz. proximal stomach, and the antrum is usu-ally spared. Mucosal biopsy shows diffuse hyperplasia of the surface mucus-secreting cells and usually decreased parietal cells (Fig. 26-60). It has recently been suggested that Méné-trier’s disease is caused by local overexpression of transform-ing growth factor-α in the gastric mucosa, which stimulates the epidermal growth factor receptor, a receptor tyrosine kinase, on gastric SECs. This results in the selective expan-sion of surface mucous cells in the gastric body and fundus. A few patients with this unusual disease have been successfully Figure 26-60. Mucosal biopsy in Ménétrier’s disease. (Repro-duced with permission from Ming S-C, Goldman H: Pathology of the Gastrointestinal Tract, 2nd ed. Baltimore, MD: Williams & Wilkins; 1998.)Brunicardi_Ch26_p1099-p1166.indd 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with |
Surgery_Schwartz_7612 | Surgery_Schwartz | 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with Ménétrier’s disease are middle-aged men who present with epigastric pain, weight loss, diarrhea, and hypoproteinemia. There may be an increased risk of gastric cancer. Sometimes, the disease regresses spontaneously. Occa-sionally it is associated with H pylori infection, and the disease improves with helicobacter eradication. Total gastrectomy may be indicated for bleeding, severe hypoproteinemia, or cancer.Watermelon Stomach (Gastric Antral Vascular Ectasia)The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its sobriquet. Histologically, gas-tric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The | Surgery_Schwartz. 115301/03/19 7:13 PM 1154SPECIFIC CONSIDERATIONS PART IItreated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.201Most patients with Ménétrier’s disease are middle-aged men who present with epigastric pain, weight loss, diarrhea, and hypoproteinemia. There may be an increased risk of gastric cancer. Sometimes, the disease regresses spontaneously. Occa-sionally it is associated with H pylori infection, and the disease improves with helicobacter eradication. Total gastrectomy may be indicated for bleeding, severe hypoproteinemia, or cancer.Watermelon Stomach (Gastric Antral Vascular Ectasia)The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its sobriquet. Histologically, gas-tric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The |
Surgery_Schwartz_7613 | Surgery_Schwartz | (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach pre-dominantly affects the distal stomach. β-Blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia. Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion. Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease. Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite | Surgery_Schwartz. (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-61). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach pre-dominantly affects the distal stomach. β-Blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia. Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion. Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease. Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite |
Surgery_Schwartz_7614 | Surgery_Schwartz | and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group. Patients with portal hypertension and antral vascular ectasia should be consid-ered for transjugular intrahepatic portosystemic shunt (TIPSS).Dieulafoy’s LesionDieulafoy’s lesion is a congenital arteriovenous malformation characterized by an unusually large tortuous submucosal artery. If this artery is eroded, impressive pulsatile bleeding may occur. To the endoscopist or surgeon, this appears as a stream of arte-rial blood emanating from what appears grossly to be a normal gastric mucosa. The lesion typically occurs in middle-aged or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is | Surgery_Schwartz. and endoscopic treatment with the neodymium yttrium-aluminum garnet (Nd:YAG) laser or argon plasma coagulator.202 Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group. Patients with portal hypertension and antral vascular ectasia should be consid-ered for transjugular intrahepatic portosystemic shunt (TIPSS).Dieulafoy’s LesionDieulafoy’s lesion is a congenital arteriovenous malformation characterized by an unusually large tortuous submucosal artery. If this artery is eroded, impressive pulsatile bleeding may occur. To the endoscopist or surgeon, this appears as a stream of arte-rial blood emanating from what appears grossly to be a normal gastric mucosa. The lesion typically occurs in middle-aged or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is |
Surgery_Schwartz_7615 | Surgery_Schwartz | or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is not actively bleeding. Treatment options include endoscopic hemostatic therapy, angiographic embolization, or operation. At surgery, the lesion may be oversewn or resected.Bezoars/DiverticulaBezoars are concretions of indigestible matter that accumulate in the stomach. Trichobezoars are composed of swallowed hair (Fig. 26-62). Phytobezoars are composed of vegetable matter and, in the United States, are usually seen in association with gastroparesis or gastric outlet obstruction. They also are asso-ciated with persimmon ingestion. Most commonly, bezoars produce obstructive symptoms, but they may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic | Surgery_Schwartz. or elderly men and may be more common in patients with liver disease.203 Patients typically present with upper GI bleeding, which may be intermittent, and endoscopy can miss the lesion if it is not actively bleeding. Treatment options include endoscopic hemostatic therapy, angiographic embolization, or operation. At surgery, the lesion may be oversewn or resected.Bezoars/DiverticulaBezoars are concretions of indigestible matter that accumulate in the stomach. Trichobezoars are composed of swallowed hair (Fig. 26-62). Phytobezoars are composed of vegetable matter and, in the United States, are usually seen in association with gastroparesis or gastric outlet obstruction. They also are asso-ciated with persimmon ingestion. Most commonly, bezoars produce obstructive symptoms, but they may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic |
Surgery_Schwartz_7616 | Surgery_Schwartz | may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic dis-ruption and removal, or surgical removal.Gastric diverticula are usually solitary and may be con-genital or acquired. Congenital diverticula are true diverticula and contain a full coat of muscularis propria, whereas acquired diverticula (perhaps caused by pulsion) usually have a negli-gible outer muscle layer. Most gastric diverticula occur in the posterior cardia or fundus (Fig. 26-63) and are usually asymp-tomatic. However, they can become inflamed and may produce pain or bleeding. Perforation is rare. Asymptomatic diverticula do not require treatment, but symptomatic lesions should be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure | Surgery_Schwartz. may cause ulceration and bleeding. Diagnosis is suggested by upper GI series and confirmed by endoscopy. Treatment options include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic dis-ruption and removal, or surgical removal.Gastric diverticula are usually solitary and may be con-genital or acquired. Congenital diverticula are true diverticula and contain a full coat of muscularis propria, whereas acquired diverticula (perhaps caused by pulsion) usually have a negli-gible outer muscle layer. Most gastric diverticula occur in the posterior cardia or fundus (Fig. 26-63) and are usually asymp-tomatic. However, they can become inflamed and may produce pain or bleeding. Perforation is rare. Asymptomatic diverticula do not require treatment, but symptomatic lesions should be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure |
Surgery_Schwartz_7617 | Surgery_Schwartz | be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure 26-62. Trichobezoar forming cast of stomach and duode-num; removed from 15-year-old girl. (Reproduced with permission from DeBakey M, Ochsner A: Bezoars and concretions, Surgery. 1938;Dec;4:934.)Figure 26-61. Gastric antral vascular ectasia (watermelon stom-ach). (Reproduced with permission from Godlman H, Hayek J, Federman M: Gastrointestinal Mucosal Biopsy. New York, NY: Churchill Livingstone; 1996.)Brunicardi_Ch26_p1099-p1166.indd 115401/03/19 7:13 PM 1155STOMACHCHAPTER 26large objects in the stomach should be removed. This can usu-ally be done endoscopically, with an overtube technique. Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in | Surgery_Schwartz. be removed. This can often be done laparoscopically.Foreign BodiesIngested foreign bodies are usually asymptomatic. Small coins usually pass through the GI tract without difficulty. Sharp or Figure 26-62. Trichobezoar forming cast of stomach and duode-num; removed from 15-year-old girl. (Reproduced with permission from DeBakey M, Ochsner A: Bezoars and concretions, Surgery. 1938;Dec;4:934.)Figure 26-61. Gastric antral vascular ectasia (watermelon stom-ach). (Reproduced with permission from Godlman H, Hayek J, Federman M: Gastrointestinal Mucosal Biopsy. New York, NY: Churchill Livingstone; 1996.)Brunicardi_Ch26_p1099-p1166.indd 115401/03/19 7:13 PM 1155STOMACHCHAPTER 26large objects in the stomach should be removed. This can usu-ally be done endoscopically, with an overtube technique. Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in |
Surgery_Schwartz_7618 | Surgery_Schwartz | Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in body packers who ingest drug parcels for smuggling and in patients with large jagged objects that cannot be safely removed endoscopically. Corrosive objects (i.e., batteries) should be removed promptly usually endoscopically. Ingested magnets should be removed unless they are small and singular and without other ingested metal objects.Mallory-Weiss SyndromeThe Mallory-Weiss lesion is a longitudinal tear in the mucosa of the GE junction.204 It is presumably caused by forceful vom-iting and/or retching, and it is commonly seen in alcoholics. It presents with upper GI bleeding, often with hematemesis. Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade, | Surgery_Schwartz. Rec-ognized dangers include aspiration of the foreign body during removal and rupture of drug-containing bags in “body packers.” Both complications can be fatal. Surgical removal is recom-mended in body packers who ingest drug parcels for smuggling and in patients with large jagged objects that cannot be safely removed endoscopically. Corrosive objects (i.e., batteries) should be removed promptly usually endoscopically. Ingested magnets should be removed unless they are small and singular and without other ingested metal objects.Mallory-Weiss SyndromeThe Mallory-Weiss lesion is a longitudinal tear in the mucosa of the GE junction.204 It is presumably caused by forceful vom-iting and/or retching, and it is commonly seen in alcoholics. It presents with upper GI bleeding, often with hematemesis. Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade, |
Surgery_Schwartz_7619 | Surgery_Schwartz | Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade, angiographic embolization, or selective infusion of vasopressin, systemic vasopressin, and operation. Surgical treat-ment consists of oversewing the bleeding lesion through a long gastrotomy.VolvulusGastric volvulus is a twist of the stomach that usually occurs in association with a large hiatal hernia. It also can occur in patients with an unusually mobile stomach without hiatal hernia. Typically, the stomach twists along its long axis (organoaxial volvulus), and the greater curvature flips up (Fig. 26-64C). If the stomach twists around the transverse axis, it is called mesentero-axial rotation (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in | Surgery_Schwartz. Endoscopy confirms the diagnosis and may be useful in con-trolling the bleeding, but 90% of patients stop bleeding sponta-neously. Other options to control the bleeding include balloon tamponade, angiographic embolization, or selective infusion of vasopressin, systemic vasopressin, and operation. Surgical treat-ment consists of oversewing the bleeding lesion through a long gastrotomy.VolvulusGastric volvulus is a twist of the stomach that usually occurs in association with a large hiatal hernia. It also can occur in patients with an unusually mobile stomach without hiatal hernia. Typically, the stomach twists along its long axis (organoaxial volvulus), and the greater curvature flips up (Fig. 26-64C). If the stomach twists around the transverse axis, it is called mesentero-axial rotation (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in |
Surgery_Schwartz_7620 | Surgery_Schwartz | (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in the elderly. The risk of strangulation and infarction has been overestimated in asymptomatic patients. Symptomatic patients should be considered for operation, espe-cially if the symptoms are severe and/or progressive. Patients may present with symptoms of pain and pressure related to the intermittently distending and poorly emptying twisted stomach. Pressure on the lung may produce dyspnea, pressure on the peri-cardium may produce palpitations, and pressure on the esopha-gus may produce dysphagia. Symptoms are often relieved with vomiting or passage of a nasogastric tube. Gastric infarction is a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy | Surgery_Schwartz. (Fig. 26-64A and Fig. 26-64B). Often, volvulus is a chronic condition that can be surprisingly asymptomatic. In these instances, expectant nonoperative management is typi-cally advised, especially in the elderly. The risk of strangulation and infarction has been overestimated in asymptomatic patients. Symptomatic patients should be considered for operation, espe-cially if the symptoms are severe and/or progressive. Patients may present with symptoms of pain and pressure related to the intermittently distending and poorly emptying twisted stomach. Pressure on the lung may produce dyspnea, pressure on the peri-cardium may produce palpitations, and pressure on the esopha-gus may produce dysphagia. Symptoms are often relieved with vomiting or passage of a nasogastric tube. Gastric infarction is a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy |
Surgery_Schwartz_7621 | Surgery_Schwartz | a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy with or without repair of hiatal hernia. Gastropexy alone should be considered for high-risk patients since it can nearly always be performed laparoscopically and may be surprisingly effective in relieving mechanical symptoms.GASTROSTOMYA gastrostomy is performed either for alimentation or for gastric drainage/decompression. Gastrostomy may be done percutane-ously, laparoscopically, or via open technique.205,206 Currently, percutaneous endoscopic gastrostomy is the most common method used. The open techniques include the Stamm method (Fig. 26-65), the Witzel method (Fig. 26-66), and the Janeway method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely | Surgery_Schwartz. a surgical emergency, and the patient can be moribund. Gastric necrosis may be extensive or focal. Elective operation for gas-tric volvulus usually involves reduction of the stomach and gas-tropexy with or without repair of hiatal hernia. Gastropexy alone should be considered for high-risk patients since it can nearly always be performed laparoscopically and may be surprisingly effective in relieving mechanical symptoms.GASTROSTOMYA gastrostomy is performed either for alimentation or for gastric drainage/decompression. Gastrostomy may be done percutane-ously, laparoscopically, or via open technique.205,206 Currently, percutaneous endoscopic gastrostomy is the most common method used. The open techniques include the Stamm method (Fig. 26-65), the Witzel method (Fig. 26-66), and the Janeway method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely |
Surgery_Schwartz_7622 | Surgery_Schwartz | method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely necessary. By far the most common surgical tech-nique is the Stamm gastrostomy, which can be performed open or laparoscopically.Complications of gastrostomy include infection, dis-lodgment, leakage with peritonitis, and aspiration pneumonia. Although gastrostomy tubes usually do prevent tense gastric dil-atation, they may not adequately drain the stomach, especially when the patient is bedridden, and they cannot always be relied upon to prevent pulmonary aspiration of gastric contents.ABCFigure 26-64. A through C. Gastric volvulus. (Reproduced with permission from Buchanan J: Volvulus of the stomach, Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd | Surgery_Schwartz. method. The Janeway gastrostomy, designed to create a per-manent nondraining gastric stoma that can be intermittently intubated, is more complicated than the other open techniques, and is rarely necessary. By far the most common surgical tech-nique is the Stamm gastrostomy, which can be performed open or laparoscopically.Complications of gastrostomy include infection, dis-lodgment, leakage with peritonitis, and aspiration pneumonia. Although gastrostomy tubes usually do prevent tense gastric dil-atation, they may not adequately drain the stomach, especially when the patient is bedridden, and they cannot always be relied upon to prevent pulmonary aspiration of gastric contents.ABCFigure 26-64. A through C. Gastric volvulus. (Reproduced with permission from Buchanan J: Volvulus of the stomach, Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd |
Surgery_Schwartz_7623 | Surgery_Schwartz | Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd 115501/03/19 7:13 PM 1156SPECIFIC CONSIDERATIONS PART IIPOSTGASTRECTOMY PROBLEMS207Dumping SyndromeDumping is a phenomenon caused by the destruction or bypass of the pyloric sphincter.208 However, other factors undoubtedly play a role because dumping can occur after operations that pre-serve the pylorus, such as parietal cell vagotomy. Also, an appro-priate stimulus may provoke dumping symptoms, even in some patients who have not undergone surgery. Clinically significant dumping occurs in 5% to 10% of patients after pyloroplasty, pyloromyotomy, or gastrectomy, and consists of a constellation of postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of | Surgery_Schwartz. Br J Surg. 1930;July;18(69):99-112.)Figure 26-63. Upper GI contrast study showing a diverticulum of the stomach. (Used with permission from Marc Levine, MD.)Brunicardi_Ch26_p1099-p1166.indd 115501/03/19 7:13 PM 1156SPECIFIC CONSIDERATIONS PART IIPOSTGASTRECTOMY PROBLEMS207Dumping SyndromeDumping is a phenomenon caused by the destruction or bypass of the pyloric sphincter.208 However, other factors undoubtedly play a role because dumping can occur after operations that pre-serve the pylorus, such as parietal cell vagotomy. Also, an appro-priate stimulus may provoke dumping symptoms, even in some patients who have not undergone surgery. Clinically significant dumping occurs in 5% to 10% of patients after pyloroplasty, pyloromyotomy, or gastrectomy, and consists of a constellation of postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of |
Surgery_Schwartz_7624 | Surgery_Schwartz | postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance. Typi-cally, 15 to 30 minutes after a meal, the patient becomes dia-phoretic, weak, light-headed, and tachycardic. These symptoms may be ameliorated by recumbence or saline infusion. Crampy abdominal pain is not uncommon, and diarrhea often follows. This is referred to as early dumping and should be distinguished from postprandial (reactive) hypoglycemia, also called late dumping, which usually occurs later (2–3 hours following a meal) and is relieved by the administration of sugar. A variety Figure 26-65. Stamm gastrostomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with | Surgery_Schwartz. postprandial symptoms ranging in severity from annoying to disabling. The symptoms are thought to be the result of the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance. Typi-cally, 15 to 30 minutes after a meal, the patient becomes dia-phoretic, weak, light-headed, and tachycardic. These symptoms may be ameliorated by recumbence or saline infusion. Crampy abdominal pain is not uncommon, and diarrhea often follows. This is referred to as early dumping and should be distinguished from postprandial (reactive) hypoglycemia, also called late dumping, which usually occurs later (2–3 hours following a meal) and is relieved by the administration of sugar. A variety Figure 26-65. Stamm gastrostomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with |
Surgery_Schwartz_7625 | Surgery_Schwartz | from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Sur-gery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Brunicardi_Ch26_p1099-p1166.indd 115601/03/19 7:13 PM 1157STOMACHCHAPTER 26of hormonal aberrations have been observed in early dumping, including increased serum levels of VIP, CCK, neurotensin, peripheral hormone peptide YY, renin-angiotensin-aldosterone, and decreased atrial natriuretic peptide. Late dumping is associ-ated with hypoglycemia and hyperinsulinemia.Medical therapy for the dumping syndrome consists of dietary modification and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that | Surgery_Schwartz. from Zuidema GD, Yeo CJ: Shackelford’s Surgery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Figure 26-66. A through F. Witzel gastros-tomy. (Reproduced with permission from Zuidema GD, Yeo CJ: Shackelford’s Sur-gery of the Alimentary Tract, 5th ed. Vol. II. Philadelphia, PA: Elsevier/Saunders; 2002.)Brunicardi_Ch26_p1099-p1166.indd 115601/03/19 7:13 PM 1157STOMACHCHAPTER 26of hormonal aberrations have been observed in early dumping, including increased serum levels of VIP, CCK, neurotensin, peripheral hormone peptide YY, renin-angiotensin-aldosterone, and decreased atrial natriuretic peptide. Late dumping is associ-ated with hypoglycemia and hyperinsulinemia.Medical therapy for the dumping syndrome consists of dietary modification and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that |
Surgery_Schwartz_7626 | Surgery_Schwartz | analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome. If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long-acting depot octreo-tide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but it also promotes restoration of a fasting motility pattern in the small intestine (i.e., restoration of the MMC). The α-glucosidase inhibitor acarbose may be particularly helpful in ameliorating the symptoms of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication. | Surgery_Schwartz. analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (e.g., milk shakes) may be particu-larly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome. If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long-acting depot octreo-tide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but it also promotes restoration of a fasting motility pattern in the small intestine (i.e., restoration of the MMC). The α-glucosidase inhibitor acarbose may be particularly helpful in ameliorating the symptoms of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication. |
Surgery_Schwartz_7627 | Surgery_Schwartz | of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication. Therefore, the surgeon should not rush to reoper-ate on the patient with dumping symptoms. Multidisciplinary nonsurgical management must be optimized first. Before reop-eration, a period of inhospital observation is useful to define the severity of the patient’s symptoms and patient compliance with prescribed dietary and medical therapy.The results of remedial operation for dumping are variable and unpredictable. There are a variety of surgical approaches, none of which work consistently well. Addition-ally, there is not a great deal of experience reported in the literature with any of these methods and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel | Surgery_Schwartz. of late dumping.Only a very small percentage of patients with dumping symptoms ultimately require surgery. Most patients improve with time (months and even years), dietary management, and medication. Therefore, the surgeon should not rush to reoper-ate on the patient with dumping symptoms. Multidisciplinary nonsurgical management must be optimized first. Before reop-eration, a period of inhospital observation is useful to define the severity of the patient’s symptoms and patient compliance with prescribed dietary and medical therapy.The results of remedial operation for dumping are variable and unpredictable. There are a variety of surgical approaches, none of which work consistently well. Addition-ally, there is not a great deal of experience reported in the literature with any of these methods and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel |
Surgery_Schwartz_7628 | Surgery_Schwartz | and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel is patent. The reversed intestinal segment is rarely used today—and rightly so. This operation interposes a 10-cm reversed segment of intestine between the stomach and the proximal small bowel. This slows gastric emptying, but often leads to obstruction, requiring reoperation. Isoperistaltic interposition (Henley loop) has not been successful in ameliorating severe dumping over the long term. The Roux-en-Y gastrojejunostomy is asso-ciated with delayed gastric emptying, probably on the basis of disordered motility in the Roux limb. Taking advantage of this disordered physiology, surgeons have used this operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing | Surgery_Schwartz. and long-term follow-up is rare. Patients with disabling refractory dumping after gas-trojejunostomy can be considered for simple takedown of this anastomosis provided that the pyloric channel is patent. The reversed intestinal segment is rarely used today—and rightly so. This operation interposes a 10-cm reversed segment of intestine between the stomach and the proximal small bowel. This slows gastric emptying, but often leads to obstruction, requiring reoperation. Isoperistaltic interposition (Henley loop) has not been successful in ameliorating severe dumping over the long term. The Roux-en-Y gastrojejunostomy is asso-ciated with delayed gastric emptying, probably on the basis of disordered motility in the Roux limb. Taking advantage of this disordered physiology, surgeons have used this operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing |
Surgery_Schwartz_7629 | Surgery_Schwartz | operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing gastric resection, gastric stasis may result, particularly if a large gastric remnant is left. In the presence of significant gastric acid secretion, marginal ulceration is common after both jejunal interposition and Roux-en-Y procedures; thus, concomitant vagotomy and hemigastrectomy should be con-sidered. The theoretical possibility of treating postpyloroplasty dumping with a Roux-en-Y to the proximal duodenum (the duodenal switch, a potentially reversible operation) has not yet been reported (Fig. 26-67). Because pyloric ablation seems to be the dominant factor in the etiology of dumping, it is not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal | Surgery_Schwartz. operation successfully in the management of the dumping syndrome. Although this is probably the procedure of choice in the small group of patients requiring operation for severe dumping fol-lowing gastric resection, gastric stasis may result, particularly if a large gastric remnant is left. In the presence of significant gastric acid secretion, marginal ulceration is common after both jejunal interposition and Roux-en-Y procedures; thus, concomitant vagotomy and hemigastrectomy should be con-sidered. The theoretical possibility of treating postpyloroplasty dumping with a Roux-en-Y to the proximal duodenum (the duodenal switch, a potentially reversible operation) has not yet been reported (Fig. 26-67). Because pyloric ablation seems to be the dominant factor in the etiology of dumping, it is not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal |
Surgery_Schwartz_7630 | Surgery_Schwartz | not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal vagotomy, dumping, or malabsorption. Truncal vagotomy is associated with clinically significant diarrhea in 5% to 10% of patients. It occurs soon after surgery and usually is not associ-ated with other symptoms, a fact that helps to distinguish it from dumping. The diarrhea may be a daily occurrence, or there may be significant periods of relatively normal bowel function. The symptoms tend to improve over the months and years after the index operation. The cause of postvagotomy diarrhea is unclear. Possible mechanisms include intestinal dysmotility and accel-erated transit, bile acid malabsorption, rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be | Surgery_Schwartz. not sur-prising that conversion of Billroth II to Billroth I anastomosis has not been successful in the treatment of dumping.DiarrheaDiarrhea following gastric surgery may be the result of trun-cal vagotomy, dumping, or malabsorption. Truncal vagotomy is associated with clinically significant diarrhea in 5% to 10% of patients. It occurs soon after surgery and usually is not associ-ated with other symptoms, a fact that helps to distinguish it from dumping. The diarrhea may be a daily occurrence, or there may be significant periods of relatively normal bowel function. The symptoms tend to improve over the months and years after the index operation. The cause of postvagotomy diarrhea is unclear. Possible mechanisms include intestinal dysmotility and accel-erated transit, bile acid malabsorption, rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be |
Surgery_Schwartz_7631 | Surgery_Schwartz | rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be confirmed with the hydrogen breath test, a simpler test is an empirical trial of oral antibiotics. Some patients with postvagotomy diarrhea respond to cholestyramine, while in others codeine or loperamide may be useful. Octreotide should also be tried. Another theoretical cause of diarrhea following gastric surgery is fat malabsorption due to acid inactivation of pancreatic enzymes or poorly coor-dinated mixing of food and digestive juices. This can be con-firmed with a qualitative test for fecal fat and treated with acid suppression. Postvagotomy diarrhea usually does not respond to treatment with pancreatic enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of | Surgery_Schwartz. rapid gastric emptying, and bacterial overgrowth. The latter problem is facilitated by decreased gastric acid secretion and (even small) blind loops. Although bacterial overgrowth can be confirmed with the hydrogen breath test, a simpler test is an empirical trial of oral antibiotics. Some patients with postvagotomy diarrhea respond to cholestyramine, while in others codeine or loperamide may be useful. Octreotide should also be tried. Another theoretical cause of diarrhea following gastric surgery is fat malabsorption due to acid inactivation of pancreatic enzymes or poorly coor-dinated mixing of food and digestive juices. This can be con-firmed with a qualitative test for fecal fat and treated with acid suppression. Postvagotomy diarrhea usually does not respond to treatment with pancreatic enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of |
Surgery_Schwartz_7632 | Surgery_Schwartz | enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of choice is probably a 10-cm reversed jejunal interposition placed in continuity 100 cm distal to the ligament of Treitz. Another option is the onlay antiperi-staltic distal ileal graft. Both operations can cause obstructive symptoms and/or bacterial overgrowth.209Gastric Stasis210,211Gastric stasis following surgery on the stomach may be due to a problem with gastric motor function or caused by an obstruc-tion. The gastric motility abnormality could have been preexist-ing and unrecognized by the operating surgeon. Alternatively, Figure 26-67. Duodenal switch operation. (Reproduced with per-mission from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC | Surgery_Schwartz. enzymes. In the rare patient who is debilitated by postvagotomy diarrhea unresponsive to medical management, operation might be considered, but outcomes can be problematic. The operation of choice is probably a 10-cm reversed jejunal interposition placed in continuity 100 cm distal to the ligament of Treitz. Another option is the onlay antiperi-staltic distal ileal graft. Both operations can cause obstructive symptoms and/or bacterial overgrowth.209Gastric Stasis210,211Gastric stasis following surgery on the stomach may be due to a problem with gastric motor function or caused by an obstruc-tion. The gastric motility abnormality could have been preexist-ing and unrecognized by the operating surgeon. Alternatively, Figure 26-67. Duodenal switch operation. (Reproduced with per-mission from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC |
Surgery_Schwartz_7633 | Surgery_Schwartz | from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC CONSIDERATIONS PART IIit may be secondary to deliberate or unintentional vagotomy, or resection of the dominant gastric pacemaker. An obstruction may be mechanical (e.g., anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a proximal small-bowel obstruction) or functional (e.g., retrograde peristal-sis in a Roux limb). Gastric stasis presents with vomiting (often of undigested food), bloating, epigastric pain, and weight loss.The evaluation of a patient with suspected postoperative gastric stasis includes EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb | Surgery_Schwartz. from Hinder RA: Duodenal switch: a new form of pancreati-cobiliary diversion, Surg Clin North Am. 1992 Apr;72(2):487-499.)Brunicardi_Ch26_p1099-p1166.indd 115701/03/19 7:13 PM 1158SPECIFIC CONSIDERATIONS PART IIit may be secondary to deliberate or unintentional vagotomy, or resection of the dominant gastric pacemaker. An obstruction may be mechanical (e.g., anastomotic stricture, efferent limb kink from adhesions or constricting mesocolon, or a proximal small-bowel obstruction) or functional (e.g., retrograde peristal-sis in a Roux limb). Gastric stasis presents with vomiting (often of undigested food), bloating, epigastric pain, and weight loss.The evaluation of a patient with suspected postoperative gastric stasis includes EGD, upper GI and small bowel series, gastric emptying scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb |
Surgery_Schwartz_7634 | Surgery_Schwartz | scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb suggests chronic stasis, either from a motor abnormality (e.g., Roux syndrome) or mechanical small bowel obstruction (e.g., chronic adhesion). If the problem is thought to be primarily a disorder of intrinsic motor func-tion, newer techniques such as EGG and GI manometry should be considered, but chronic distal mechanical obstruction may result in disordered motility in the proximal organ confounding interpretation.Once mechanical obstruction has been ruled out, medi-cal treatment is successful in most cases of motor dysfunction following previous gastric surgery. This consists of dietary modification and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis | Surgery_Schwartz. scan, and gastric motor testing. Endoscopy shows gastritis and retained food or bezoar. The anastomosis and efferent limb should be evaluated for stricture or narrow-ing. A dilated efferent limb suggests chronic stasis, either from a motor abnormality (e.g., Roux syndrome) or mechanical small bowel obstruction (e.g., chronic adhesion). If the problem is thought to be primarily a disorder of intrinsic motor func-tion, newer techniques such as EGG and GI manometry should be considered, but chronic distal mechanical obstruction may result in disordered motility in the proximal organ confounding interpretation.Once mechanical obstruction has been ruled out, medi-cal treatment is successful in most cases of motor dysfunction following previous gastric surgery. This consists of dietary modification and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis |
Surgery_Schwartz_7635 | Surgery_Schwartz | and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis following V + D may be treated with subto-tal gastrectomy but simple loop gastrojejunoctomy (GJ) should be tried if previous drainage was pyloroplasty. Billroth II anas-tomosis with Braun enteroenterostomy may be preferable to Roux-en-Y reconstruction after subtotal gastrectomy for gas-tric stasis, but bile reflux can still occur. Initial operation for gastric stasis is often associated with persistent gastric empty-ing problems that may subsequently require near-total or total gastrectomy, a nutritionally unattractive option. Delayed gastric emptying following ulcer surgery (V + D or V + A) may rep-resent an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and | Surgery_Schwartz. and promotility agents. Intermittent oral antibiotic therapy may be helpful in treating bacterial overgrowth, with its attendant symptoms of bloating, flatulence, and diarrhea.Gastroparesis following V + D may be treated with subto-tal gastrectomy but simple loop gastrojejunoctomy (GJ) should be tried if previous drainage was pyloroplasty. Billroth II anas-tomosis with Braun enteroenterostomy may be preferable to Roux-en-Y reconstruction after subtotal gastrectomy for gas-tric stasis, but bile reflux can still occur. Initial operation for gastric stasis is often associated with persistent gastric empty-ing problems that may subsequently require near-total or total gastrectomy, a nutritionally unattractive option. Delayed gastric emptying following ulcer surgery (V + D or V + A) may rep-resent an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and |
Surgery_Schwartz_7636 | Surgery_Schwartz | an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and smoking. And if necessary, endoscopic dilation is occa-sionally helpful. However, when associated with symptomatic gastric stasis, reoperation is often necessary. Gastroparesis fol-lowing subtotal gastric resection is best treated with near-total (95%) or total gastric resection and Roux-en-Y reconstruction. If total gastrectomy is performed, a jejunal reservoir should be considered. Gastric pacing is promising, but it has not achieved widespread clinical usefulness in the treatment of postoperative gastric atony.Bile Reflux Gastritis and EsophagitisMost patients who have undergone ablation or resection of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux | Surgery_Schwartz. an anastomotic stricture (often due to recurrent ulcer) or proximal small bowel obstruction. Recurrent ulcer may respond to medical therapy with PPI and abstinence from NSAIDs, aspi-rin, and smoking. And if necessary, endoscopic dilation is occa-sionally helpful. However, when associated with symptomatic gastric stasis, reoperation is often necessary. Gastroparesis fol-lowing subtotal gastric resection is best treated with near-total (95%) or total gastric resection and Roux-en-Y reconstruction. If total gastrectomy is performed, a jejunal reservoir should be considered. Gastric pacing is promising, but it has not achieved widespread clinical usefulness in the treatment of postoperative gastric atony.Bile Reflux Gastritis and EsophagitisMost patients who have undergone ablation or resection of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux |
Surgery_Schwartz_7637 | Surgery_Schwartz | of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux is problematic because most asymptomatic patients have bile reflux too. However, it is generally accepted that a small subset of patients have bile reflux gastritis syndrome. These patients present with nausea, bilious vomiting, and epigastric pain, and quantitative evidence of excess enterogastric reflux. Curiously, symptoms often develop months or years after the index operation. The differential diagnosis includes afferent or efferent loop obstruction, gastric stasis, and small-bowel obstruction. Plain abdominal X-rays, upper endoscopy, upper GI series, abdominal CT scan, and gastric emptying scans are helpful in evaluating these possibilities.Bile reflux may be quantified with gastric analysis or esophageal impedance testing or with scintigraphy (bile reflux scan). Typically, | Surgery_Schwartz. of the pylorus have bile in the stomach on endoscopic examination, along with some degree of gross or microscopic gastric inflam-mation. Therefore, attributing postoperative symptoms to bile reflux is problematic because most asymptomatic patients have bile reflux too. However, it is generally accepted that a small subset of patients have bile reflux gastritis syndrome. These patients present with nausea, bilious vomiting, and epigastric pain, and quantitative evidence of excess enterogastric reflux. Curiously, symptoms often develop months or years after the index operation. The differential diagnosis includes afferent or efferent loop obstruction, gastric stasis, and small-bowel obstruction. Plain abdominal X-rays, upper endoscopy, upper GI series, abdominal CT scan, and gastric emptying scans are helpful in evaluating these possibilities.Bile reflux may be quantified with gastric analysis or esophageal impedance testing or with scintigraphy (bile reflux scan). Typically, |
Surgery_Schwartz_7638 | Surgery_Schwartz | emptying scans are helpful in evaluating these possibilities.Bile reflux may be quantified with gastric analysis or esophageal impedance testing or with scintigraphy (bile reflux scan). Typically, enterogastric reflux is greatest after Billroth II gastrectomy or gastrojejunostomy, and least after vagotomy and pyloroplasty, with Billroth I gastrectomy giving intermediate values. Patients who are well into the abnormal range of bile reflux may be considered for remedial surgery if symptoms are severe. Remedial surgery will eliminate the bile from the vomi-tus and may improve the patient’s pain, but it is quite unusual to render these patients completely asymptomatic, especially if they are narcotic dependent.Bile reflux gastritis after distal gastric resection may be treated by one of the following options: Roux-en-Y gastroje-junostomy; interposition of a 40-cm isoperistaltic jejunal loop between the gastric remnant and the duodenum (Henley loop); Billroth II gastro jejunostomy with | Surgery_Schwartz. emptying scans are helpful in evaluating these possibilities.Bile reflux may be quantified with gastric analysis or esophageal impedance testing or with scintigraphy (bile reflux scan). Typically, enterogastric reflux is greatest after Billroth II gastrectomy or gastrojejunostomy, and least after vagotomy and pyloroplasty, with Billroth I gastrectomy giving intermediate values. Patients who are well into the abnormal range of bile reflux may be considered for remedial surgery if symptoms are severe. Remedial surgery will eliminate the bile from the vomi-tus and may improve the patient’s pain, but it is quite unusual to render these patients completely asymptomatic, especially if they are narcotic dependent.Bile reflux gastritis after distal gastric resection may be treated by one of the following options: Roux-en-Y gastroje-junostomy; interposition of a 40-cm isoperistaltic jejunal loop between the gastric remnant and the duodenum (Henley loop); Billroth II gastro jejunostomy with |
Surgery_Schwartz_7639 | Surgery_Schwartz | following options: Roux-en-Y gastroje-junostomy; interposition of a 40-cm isoperistaltic jejunal loop between the gastric remnant and the duodenum (Henley loop); Billroth II gastro jejunostomy with Braun enteroenterostomy; total gastrectomy with Roux esophagojejunostomy. To mini-mize reflux of bile into the stomach or the esophagus, the Roux limb should be at least 45 cm long (preferably 60 cm). The Braun enteroenterostomy should be placed at a similar distance from the stomach. Excessively long limbs may be associated with obstruction or malabsorption. All of these operations can result in marginal ulceration on the jejunal side of the gastrojeju-nostomy and thus are combined with a generous distal gastrec-tomy. If this has already been done at a previous operation, the Roux or Braun operations may be attractively simple. Whether truncal vagotomy should be considered to decrease the risk of marginal ulceration is controversial because acid-suppressing medications may be equally | Surgery_Schwartz. following options: Roux-en-Y gastroje-junostomy; interposition of a 40-cm isoperistaltic jejunal loop between the gastric remnant and the duodenum (Henley loop); Billroth II gastro jejunostomy with Braun enteroenterostomy; total gastrectomy with Roux esophagojejunostomy. To mini-mize reflux of bile into the stomach or the esophagus, the Roux limb should be at least 45 cm long (preferably 60 cm). The Braun enteroenterostomy should be placed at a similar distance from the stomach. Excessively long limbs may be associated with obstruction or malabsorption. All of these operations can result in marginal ulceration on the jejunal side of the gastrojeju-nostomy and thus are combined with a generous distal gastrec-tomy. If this has already been done at a previous operation, the Roux or Braun operations may be attractively simple. Whether truncal vagotomy should be considered to decrease the risk of marginal ulceration is controversial because acid-suppressing medications may be equally |
Surgery_Schwartz_7640 | Surgery_Schwartz | operations may be attractively simple. Whether truncal vagotomy should be considered to decrease the risk of marginal ulceration is controversial because acid-suppressing medications may be equally effective. In addition, the benefits of decreased acid secretion following vagotomy may be out-weighed by problems with vagotomy-associated dysmotility in the gastric remnant. The Roux operation may be associated with an increased risk of emptying problems compared to the other two options, but controlled data are lacking. Patients with debilitating bile reflux after gastrojejunostomy can be consid-ered for simple takedown of this anastomosis provided that the pyloric channel is open.Primary bile reflux gastritis (i.e., no previous operation) is rare, and may be treated with the duodenal switch operation, essentially an end-to-end Roux-en-Y to the proximal duodenum (see Fig. 26-68). The Achilles’ heel of this operation is, not sur-prisingly, marginal ulceration. Thus, it should be combined | Surgery_Schwartz. operations may be attractively simple. Whether truncal vagotomy should be considered to decrease the risk of marginal ulceration is controversial because acid-suppressing medications may be equally effective. In addition, the benefits of decreased acid secretion following vagotomy may be out-weighed by problems with vagotomy-associated dysmotility in the gastric remnant. The Roux operation may be associated with an increased risk of emptying problems compared to the other two options, but controlled data are lacking. Patients with debilitating bile reflux after gastrojejunostomy can be consid-ered for simple takedown of this anastomosis provided that the pyloric channel is open.Primary bile reflux gastritis (i.e., no previous operation) is rare, and may be treated with the duodenal switch operation, essentially an end-to-end Roux-en-Y to the proximal duodenum (see Fig. 26-68). The Achilles’ heel of this operation is, not sur-prisingly, marginal ulceration. Thus, it should be combined |
Surgery_Schwartz_7641 | Surgery_Schwartz | operation, essentially an end-to-end Roux-en-Y to the proximal duodenum (see Fig. 26-68). The Achilles’ heel of this operation is, not sur-prisingly, marginal ulceration. Thus, it should be combined with highly selective vagotomy, and/or long-term acid suppressive medication.Bile gastritis or esophagitis is a recognized complication after esophagogastrectomy with or without pyloroplasty. This can be effectively treated by division of the duodenum immedi-ately distal to the pylorus with drainage of the prepyloric antrum into a Roux limb. Preservation of the right gastroepiploic pedi-cal is important. Proximal subtotal gastrectomy with esophago-antral anastomosis should be avoided, but when performed, the pylorus should be left intact.Roux SyndromeA subset of patients who have had distal gastrectomy and Roux-en-Y gastrojejunostomy will have great difficulty with gastric emptying in the absence of mechanical obstruc-tion. These patients present with vomiting, epigastric pain, and weight | Surgery_Schwartz. operation, essentially an end-to-end Roux-en-Y to the proximal duodenum (see Fig. 26-68). The Achilles’ heel of this operation is, not sur-prisingly, marginal ulceration. Thus, it should be combined with highly selective vagotomy, and/or long-term acid suppressive medication.Bile gastritis or esophagitis is a recognized complication after esophagogastrectomy with or without pyloroplasty. This can be effectively treated by division of the duodenum immedi-ately distal to the pylorus with drainage of the prepyloric antrum into a Roux limb. Preservation of the right gastroepiploic pedi-cal is important. Proximal subtotal gastrectomy with esophago-antral anastomosis should be avoided, but when performed, the pylorus should be left intact.Roux SyndromeA subset of patients who have had distal gastrectomy and Roux-en-Y gastrojejunostomy will have great difficulty with gastric emptying in the absence of mechanical obstruc-tion. These patients present with vomiting, epigastric pain, and weight |
Surgery_Schwartz_7642 | Surgery_Schwartz | and Roux-en-Y gastrojejunostomy will have great difficulty with gastric emptying in the absence of mechanical obstruc-tion. These patients present with vomiting, epigastric pain, and weight loss. This clinical scenario has been labeled the Brunicardi_Ch26_p1099-p1166.indd 115801/03/19 7:13 PM 1159STOMACHCHAPTER 26Roux syndrome. Endoscopy may show retained food or bezoars, dilation of the gastric remnant, and/or dilation of the Roux limb. Anastomotic inflammation and stricture from mar-ginal ulceration is a confounding finding. An upper GI series confirms these findings and may show delayed gastric empty-ing. This is better quantified by a gastric emptying scan, which always shows delayed solid emptying and may show delayed liquid emptying as well.GI motility testing shows abnormal motility in the Roux limb, with much of the propulsive activity toward, rather than away from, the stomach.212 Gastric motility also may be abnor-mal. Presumably, the disordered motility in the Roux | Surgery_Schwartz. and Roux-en-Y gastrojejunostomy will have great difficulty with gastric emptying in the absence of mechanical obstruc-tion. These patients present with vomiting, epigastric pain, and weight loss. This clinical scenario has been labeled the Brunicardi_Ch26_p1099-p1166.indd 115801/03/19 7:13 PM 1159STOMACHCHAPTER 26Roux syndrome. Endoscopy may show retained food or bezoars, dilation of the gastric remnant, and/or dilation of the Roux limb. Anastomotic inflammation and stricture from mar-ginal ulceration is a confounding finding. An upper GI series confirms these findings and may show delayed gastric empty-ing. This is better quantified by a gastric emptying scan, which always shows delayed solid emptying and may show delayed liquid emptying as well.GI motility testing shows abnormal motility in the Roux limb, with much of the propulsive activity toward, rather than away from, the stomach.212 Gastric motility also may be abnor-mal. Presumably, the disordered motility in the Roux |
Surgery_Schwartz_7643 | Surgery_Schwartz | motility in the Roux limb, with much of the propulsive activity toward, rather than away from, the stomach.212 Gastric motility also may be abnor-mal. Presumably, the disordered motility in the Roux limb occurs in all patients with this operation. Why only a subset develops the Roux syndrome is unclear. Perhaps patients with disordered gastric motility are at most risk. The disorder seems to be more common in patients with a generous gastric remnant. Truncal vagotomy also has been implicated.Medical treatment consists of promotility agents. Surgi-cal treatment consists of paring down the gastric remnant. Care should be taken to preserve adequate blood supply to the new gastric pouch. If the left gastric artery is intact, a vertically ori-ented lesser curvature based pouch (similar to gastric bypass) with excision of the fundus can be considered. If gastric motility is severely disordered, 95% gastrectomy or total gastrectomy should be considered. The Roux limb should be resected if it | Surgery_Schwartz. motility in the Roux limb, with much of the propulsive activity toward, rather than away from, the stomach.212 Gastric motility also may be abnor-mal. Presumably, the disordered motility in the Roux limb occurs in all patients with this operation. Why only a subset develops the Roux syndrome is unclear. Perhaps patients with disordered gastric motility are at most risk. The disorder seems to be more common in patients with a generous gastric remnant. Truncal vagotomy also has been implicated.Medical treatment consists of promotility agents. Surgi-cal treatment consists of paring down the gastric remnant. Care should be taken to preserve adequate blood supply to the new gastric pouch. If the left gastric artery is intact, a vertically ori-ented lesser curvature based pouch (similar to gastric bypass) with excision of the fundus can be considered. If gastric motility is severely disordered, 95% gastrectomy or total gastrectomy should be considered. The Roux limb should be resected if it |
Surgery_Schwartz_7644 | Surgery_Schwartz | bypass) with excision of the fundus can be considered. If gastric motility is severely disordered, 95% gastrectomy or total gastrectomy should be considered. The Roux limb should be resected if it is dilated and flaccid, unless doing so puts the patient at risk for short bowel.GallstonesGallstone formation following gastric surgery generally is thought to be secondary to vagal denervation of the gallblad-der with attendant gallbladder dysmotility and stasis. Although prophylactic cholecystectomy is not justified with most gas-tric surgery, it should be considered if the gallbladder appears abnormal, especially if subsequent cholecystectomy is likely to be difficult. If preoperative evaluation reveals sludge or gall-stones, or if intraoperative evaluation reveals stones, incidental cholecystectomy should be considered.Weight LossWeight loss is common in patients who have had a vagotomy and/or gastric resection. The degree of weight loss tends to par-allel the magnitude of the | Surgery_Schwartz. bypass) with excision of the fundus can be considered. If gastric motility is severely disordered, 95% gastrectomy or total gastrectomy should be considered. The Roux limb should be resected if it is dilated and flaccid, unless doing so puts the patient at risk for short bowel.GallstonesGallstone formation following gastric surgery generally is thought to be secondary to vagal denervation of the gallblad-der with attendant gallbladder dysmotility and stasis. Although prophylactic cholecystectomy is not justified with most gas-tric surgery, it should be considered if the gallbladder appears abnormal, especially if subsequent cholecystectomy is likely to be difficult. If preoperative evaluation reveals sludge or gall-stones, or if intraoperative evaluation reveals stones, incidental cholecystectomy should be considered.Weight LossWeight loss is common in patients who have had a vagotomy and/or gastric resection. The degree of weight loss tends to par-allel the magnitude of the |
Surgery_Schwartz_7645 | Surgery_Schwartz | cholecystectomy should be considered.Weight LossWeight loss is common in patients who have had a vagotomy and/or gastric resection. The degree of weight loss tends to par-allel the magnitude of the operation. It may be insignificant in the obese but devastating in the asthenic patient. The surgeon should always consider the possible nutritional consequences before performing a gastric resection for benign disease in a thin patient. The causes of weight loss after gastric surgery generally fall into one of two categories: altered dietary intake or malabsorption. If a stool stain for fecal fat is negative, it is likely that decreased caloric intake is the cause. This is the most common cause of weight loss after gastric surgery, and it may be due to small stomach syndrome, postoperative gastroparesis, anorexia due to loss of ghrelin, or self-imposed dietary modifi-cation because of dumping and/or diarrhea. Consultation with an experienced dietitian may prove invaluable.AnemiaIron | Surgery_Schwartz. cholecystectomy should be considered.Weight LossWeight loss is common in patients who have had a vagotomy and/or gastric resection. The degree of weight loss tends to par-allel the magnitude of the operation. It may be insignificant in the obese but devastating in the asthenic patient. The surgeon should always consider the possible nutritional consequences before performing a gastric resection for benign disease in a thin patient. The causes of weight loss after gastric surgery generally fall into one of two categories: altered dietary intake or malabsorption. If a stool stain for fecal fat is negative, it is likely that decreased caloric intake is the cause. This is the most common cause of weight loss after gastric surgery, and it may be due to small stomach syndrome, postoperative gastroparesis, anorexia due to loss of ghrelin, or self-imposed dietary modifi-cation because of dumping and/or diarrhea. Consultation with an experienced dietitian may prove invaluable.AnemiaIron |
Surgery_Schwartz_7646 | Surgery_Schwartz | gastroparesis, anorexia due to loss of ghrelin, or self-imposed dietary modifi-cation because of dumping and/or diarrhea. Consultation with an experienced dietitian may prove invaluable.AnemiaIron absorption takes place primarily in the proximal GI tract, and it is facilitated by an acidic environment. Intrinsic factor, essential for the enteric absorption of vitamin B12, is made by the parietal cells of the stomach. Vitamin B12 bioavailability also is facilitated by an acidic environment. Folate-rich vegetables may be poorly tolerated if gastric emptying is delayed or if 10gastric capacity is limited. Since iron, B12, and folate play vital roles in hematopoiesis, it is easy to understand why patients who have had a gastric operation are at risk for anemia. Ane-mia is the most common metabolic side effect in patients who have had a gastric bypass for morbid obesity. It also occurs in up to one-third of patients who have had a vagotomy and/or gastric resection. Iron deficiency is the | Surgery_Schwartz. gastroparesis, anorexia due to loss of ghrelin, or self-imposed dietary modifi-cation because of dumping and/or diarrhea. Consultation with an experienced dietitian may prove invaluable.AnemiaIron absorption takes place primarily in the proximal GI tract, and it is facilitated by an acidic environment. Intrinsic factor, essential for the enteric absorption of vitamin B12, is made by the parietal cells of the stomach. Vitamin B12 bioavailability also is facilitated by an acidic environment. Folate-rich vegetables may be poorly tolerated if gastric emptying is delayed or if 10gastric capacity is limited. Since iron, B12, and folate play vital roles in hematopoiesis, it is easy to understand why patients who have had a gastric operation are at risk for anemia. Ane-mia is the most common metabolic side effect in patients who have had a gastric bypass for morbid obesity. It also occurs in up to one-third of patients who have had a vagotomy and/or gastric resection. Iron deficiency is the |
Surgery_Schwartz_7647 | Surgery_Schwartz | side effect in patients who have had a gastric bypass for morbid obesity. It also occurs in up to one-third of patients who have had a vagotomy and/or gastric resection. Iron deficiency is the most common cause, but vitamin B12 or folate deficiency also occurs, even in patients who have not had total gastrectomy. Of course, patients who have had a total gastrectomy will all develop B12 deficiency with-out some type of regular nonenteral vitamin B12 administration. Gastric bypass patients should be given oral iron supplements and monitored for iron, B12, and folate deficiency. Patients who have had a vagotomy and/or gastrectomy should be similarly monitored with periodic determination of hematocrit, red blood cell indices, iron and transferrin levels, B12, and folate levels. Marginal nutrient status should be corrected with oral and/or parenteral supplementation.Bone DiseaseGastric surgery sometimes disturbs calcium and vitamin D metabolism. Calcium absorption occurs primarily in the | Surgery_Schwartz. side effect in patients who have had a gastric bypass for morbid obesity. It also occurs in up to one-third of patients who have had a vagotomy and/or gastric resection. Iron deficiency is the most common cause, but vitamin B12 or folate deficiency also occurs, even in patients who have not had total gastrectomy. Of course, patients who have had a total gastrectomy will all develop B12 deficiency with-out some type of regular nonenteral vitamin B12 administration. Gastric bypass patients should be given oral iron supplements and monitored for iron, B12, and folate deficiency. Patients who have had a vagotomy and/or gastrectomy should be similarly monitored with periodic determination of hematocrit, red blood cell indices, iron and transferrin levels, B12, and folate levels. Marginal nutrient status should be corrected with oral and/or parenteral supplementation.Bone DiseaseGastric surgery sometimes disturbs calcium and vitamin D metabolism. Calcium absorption occurs primarily in the |
Surgery_Schwartz_7648 | Surgery_Schwartz | status should be corrected with oral and/or parenteral supplementation.Bone DiseaseGastric surgery sometimes disturbs calcium and vitamin D metabolism. Calcium absorption occurs primarily in the duo-denum, which is bypassed with gastrojejunostomy. Fat mal-absorption may occur because of blind loop syndrome and bacterial overgrowth or because of inefficient mixing of food and digestive enzymes. This can significantly affect the absorp-tion of vitamin D, a fat-soluble vitamin. Both abnormalities of calcium and vitamin D metabolism can contribute to metabolic bone disease in patients following gastric surgery. The prob-lems usually manifest as pain and/or fractures many years after the index operation. Musculoskeletal symptoms should prompt a study of bone density. Dietary supplementation of calcium and vitamin D may be useful in preventing these complications. Routine skeletal monitoring of patients at high-risk (e.g., elderly males and females and postmenopausal females) may prove | Surgery_Schwartz. status should be corrected with oral and/or parenteral supplementation.Bone DiseaseGastric surgery sometimes disturbs calcium and vitamin D metabolism. Calcium absorption occurs primarily in the duo-denum, which is bypassed with gastrojejunostomy. Fat mal-absorption may occur because of blind loop syndrome and bacterial overgrowth or because of inefficient mixing of food and digestive enzymes. This can significantly affect the absorp-tion of vitamin D, a fat-soluble vitamin. Both abnormalities of calcium and vitamin D metabolism can contribute to metabolic bone disease in patients following gastric surgery. The prob-lems usually manifest as pain and/or fractures many years after the index operation. Musculoskeletal symptoms should prompt a study of bone density. Dietary supplementation of calcium and vitamin D may be useful in preventing these complications. Routine skeletal monitoring of patients at high-risk (e.g., elderly males and females and postmenopausal females) may prove |
Surgery_Schwartz_7649 | Surgery_Schwartz | of calcium and vitamin D may be useful in preventing these complications. Routine skeletal monitoring of patients at high-risk (e.g., elderly males and females and postmenopausal females) may prove useful in identifying skeletal deterioration that may be slowed or stopped with appropriate treatment after gastric surgery.LAPAROSCOPIC GASTRIC OPERATIONSThe most common laparoscopic gastric operations performed today are for GERD and obesity. However, all conventional gastric operations can be performed with minimal access techniques.213 Some are more technically challenging (e.g., partial or total gastric resection) are of debatable advantage over conventional open approaches. Certainly, highly selective vagotomy, vagotomy and gastrojejunostomy, and gastrostomy lend themselves to a minimal access approach. Laparoscopic local excision is often feasible for GI stromal tumors, leiomyo-mas, or gastric diverticula. Difficult to access lesions near the GE junction or pylorus may be removed | Surgery_Schwartz. of calcium and vitamin D may be useful in preventing these complications. Routine skeletal monitoring of patients at high-risk (e.g., elderly males and females and postmenopausal females) may prove useful in identifying skeletal deterioration that may be slowed or stopped with appropriate treatment after gastric surgery.LAPAROSCOPIC GASTRIC OPERATIONSThe most common laparoscopic gastric operations performed today are for GERD and obesity. However, all conventional gastric operations can be performed with minimal access techniques.213 Some are more technically challenging (e.g., partial or total gastric resection) are of debatable advantage over conventional open approaches. Certainly, highly selective vagotomy, vagotomy and gastrojejunostomy, and gastrostomy lend themselves to a minimal access approach. Laparoscopic local excision is often feasible for GI stromal tumors, leiomyo-mas, or gastric diverticula. Difficult to access lesions near the GE junction or pylorus may be removed |
Surgery_Schwartz_7650 | Surgery_Schwartz | access approach. Laparoscopic local excision is often feasible for GI stromal tumors, leiomyo-mas, or gastric diverticula. Difficult to access lesions near the GE junction or pylorus may be removed through an anterior gastrotomy; more recent approaches utilizing transgastric ports or combined laparoscopic and endoscopic approaches show promise in allowing removal of practically any small gastric lesion with limited incisions.In Japan and Korea, laparoscopic and robotic assisted approaches have been applied increasingly in the manage-ment of gastric cancer.214,215 Indeed, laparoscopic subtotal gas-trectomy has supplanted the traditional open operation as the preferred operation for patients with earlier stage tumors, and laparocopic total gastrectomy for proximal tumors is performed with regularity and excellent outcomes. The Asian experience Brunicardi_Ch26_p1099-p1166.indd 115901/03/19 7:13 PM 1160SPECIFIC CONSIDERATIONS PART IIhas firmly established the feasibility of safe | Surgery_Schwartz. access approach. Laparoscopic local excision is often feasible for GI stromal tumors, leiomyo-mas, or gastric diverticula. Difficult to access lesions near the GE junction or pylorus may be removed through an anterior gastrotomy; more recent approaches utilizing transgastric ports or combined laparoscopic and endoscopic approaches show promise in allowing removal of practically any small gastric lesion with limited incisions.In Japan and Korea, laparoscopic and robotic assisted approaches have been applied increasingly in the manage-ment of gastric cancer.214,215 Indeed, laparoscopic subtotal gas-trectomy has supplanted the traditional open operation as the preferred operation for patients with earlier stage tumors, and laparocopic total gastrectomy for proximal tumors is performed with regularity and excellent outcomes. The Asian experience Brunicardi_Ch26_p1099-p1166.indd 115901/03/19 7:13 PM 1160SPECIFIC CONSIDERATIONS PART IIhas firmly established the feasibility of safe |
Surgery_Schwartz_7651 | Surgery_Schwartz | regularity and excellent outcomes. The Asian experience Brunicardi_Ch26_p1099-p1166.indd 115901/03/19 7:13 PM 1160SPECIFIC CONSIDERATIONS PART IIhas firmly established the feasibility of safe laparoscopic D2 gastrectomy. Translation of this experience to the United States, however, is not easily accomplished. Studies from Asia suggest that expertise in the laparoscopic approach require upwards of 40 cases, a challenging baseline given the much lower incidence of gastric cancer in the United States.216-219 A more advanced spectrum of disease and higher mean BMI in Western coun-tries are additional barriers to widespread implementation of laparoscopic resection for gastric cancer. Notwithstanding, several high volume centers in the United States have reported excellent outcomes after laparoscopic gastrectomy. As robotic technology that facilitates dissection and anastomosis with articulated instrumentation and enhanced visualization becomes increasingly ubiquitous, the pendulum | Surgery_Schwartz. regularity and excellent outcomes. The Asian experience Brunicardi_Ch26_p1099-p1166.indd 115901/03/19 7:13 PM 1160SPECIFIC CONSIDERATIONS PART IIhas firmly established the feasibility of safe laparoscopic D2 gastrectomy. Translation of this experience to the United States, however, is not easily accomplished. Studies from Asia suggest that expertise in the laparoscopic approach require upwards of 40 cases, a challenging baseline given the much lower incidence of gastric cancer in the United States.216-219 A more advanced spectrum of disease and higher mean BMI in Western coun-tries are additional barriers to widespread implementation of laparoscopic resection for gastric cancer. Notwithstanding, several high volume centers in the United States have reported excellent outcomes after laparoscopic gastrectomy. As robotic technology that facilitates dissection and anastomosis with articulated instrumentation and enhanced visualization becomes increasingly ubiquitous, the pendulum |
Surgery_Schwartz_7652 | Surgery_Schwartz | laparoscopic gastrectomy. As robotic technology that facilitates dissection and anastomosis with articulated instrumentation and enhanced visualization becomes increasingly ubiquitous, the pendulum will likely swing toward increasing utilization of minimal access approaches for all gas-tric operations.220REFERENCESEntries highlighted in bright blue are key references. 1. Beaumont W. Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Plattsburgh: PP Allen; 1833. 2. Wangensteen OH, Wangensteen SD. Gastric surgery. In: The Rise of Surgery. Minneapolis: University of Minnesota Press; 1978. 3. Herrington JL. Historical aspects of gastric surgery. In: Scott HW, Jr, Sawyers JL, eds. Surgery of the Stomach, Duodenum, and Small Intestine. 2nd ed. Boston: Blackwell; 1992. 4. Dragstedt LR. Vagotomy for the gastroduodenal ulcer. Ann Surg. 1945;122:973-989. 5. Zollinger RM, Ellison EH. Primary peptic ulcerations of the jejunum associated with islet cell tumors of | Surgery_Schwartz. laparoscopic gastrectomy. As robotic technology that facilitates dissection and anastomosis with articulated instrumentation and enhanced visualization becomes increasingly ubiquitous, the pendulum will likely swing toward increasing utilization of minimal access approaches for all gas-tric operations.220REFERENCESEntries highlighted in bright blue are key references. 1. Beaumont W. Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Plattsburgh: PP Allen; 1833. 2. Wangensteen OH, Wangensteen SD. Gastric surgery. In: The Rise of Surgery. Minneapolis: University of Minnesota Press; 1978. 3. Herrington JL. Historical aspects of gastric surgery. In: Scott HW, Jr, Sawyers JL, eds. Surgery of the Stomach, Duodenum, and Small Intestine. 2nd ed. Boston: Blackwell; 1992. 4. Dragstedt LR. Vagotomy for the gastroduodenal ulcer. Ann Surg. 1945;122:973-989. 5. Zollinger RM, Ellison EH. Primary peptic ulcerations of the jejunum associated with islet cell tumors of |
Surgery_Schwartz_7653 | Surgery_Schwartz | 1992. 4. Dragstedt LR. Vagotomy for the gastroduodenal ulcer. Ann Surg. 1945;122:973-989. 5. Zollinger RM, Ellison EH. Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas. Ann Surg. 1955;142:709-728. 6. Flora ED, Wilson TG, Martin IJ, et al. A review of natural orifice translumenal endoscopic surgery (NOTES) for intraab-dominal surgery: experimental models, techniques, and appli-cability to the clinical setting. Ann Surg. 2008;247:583-602. 7. Mercer DW, Liu TH, Castaneda A. Anatomy and physiology of the stomach. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5th ed. Vol 2. Philadelphia: WB Saunders; 2002:3. 8. Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal spleno-renal shunt. Ann Surg. 1967;166:437-455. 9. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363-372. 10. Leung | Surgery_Schwartz. 1992. 4. Dragstedt LR. Vagotomy for the gastroduodenal ulcer. Ann Surg. 1945;122:973-989. 5. Zollinger RM, Ellison EH. Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas. Ann Surg. 1955;142:709-728. 6. Flora ED, Wilson TG, Martin IJ, et al. A review of natural orifice translumenal endoscopic surgery (NOTES) for intraab-dominal surgery: experimental models, techniques, and appli-cability to the clinical setting. Ann Surg. 2008;247:583-602. 7. Mercer DW, Liu TH, Castaneda A. Anatomy and physiology of the stomach. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5th ed. Vol 2. Philadelphia: WB Saunders; 2002:3. 8. Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal spleno-renal shunt. Ann Surg. 1967;166:437-455. 9. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363-372. 10. Leung |
Surgery_Schwartz_7654 | Surgery_Schwartz | shunt. Ann Surg. 1967;166:437-455. 9. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363-372. 10. Leung WK, et al. Tumors of the stomach. In: Yamada T, et al, eds. Textbook of Gastroenterology. 4th ed. Philadelphia: Lip-pincott, Williams & Wilkins; 2003:1416. 11. Japanese Gastric Cancer Association. Japanese classifications of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14:101-112. 12. Jansen EPM, Boot H, Verheij M, van de Velde CJ. Opti-mal locoregional treatment in gastric cancer. J Clin Oncol. 2005:23:4509-4517. 13. Johnson LR, ed. Physiology of the Gastrointestinal Tract. 5th ed. New York: Elsevier; 2012. 14. Browning KN, Verheijden S, Boeckxstaens GE. The vagus nerve in appetite regulation, mood, and intestinal inflamma-tion. Gastroenterology. 2017;152(4):730-744. 15. Matteoli G, Boeckxstaens GE. The vagal innervation of the gut and immune homeostasis. Gut. | Surgery_Schwartz. shunt. Ann Surg. 1967;166:437-455. 9. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363-372. 10. Leung WK, et al. Tumors of the stomach. In: Yamada T, et al, eds. Textbook of Gastroenterology. 4th ed. Philadelphia: Lip-pincott, Williams & Wilkins; 2003:1416. 11. Japanese Gastric Cancer Association. Japanese classifications of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14:101-112. 12. Jansen EPM, Boot H, Verheij M, van de Velde CJ. Opti-mal locoregional treatment in gastric cancer. J Clin Oncol. 2005:23:4509-4517. 13. Johnson LR, ed. Physiology of the Gastrointestinal Tract. 5th ed. New York: Elsevier; 2012. 14. Browning KN, Verheijden S, Boeckxstaens GE. The vagus nerve in appetite regulation, mood, and intestinal inflamma-tion. Gastroenterology. 2017;152(4):730-744. 15. Matteoli G, Boeckxstaens GE. The vagal innervation of the gut and immune homeostasis. Gut. |
Surgery_Schwartz_7655 | Surgery_Schwartz | nerve in appetite regulation, mood, and intestinal inflamma-tion. Gastroenterology. 2017;152(4):730-744. 15. Matteoli G, Boeckxstaens GE. The vagal innervation of the gut and immune homeostasis. Gut. 2013;62(8):1214-1222. 16. Fawcett DW, Jensh R. In: Bloom and Fawcett: Concise Histol-ogy. 2nd ed. Oxford University Press: London. 17. Ashley SW, Evoy D, Daly JM. Stomach. In: Schwartz SI, ed. Principles of Surgery. 7nd ed. New York:McGraw-Hill; 1999:1181. 18. Antonioli DA, Madara JL. Functional anatomy of the gas-trointestinal tract. In: Ming S-C, Goldman H, eds. Pathology of the Gastrointestinal Tract. 2nd ed. Baltimore: Williams & Wilkins; 1998:13. 19. Aloia L, McKie MA, Huch M. Cellular plasticity in the adult liver and stomach. J Physiol. 2016;594(17):4815-4825. 20. Feldman M. Gastric secretion. In: Feldman M, ed. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7nd ed. Philadelphia: Saunders; 2002;715. 21. Minalyan A, Gabrielyan L, Scott D, Jacobs J, Pisegna JR. The | Surgery_Schwartz. nerve in appetite regulation, mood, and intestinal inflamma-tion. Gastroenterology. 2017;152(4):730-744. 15. Matteoli G, Boeckxstaens GE. The vagal innervation of the gut and immune homeostasis. Gut. 2013;62(8):1214-1222. 16. Fawcett DW, Jensh R. In: Bloom and Fawcett: Concise Histol-ogy. 2nd ed. Oxford University Press: London. 17. Ashley SW, Evoy D, Daly JM. Stomach. In: Schwartz SI, ed. Principles of Surgery. 7nd ed. New York:McGraw-Hill; 1999:1181. 18. Antonioli DA, Madara JL. Functional anatomy of the gas-trointestinal tract. In: Ming S-C, Goldman H, eds. Pathology of the Gastrointestinal Tract. 2nd ed. Baltimore: Williams & Wilkins; 1998:13. 19. Aloia L, McKie MA, Huch M. Cellular plasticity in the adult liver and stomach. J Physiol. 2016;594(17):4815-4825. 20. Feldman M. Gastric secretion. In: Feldman M, ed. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7nd ed. Philadelphia: Saunders; 2002;715. 21. Minalyan A, Gabrielyan L, Scott D, Jacobs J, Pisegna JR. The |
Surgery_Schwartz_7656 | Surgery_Schwartz | secretion. In: Feldman M, ed. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7nd ed. Philadelphia: Saunders; 2002;715. 21. Minalyan A, Gabrielyan L, Scott D, Jacobs J, Pisegna JR. The gastric and intestinal microbiome: role of proton pump inhibi-tors. Curr Gastroenterol Rep. 2017;19(8):42. 22. Loo VG, Bourgault AM, Poirier L, et al. Host and pathogen factors for Clostridium Difficile infection and colonization. N Engl J Med. 2011;365:1693-1703. 23. Canani RB, Terrin G. Gastric acidity inhibitors and the risk of intestinal infections. Curr Opin Gastroenterol. 2010;26:31-35. 24. Kopic S, Murek M, Geibel JP. Revisiting the parietal cell. Am J Physiol Cell Physiol. 2010;298:C1-C10. 25. Wolfe MM, Soll AH. The physiology of gastric acid secretion. N Engl J Med. 1988;319:1707-1715. 26. Schubert ML. Physiologic, pathophysiologic, and pharmaco-logic regulation of gastric acid secretion. Curr Opin Gastro-enterol. 2017;33(6): pp. 430-438. 27. Schubert ML, Peura DA. Control of | Surgery_Schwartz. secretion. In: Feldman M, ed. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7nd ed. Philadelphia: Saunders; 2002;715. 21. Minalyan A, Gabrielyan L, Scott D, Jacobs J, Pisegna JR. The gastric and intestinal microbiome: role of proton pump inhibi-tors. Curr Gastroenterol Rep. 2017;19(8):42. 22. Loo VG, Bourgault AM, Poirier L, et al. Host and pathogen factors for Clostridium Difficile infection and colonization. N Engl J Med. 2011;365:1693-1703. 23. Canani RB, Terrin G. Gastric acidity inhibitors and the risk of intestinal infections. Curr Opin Gastroenterol. 2010;26:31-35. 24. Kopic S, Murek M, Geibel JP. Revisiting the parietal cell. Am J Physiol Cell Physiol. 2010;298:C1-C10. 25. Wolfe MM, Soll AH. The physiology of gastric acid secretion. N Engl J Med. 1988;319:1707-1715. 26. Schubert ML. Physiologic, pathophysiologic, and pharmaco-logic regulation of gastric acid secretion. Curr Opin Gastro-enterol. 2017;33(6): pp. 430-438. 27. Schubert ML, Peura DA. Control of |
Surgery_Schwartz_7657 | Surgery_Schwartz | ML. Physiologic, pathophysiologic, and pharmaco-logic regulation of gastric acid secretion. Curr Opin Gastro-enterol. 2017;33(6): pp. 430-438. 27. Schubert ML, Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology. 2008;134(7):1842-1860. 28. Lloyd KCK, Debas HT. Hormonal and neural regulation of gastric acid secretion. In: Johnson LR, ed. Physiology of the Gastrointestinal Tract. 3rd ed. New York: Raven; 1993. 29. Del Valle J, Todisco A. Gastric secretion. In: Yamada T, et al, eds. Textbook of Gastroenterology. 4nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2003:266. 30. Norlén P, Ericsson P, Kitano M, Ekelund M, Håkanson R. The vagus regulates histamine mobilization from rat stomach ECL cells by controlling their sensitivity to gastrin. J Physiol. 2005;564(pt 3):895-905. 31. Holst JJ, Knuhtsen S, Orskov C, et al. GRP nerves in pig antrum: role of GRP in vagal control of gastrin secretion. Am J Physiol. 1987;253(5 pt 1):G643-G649. 32. Helgadottir | Surgery_Schwartz. ML. Physiologic, pathophysiologic, and pharmaco-logic regulation of gastric acid secretion. Curr Opin Gastro-enterol. 2017;33(6): pp. 430-438. 27. Schubert ML, Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology. 2008;134(7):1842-1860. 28. Lloyd KCK, Debas HT. Hormonal and neural regulation of gastric acid secretion. In: Johnson LR, ed. Physiology of the Gastrointestinal Tract. 3rd ed. New York: Raven; 1993. 29. Del Valle J, Todisco A. Gastric secretion. In: Yamada T, et al, eds. Textbook of Gastroenterology. 4nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2003:266. 30. Norlén P, Ericsson P, Kitano M, Ekelund M, Håkanson R. The vagus regulates histamine mobilization from rat stomach ECL cells by controlling their sensitivity to gastrin. J Physiol. 2005;564(pt 3):895-905. 31. Holst JJ, Knuhtsen S, Orskov C, et al. GRP nerves in pig antrum: role of GRP in vagal control of gastrin secretion. Am J Physiol. 1987;253(5 pt 1):G643-G649. 32. Helgadottir |
Surgery_Schwartz_7658 | Surgery_Schwartz | 3):895-905. 31. Holst JJ, Knuhtsen S, Orskov C, et al. GRP nerves in pig antrum: role of GRP in vagal control of gastrin secretion. Am J Physiol. 1987;253(5 pt 1):G643-G649. 32. Helgadottir H, Metz DC, Yang YX, Rhim AD, Björnsson ES. The effects of long-term therapy with proton pump inhibitors on meal stimulated gastrin. Dig Liver Dis. 2014;46(2):125-130. 33. Lodrup AB, Reimer C, Bytzer P. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibi-tor treatment. Scand J Gastroenterol. 2013;48(5):515-522. 34. Boyce M, et al. Randomised trial of the effect of a gastrin/CCK2 receptor antagonist on esomeprazole-induced hyper-gastrinaemia: evidence against rebound hyperacidity. Eur J Clin Pharmacol. 2017;73(2):129-139. 35. Agreus L, et al. Rationale in diagnosis and screening of atro-phic gastritis with stomach-specific plasma biomarkers. Scand J Gastroenterol. 2012;47(2):136-147. 36. Wallace JL. Prostaglandins, NSAIDs, and gastric mucosal pro-tection: why | Surgery_Schwartz. 3):895-905. 31. Holst JJ, Knuhtsen S, Orskov C, et al. GRP nerves in pig antrum: role of GRP in vagal control of gastrin secretion. Am J Physiol. 1987;253(5 pt 1):G643-G649. 32. Helgadottir H, Metz DC, Yang YX, Rhim AD, Björnsson ES. The effects of long-term therapy with proton pump inhibitors on meal stimulated gastrin. Dig Liver Dis. 2014;46(2):125-130. 33. Lodrup AB, Reimer C, Bytzer P. Systematic review: symptoms of rebound acid hypersecretion following proton pump inhibi-tor treatment. Scand J Gastroenterol. 2013;48(5):515-522. 34. Boyce M, et al. Randomised trial of the effect of a gastrin/CCK2 receptor antagonist on esomeprazole-induced hyper-gastrinaemia: evidence against rebound hyperacidity. Eur J Clin Pharmacol. 2017;73(2):129-139. 35. Agreus L, et al. Rationale in diagnosis and screening of atro-phic gastritis with stomach-specific plasma biomarkers. Scand J Gastroenterol. 2012;47(2):136-147. 36. Wallace JL. Prostaglandins, NSAIDs, and gastric mucosal pro-tection: why |
Surgery_Schwartz_7659 | Surgery_Schwartz | and screening of atro-phic gastritis with stomach-specific plasma biomarkers. Scand J Gastroenterol. 2012;47(2):136-147. 36. Wallace JL. Prostaglandins, NSAIDs, and gastric mucosal pro-tection: why doesn’t the stomach digest itself? Physiol Rev. 2008;88:1547-1565. 37. Choi SR, Lee SA, Kim YJ, et al. Role of heat shock proteins in gastric inflammation and ulcer healing. J Physiol Pharmacol. 2009;60:5-17. 38. Yandrapu H, Sarosiek J. Protective factors of the gastric and duodenal mucosa: an overview. Curr Gastroenterol Rep. 2015;17(6):24. 39. Cummings DE, Overduin J. Gastrointestinal regulation of food intake. J Clin Invest. 2007;117(1):13-23. 40. Dimaline R, Varro A. Novel roles of gastrin. J Physiol. 2014;592(14):2951-2958.Brunicardi_Ch26_p1099-p1166.indd 116001/03/19 7:13 PM 1161STOMACHCHAPTER 26 41. Bartfeld S, et al. In vitro expansion of human gastric epithelial stem cells and their responses to bacterial infection. Gastroen-terology. 2015;148(1):126-136 e6. 42. Winsett OE, et | Surgery_Schwartz. and screening of atro-phic gastritis with stomach-specific plasma biomarkers. Scand J Gastroenterol. 2012;47(2):136-147. 36. Wallace JL. Prostaglandins, NSAIDs, and gastric mucosal pro-tection: why doesn’t the stomach digest itself? Physiol Rev. 2008;88:1547-1565. 37. Choi SR, Lee SA, Kim YJ, et al. Role of heat shock proteins in gastric inflammation and ulcer healing. J Physiol Pharmacol. 2009;60:5-17. 38. Yandrapu H, Sarosiek J. Protective factors of the gastric and duodenal mucosa: an overview. Curr Gastroenterol Rep. 2015;17(6):24. 39. Cummings DE, Overduin J. Gastrointestinal regulation of food intake. J Clin Invest. 2007;117(1):13-23. 40. Dimaline R, Varro A. Novel roles of gastrin. J Physiol. 2014;592(14):2951-2958.Brunicardi_Ch26_p1099-p1166.indd 116001/03/19 7:13 PM 1161STOMACHCHAPTER 26 41. Bartfeld S, et al. In vitro expansion of human gastric epithelial stem cells and their responses to bacterial infection. Gastroen-terology. 2015;148(1):126-136 e6. 42. Winsett OE, et |
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Surgery_Schwartz_7693 | Surgery_Schwartz | Neuroendo-crinology. 2017;105(3):196-200. 195. Parkman HP, Hasler WL, Fisher RS. American Gastroen-terological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127: 1592-1622. 196. Yin J, Chen JD. Implantable gastric electrical stimulation: ready for prime time? Gastroenterology. 2008;134:665-667. 197. Zehetner J, Ravari F, Ayazi S, et al. Minimally invasive surgi-cal approach for the treatment of gastroparesis. Surg Endosc. 2013;27(1):61-66. 198. Cappell MS, Friedel D. Initial management of acute upper gas-trointestinal bleeding-from initial evaluation to gastrointestinal endoscopy. Med Clin North Am. 2008;92:491-509. 199. Dempsey DT, Burke DR, Reilly RS, McLean GK, Rosato EF. Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding. Am J Surg. 1990;159:282-286. 200. Zaman A. Portal hypertension related bleeding-management of difficult cases. Clin Liver Dis. 2006;10:353-370. 201. Coffey RJ, | Surgery_Schwartz. Neuroendo-crinology. 2017;105(3):196-200. 195. Parkman HP, Hasler WL, Fisher RS. American Gastroen-terological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127: 1592-1622. 196. Yin J, Chen JD. Implantable gastric electrical stimulation: ready for prime time? Gastroenterology. 2008;134:665-667. 197. Zehetner J, Ravari F, Ayazi S, et al. Minimally invasive surgi-cal approach for the treatment of gastroparesis. Surg Endosc. 2013;27(1):61-66. 198. Cappell MS, Friedel D. Initial management of acute upper gas-trointestinal bleeding-from initial evaluation to gastrointestinal endoscopy. Med Clin North Am. 2008;92:491-509. 199. Dempsey DT, Burke DR, Reilly RS, McLean GK, Rosato EF. Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding. Am J Surg. 1990;159:282-286. 200. Zaman A. Portal hypertension related bleeding-management of difficult cases. Clin Liver Dis. 2006;10:353-370. 201. Coffey RJ, |
Surgery_Schwartz_7694 | Surgery_Schwartz | upper gastrointestinal bleeding. Am J Surg. 1990;159:282-286. 200. Zaman A. Portal hypertension related bleeding-management of difficult cases. Clin Liver Dis. 2006;10:353-370. 201. Coffey RJ, Washington MK, Corless CL, et al. Ménétrier dis-ease and gastrointestinal stromal tumors: hyperproliferative disorders of the stomach. J Clin Invest. 2007;117:70. 202. Sebastian S, O’Morain CA, Buckley MJ. Current therapeutic options for gastric antral vascular ectasia. Aliment Pharmacol-Ther. 2003;18:157-165. 203. Akhras J, Patel P, Tobi M. Dieulafoy’s lesion-like bleeding: an under-recognized cause of upper gastrointestinal hemor-rhage in patients with advanced liver disease. Dig Dis Sci. 2007;52:722-726. 204. Harbison SP, Dempsey DT. Mallory-Weiss syndrome, in Cam-eron JL, ed. Current Surgical Therapy. 9nd ed. Philadelphia: Mosby; 2008. 205. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J | Surgery_Schwartz. upper gastrointestinal bleeding. Am J Surg. 1990;159:282-286. 200. Zaman A. Portal hypertension related bleeding-management of difficult cases. Clin Liver Dis. 2006;10:353-370. 201. Coffey RJ, Washington MK, Corless CL, et al. Ménétrier dis-ease and gastrointestinal stromal tumors: hyperproliferative disorders of the stomach. J Clin Invest. 2007;117:70. 202. Sebastian S, O’Morain CA, Buckley MJ. Current therapeutic options for gastric antral vascular ectasia. Aliment Pharmacol-Ther. 2003;18:157-165. 203. Akhras J, Patel P, Tobi M. Dieulafoy’s lesion-like bleeding: an under-recognized cause of upper gastrointestinal hemor-rhage in patients with advanced liver disease. Dig Dis Sci. 2007;52:722-726. 204. Harbison SP, Dempsey DT. Mallory-Weiss syndrome, in Cam-eron JL, ed. Current Surgical Therapy. 9nd ed. Philadelphia: Mosby; 2008. 205. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J |
Surgery_Schwartz_7695 | Surgery_Schwartz | Therapy. 9nd ed. Philadelphia: Mosby; 2008. 205. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16:407-418. 206. McClave SA. Critical care nutrition: getting involved as a gastrointestinal endoscopist. J Clin Gastroenterol. 2006;40:870-890. 207. Dempsey DT. Reoperative gastric surgery and postgastrec-tomy syndromes. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5nd ed. Vol 2. Philadelphia: Saunders; 2002:161.Brunicardi_Ch26_p1099-p1166.indd 116401/03/19 7:13 PM 1165STOMACHCHAPTER 26 208. Ukleja A. Dumping syndrome: pathophysiology and treat-ment. Nutr Clin Pract. 2005;20:517-525. 209. Cuschieri A. Postvagotomy diarrhea: is there a place for surgi-cal management? Gut. 1990;31:245-246. 210. Forster-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of | Surgery_Schwartz. Therapy. 9nd ed. Philadelphia: Mosby; 2008. 205. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16:407-418. 206. McClave SA. Critical care nutrition: getting involved as a gastrointestinal endoscopist. J Clin Gastroenterol. 2006;40:870-890. 207. Dempsey DT. Reoperative gastric surgery and postgastrec-tomy syndromes. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5nd ed. Vol 2. Philadelphia: Saunders; 2002:161.Brunicardi_Ch26_p1099-p1166.indd 116401/03/19 7:13 PM 1165STOMACHCHAPTER 26 208. Ukleja A. Dumping syndrome: pathophysiology and treat-ment. Nutr Clin Pract. 2005;20:517-525. 209. Cuschieri A. Postvagotomy diarrhea: is there a place for surgi-cal management? Gut. 1990;31:245-246. 210. Forster-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of |
Surgery_Schwartz_7696 | Surgery_Schwartz | a place for surgi-cal management? Gut. 1990;31:245-246. 210. Forster-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of early and long-term results in 62 patients. J Gastrointest Surg. 1999;3:15-21. 211. Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol. 2003;98: 2122-2129. 212. Van der Milje HC, Kleibeuker JH, Limburg AJ, et al. Mano-metric and scintigraphic studies of the relation between motility disturbances in the Roux limb and the Roux-en-Y syndrome. Am J Surg. 1993;166:11-17. 213. Farrell TM, Hunter JG. Laparoscopic surgery of the stomach and duodenum. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5nd ed. Vol 2. Philadelphia: Saunders; 2002:202. 214. Lee J, Kim W. Clinical experience of 528 laparoscopic gas-trectomies on gastric cancer in a single institution. Surgery. 2013;153(5):611-618. 215. Zeng YK, Yang ZL, Peng JS, et | Surgery_Schwartz. a place for surgi-cal management? Gut. 1990;31:245-246. 210. Forster-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of early and long-term results in 62 patients. J Gastrointest Surg. 1999;3:15-21. 211. Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol. 2003;98: 2122-2129. 212. Van der Milje HC, Kleibeuker JH, Limburg AJ, et al. Mano-metric and scintigraphic studies of the relation between motility disturbances in the Roux limb and the Roux-en-Y syndrome. Am J Surg. 1993;166:11-17. 213. Farrell TM, Hunter JG. Laparoscopic surgery of the stomach and duodenum. In: Zuidema GD, Yeo CJ, eds. Shackelford’s Surgery of the Alimentary Tract. 5nd ed. Vol 2. Philadelphia: Saunders; 2002:202. 214. Lee J, Kim W. Clinical experience of 528 laparoscopic gas-trectomies on gastric cancer in a single institution. Surgery. 2013;153(5):611-618. 215. Zeng YK, Yang ZL, Peng JS, et |
Surgery_Schwartz_7697 | Surgery_Schwartz | 2002:202. 214. Lee J, Kim W. Clinical experience of 528 laparoscopic gas-trectomies on gastric cancer in a single institution. Surgery. 2013;153(5):611-618. 215. Zeng YK, Yang ZL, Peng JS, et al. Laparoscopy-assisted ver-sus open distal gastrectomy for early gastric cancer. Ann Surg. 2012;256:39-52. 216. Kim HG, Park JH, Jeong SH, et al. Totally laparoscopic distal gastrectomy after learning curve completion: comparison with laparoscopy-assisted distal gastrectomy. J Gastric Cancer. 2013;13(1):26-33. 217. Moon JS, et al. Lessons learned from a comparative analy-sis of surgical outcomes of and learning curves for lap-aroscopy-assisted distal gastrectomy. J Gastric Cancer. 2015;15(1):29-38. 218. Kim HH, Han SU, Kim MC, et al. Long-term results of laparo-scopic gastrectomy for gastric cancer: a large-scale case-con-trol and case-matched Korean multicenter study. J Clin Oncol. 2014;32(7):627-633. 219. Jung DH, Son SY, Park YS, et al. The learning curve asso-ciated with laparoscopic total | Surgery_Schwartz. 2002:202. 214. Lee J, Kim W. Clinical experience of 528 laparoscopic gas-trectomies on gastric cancer in a single institution. Surgery. 2013;153(5):611-618. 215. Zeng YK, Yang ZL, Peng JS, et al. Laparoscopy-assisted ver-sus open distal gastrectomy for early gastric cancer. Ann Surg. 2012;256:39-52. 216. Kim HG, Park JH, Jeong SH, et al. Totally laparoscopic distal gastrectomy after learning curve completion: comparison with laparoscopy-assisted distal gastrectomy. J Gastric Cancer. 2013;13(1):26-33. 217. Moon JS, et al. Lessons learned from a comparative analy-sis of surgical outcomes of and learning curves for lap-aroscopy-assisted distal gastrectomy. J Gastric Cancer. 2015;15(1):29-38. 218. Kim HH, Han SU, Kim MC, et al. Long-term results of laparo-scopic gastrectomy for gastric cancer: a large-scale case-con-trol and case-matched Korean multicenter study. J Clin Oncol. 2014;32(7):627-633. 219. Jung DH, Son SY, Park YS, et al. The learning curve asso-ciated with laparoscopic total |
Surgery_Schwartz_7698 | Surgery_Schwartz | a large-scale case-con-trol and case-matched Korean multicenter study. J Clin Oncol. 2014;32(7):627-633. 219. Jung DH, Son SY, Park YS, et al. The learning curve asso-ciated with laparoscopic total gastrectomy. Gastric Cancer. 2016;19(1):264-272. 220. Suda K, Uyama I, Kitagawa Y. Technology beats the cur-rent standard: is robotic gastrectomy becoming the standard treatment option for gastric cancer? : “Surgical outcomes after open, laparoscopic, and robotic gastrectomy for gas-tric cancer,” by Kim, Hyuong-Il, et al. Ann Surg Oncol. 2017;24(7):1755-1757.Brunicardi_Ch26_p1099-p1166.indd 116501/03/19 7:13 PM | Surgery_Schwartz. a large-scale case-con-trol and case-matched Korean multicenter study. J Clin Oncol. 2014;32(7):627-633. 219. Jung DH, Son SY, Park YS, et al. The learning curve asso-ciated with laparoscopic total gastrectomy. Gastric Cancer. 2016;19(1):264-272. 220. Suda K, Uyama I, Kitagawa Y. Technology beats the cur-rent standard: is robotic gastrectomy becoming the standard treatment option for gastric cancer? : “Surgical outcomes after open, laparoscopic, and robotic gastrectomy for gas-tric cancer,” by Kim, Hyuong-Il, et al. Ann Surg Oncol. 2017;24(7):1755-1757.Brunicardi_Ch26_p1099-p1166.indd 116501/03/19 7:13 PM |
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Surgery_Schwartz_7700 | Surgery_Schwartz | The Surgical Management of ObesityAnita P. Courcoulas and Philip R. Schauer 27chapterINTRODUCTIONDespite the global pandemic of obesity, there has been little progress in nonsurgical treatment approaches, especially among patients with severe obesity. In addition, the evidence base for bariatric procedures has grown rapidly over the last 10 years, yielding important shortand long-term data on the safety and efficacy of the surgical treatment for obesity and related metabolic disorders. Therefore, the approach for patients con-sidering bariatric and metabolic surgery has now shifted to a well-informed and shared decision-making process as there are significant tradeoffs between the potential risks and benefits of these procedures.1HistoryDuring the 1950s, operations were first performed to treat severe hyperlipidemia with associated obesity.2 These were ileocolic bypass operations to limit absorption and were associated with severe nutritional complications and liver failure | Surgery_Schwartz. The Surgical Management of ObesityAnita P. Courcoulas and Philip R. Schauer 27chapterINTRODUCTIONDespite the global pandemic of obesity, there has been little progress in nonsurgical treatment approaches, especially among patients with severe obesity. In addition, the evidence base for bariatric procedures has grown rapidly over the last 10 years, yielding important shortand long-term data on the safety and efficacy of the surgical treatment for obesity and related metabolic disorders. Therefore, the approach for patients con-sidering bariatric and metabolic surgery has now shifted to a well-informed and shared decision-making process as there are significant tradeoffs between the potential risks and benefits of these procedures.1HistoryDuring the 1950s, operations were first performed to treat severe hyperlipidemia with associated obesity.2 These were ileocolic bypass operations to limit absorption and were associated with severe nutritional complications and liver failure |
Surgery_Schwartz_7701 | Surgery_Schwartz | to treat severe hyperlipidemia with associated obesity.2 These were ileocolic bypass operations to limit absorption and were associated with severe nutritional complications and liver failure postopera-tively. A more modest jejunoileal bypass was performed next, also a malabsorptive operation, but it bypassed only a portion of the small intestine. Complications after this procedure included severe diarrhea, electrolyte disturbances, protein-calorie malnu-trition, renal stones, and liver failure.In 1969, Mason and Ito performed the first gastric bypass, describing a loop of jejunum connected to a transverse proximal gastric pouch.3 Bile reflux esophagitis was severe postopera-tively, causing Griffin and colleagues to describe the Roux-en-Y modification of the gastric bypass in 1977.4 The gastric pouch was also altered from transverse to vertical using the upper lesser curvature at this time (Fig. 27-1).In 1980, Mason5 first performed the vertical banded gastroplasty (VBG), which was a | Surgery_Schwartz. to treat severe hyperlipidemia with associated obesity.2 These were ileocolic bypass operations to limit absorption and were associated with severe nutritional complications and liver failure postopera-tively. A more modest jejunoileal bypass was performed next, also a malabsorptive operation, but it bypassed only a portion of the small intestine. Complications after this procedure included severe diarrhea, electrolyte disturbances, protein-calorie malnu-trition, renal stones, and liver failure.In 1969, Mason and Ito performed the first gastric bypass, describing a loop of jejunum connected to a transverse proximal gastric pouch.3 Bile reflux esophagitis was severe postopera-tively, causing Griffin and colleagues to describe the Roux-en-Y modification of the gastric bypass in 1977.4 The gastric pouch was also altered from transverse to vertical using the upper lesser curvature at this time (Fig. 27-1).In 1980, Mason5 first performed the vertical banded gastroplasty (VBG), which was a |
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