Category Archives: Gastroenterology

Retained Gastric Antrum Syndrome

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Dumon K, Dempsey DT. (2019). Postgastrectomy Syndromes. Shackelford’s Surgery of the Alimentary Tract, 8th ed.: 719-734.

“Hypergastrinemia after distal gastrectomy can be caused by gastrinoma or retained antrum. In the latter there is residual antral tissue left in continuity with the duodenal stump after gastric resection with Billroth II anastomosis. The G cells in this retained antral tissue are not exposed to luminal acid, resulting in continuous secretion of gastrin and intense stimulation of acid production by parietal cells in the proximal gastric remnant. The exposure of the unbuffered jejunum to this high acid level at the Billroth II GJ results in marginal ulcer (see Fig. 62.12B ).

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Comparison of different reconstruction methods following distal gastrectomy

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Nishizaki D, Ganeko R, Hoshino N, et al. Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer. Cochrane Database Syst Rev. 2021 Sep 15;9(9): CD012998.

Matsumoto K, Tanaka S, Toyonaga T, et al. Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy. Clin Endosc. 2021 Aug 13. Epub ahead of print.

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Article of interest: The C-reactive protein-to-prealbumin ratio predicts fistula closure

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Harriman S, Rodych N, Hayes P, Moser MA. The C-reactive protein-to-prealbumin ratio predicts fistula closure. Am J Surg. 2011 Aug;202(2):175-8.

Full-text for Emory users.

Background: The purpose of this study was to evaluate the predictability of fistula closure using the ratio of C-reactive protein to prealbumin (C:P ratio).

Methods: A database of 89 patients with gastrointestinal fistulas (1994-2009) was created based on the records of our Nutrition Support Services Team. All patients had weekly blood work including C-reactive protein level, prealbumin level, and albumin level. Forty-three fistulas were managed without surgery for 6 weeks or more; of these, 29 closed.

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Abdominal surgery in neutropenic patients

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Jolissaint JS, et al. Timing and Outcomes of Abdominal Surgery in Neutropenic Patients. J Gastrointest Surg. 2019 Apr;23(4):643-650.

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Results: Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.

Conclusions: Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.

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Anti-fungal therapy in the treatment of perforated peptic ulcers: what’s the evidence?

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Huston JM, et al. Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions. Surg Infect (Larchmt). 2019 Dec;20(8):593-600.

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Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. 

Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

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Videos: The Ladd Procedure for Adult Malrotation With Volvulus

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Brady JT, Kendrick DE, Barksdale EM, Reynolds HL. The Ladd Procedure for Adult Malrotation With Volvulus. Dis Colon Rectum. 2018 Mar;61(3):410.

“Intestinal malrotation is a rare condition that develops during fetal development because of incomplete intestinal rotation or a lack of intestinal rotation around the superior mesenteric artery. Presentation in adulthood, in general, is abnormal and presentation with volvulus is rare. We demonstrate an open Ladd procedure with inversion appendectomy and reduction of paraduodenal hernia of an adult with malrotation with volvulus.”

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Characterization of ischemic colitis associated with myocardial infarction

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Cappell MS, Mahajan D, Kurupath V. Characterization of ischemic colitis associated with myocardial infarction: an analysis of 23 patients. Am J Med. 2006 Jun;119(6): 527.e1-9.

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Results: Of 17,500 patients admitted to the study sites with MI, 23 (0.13%) had IC. Study patients had a high in-hospital mortality of 39%. An Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 15 was a significant predictor of mortality in these patients (P<.04). Compared with the IC-controls, study patients had a significantly lower mean arterial pressure (MAP) (76.0 +/- 17.1 mm Hg vs 98.3 +/- 18.6 mm Hg, P<.0001) and a significantly higher rate of hypotension (57% vs 9%, odds ratio [OR] = 12.6, confidence interval [CI]: 3.10-49.7, P<.001). The 2 groups, however, had a similar mean number of risk factors for thromboembolism per patient. Study patients had more severe illness than IC-controls, as demonstrated by mean APACHE II scores (19.0 +/- 5.5 vs 10.4 +/- 4.8, P<.0001). Study patients had a significantly higher incidence of complications, including respiratory failure (57% vs 13%, P=.001), altered mental status (48% vs 13%, P<.01), and renal insufficiency or failure (61% vs 28%, P<.04). Study patients had a significantly lower minimum hematocrit. Study patients had a significantly higher rate of prolonged hospitalization (>30 days) or in-hospital death (74% vs 19%, OR = 12.3, CI: 3.47-43.5, P<.0001). Compared with MI-control patients, study patients had a significantly lower MAP, significantly higher rate of hypotension, much higher mean APACHE II score, much higher incidence of complications, and significantly worse hospital outcome.

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