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Journal of Vascular Surgery Jun 2020Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The... (Review)
Review
BACKGROUND
Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis.
METHODS
This review summarizes the literature pertaining to the pathophysiologic mechanism, presentation, diagnosis, and management of MALS. A suggested diagnostic workup and treatment algorithm are presented.
RESULTS
Individuals with MALS present with signs and symptoms of foregut ischemia, including exercise-induced or postprandial epigastric pain, nausea, vomiting, and weight loss. Consideration of MALS in patients' diagnostic workup is typically delayed. Currently, no group consensus agreement as to the diagnostic criteria for MALS exists; duplex ultrasound, angiography, and gastric exercise tonometry are used in different combinations and with varying diagnostic values throughout the literature. Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking. Patients treated nonoperatively appear to have worse outcomes.
CONCLUSIONS
MALS is an important clinical entity with significant impact on affected individuals. Presenting symptoms, patient demographics, and radiologic signs are generally consistent, as is the short-to medium-term (<5 years) response to surgical intervention. Future prospective studies should directly compare long-term symptomatic and quality of life outcomes after nonoperative management with outcomes after open, laparoscopic, endoscopic retroperitoneal, and robotic celiac artery decompression to enable the development of evidence-based guidelines for the management of MALS.
Topics: Celiac Artery; Constriction, Pathologic; Decompression, Surgical; Humans; Ligaments; Median Arcuate Ligament Syndrome; Mesenteric Ischemia; Mesenteric Vascular Occlusion; Splanchnic Circulation; Treatment Outcome; Vascular Patency
PubMed: 31882314
DOI: 10.1016/j.jvs.2019.11.012 -
World Journal of Gastroenterology Mar 2009Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of... (Review)
Review
Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in gastroenterostomy. This review discusses the differences between pre- and postpyloric feeding, indications and contraindications, advantages and disadvantages, and provides an overview of the techniques of placement of various postpyloric devices.
Topics: Digestion; Endoscopy; Enteral Nutrition; Humans; Intubation, Gastrointestinal; Jejunostomy; Jejunum; Nutritional Support; Pylorus
PubMed: 19294757
DOI: 10.3748/wjg.15.1281 -
Gut and Liver Sep 2022Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such... (Review)
Review
Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its etiology includes both benign and malignant disorders. Currently, GOO has many treatment options, including initial conservative therapeutic protocols and more invasive procedures, such as surgical gastroenterostomy, stent placement and, the most recently implemented procedure, endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Each procedure has its merits, with surgery often prevailing in patients with longer life expectancy and stents being used most often in patients with malignant gastric outlet stenosis. The newly developed EUS-GE combines the immediate effect of stents and the long-term efficacy of gastroenterostomy. However, this novel method is a technically demanding process that requires expert experience and special facilities. Thus, the true clinical effectiveness, as well as the duration of the effects of EUS-GE, still need to be determined.
Topics: Endosonography; Gastric Outlet Obstruction; Gastroenterostomy; Humans; Pylorus; Stents
PubMed: 35314520
DOI: 10.5009/gnl210327 -
BMC Pediatrics Aug 2022Findings from manometry studies and contrast imaging reveal functioning gastric physiology in newborns with duodenal atresia and stenosis. Stomach reservoir function...
BACKGROUND
Findings from manometry studies and contrast imaging reveal functioning gastric physiology in newborns with duodenal atresia and stenosis. Stomach reservoir function should therefore be valuable in aiding the postoperative phase of gastric feeding. The aim of this study was therefore to compare the feasibility of initiating oral or large volume(s) gavage feeds vs small volume bolus feeds following operation for congenital duodenal anomalies.
METHODS
Single-center electronic medical records of all babies with duodenal atresia and stenosis admitted to a university surgical center during January 1997-September 2021 were analyzed. A fast-fed group (FF) included newborns fed with oral or gavage feeds advanced at a rate of at least 2.5 ml/kg and then progressed more than once a day vs slow-fed group (SF) fed with gavage feeds at incremental rate less than 2.5 ml/kg/day for each time period of oral tolerance or by drip feeds. Total feed volume was limited to 120-150 ml/kg/day in the respective study cohort populations.
RESULTS
Fifty-one eligible patients were recruited in the study - twenty-six in FF group and twenty-five in SF group. Statistically significant differences were observed in the (i) date of first oral feeds (POD 7.7 ± 3.2 vs 16.1 ± 7.7: p < 0.001), and (ii) first full feeds (POD 12.5 ± 5.3 vs 18.8 ± 9.7: p < 0.01) in FF vs SF study groups.
CONCLUSION
Initial feeding schedules with oral or incremental gavage-fed rates of at least 2.5 ml/kg in stepwise increments and multi-steps per day is wholly feasible in the postoperative feeding regimens of neonates with congenital duodenal disorders. Significant health benefits are thus achievable in these infants allowing an earlier time to acquiring full enteral feeding and their hospital discharge.
Topics: Constriction, Pathologic; Duodenal Obstruction; Enteral Nutrition; Humans; Infant; Infant, Newborn; Intestinal Atresia; Patient Discharge
PubMed: 35922792
DOI: 10.1186/s12887-022-03524-7 -
Revista Espanola de Enfermedades... May 2023The incidence of gastric stenosis, a complication of laparoscopic sleeve gastrectomy (LSG), has been reported to range from 0.7% to 4%. Only 1.1% of stenosis develop...
The incidence of gastric stenosis, a complication of laparoscopic sleeve gastrectomy (LSG), has been reported to range from 0.7% to 4%. Only 1.1% of stenosis develop symptoms that require endoscopic or surgical intervention. We herein report a challenging case of mid-gastric stenosis and gastric tube twist following LSG. A 38-year-old woman with an initial body mass index (BMI) of 35 kg/m2 and metabolic syndrome undergoing LSG. A week after surgery, the patients developed intermittent vomiting and eating difficulty. Gastroscopy and following diagnostic laparoscopy were performed 3 weeks after LSG, subsequently revealing unusual mid-gastric stenosis and gastric tube twist. Initial conservative treatment and endoscopic balloon dilatation were implemented but failed. The patient received laparoscopic revisional Roux-en-Y gastric bypass and recovered well. A follow-up after 2 years revealed that her BMI decreased to 22.1 kg/m2. In conclusion, post-LSG stenosis is a serious complication that requires early detection and prompt management. Prompt revisional surgery is necessary for complicated stenosis.
Topics: Humans; Female; Adult; Obesity, Morbid; Constriction, Pathologic; Reoperation; Postoperative Complications; Retrospective Studies; Gastrectomy; Gastric Bypass; Laparoscopy; Treatment Outcome
PubMed: 36148662
DOI: 10.17235/reed.2022.9185/2022 -
The Yale Journal of Biology and Medicine 1999"It is not the death of GERD that I seek, but that it turns from its evil ways and follows the path of righteousness." The reflux world is fully aware of what GERD is... (Review)
Review
"It is not the death of GERD that I seek, but that it turns from its evil ways and follows the path of righteousness." The reflux world is fully aware of what GERD is and what GERD does. What the world does not know, however, is the answer to the most important yet least asked question surrounding GERD's raison-d'etre: Why is GERD here and why do we have it? What GERD is: abnormal gastric reflux into the esophagus that causes any type of mischief. What GERD does: causes discomfort and/or pain with or without destroying the mucosa; causes stricture or stenosis, preventing food from being swallowed; sets the stage for the development of esophageal adenocarcinoma; invades the surrounding lands to harass the peaceful oropharyngeal, laryngeal and broncho-pulmonary territories; reminds us that we are not only human, but that we are dust and ashes. Why GERD is here: We propose three separate and distinct etiologies of GERD, and we offer the following three hypotheses to explain why, after 1.5 million years of standing erect, we have evolved into a species (specifically Homosapiens sapiens) that is destined to live with the scourge of GERD. Hypothesis 1: congenital. The antireflux barrier, comprising the smooth-muscled lower esophageal sphincter, the skeletal-muscled right crural diaphragm and the phreno-esophageal ligament does not completely develop due to a developmental anomaly or incomplete gestation. Hypothesis 2: acute trauma: The antireflux barrier in adults suffering acute traumatic injury to the abdomen or chest is permanently disrupted by unexpected forces, such as motor vehicle accidents (with steering wheel crush impact), blows to the abdomen (from activities such as boxing, etc.), heavy lifting or moving (e.g., pianos, refrigerators) or stress positions (e.g., hand stands on parallel gym bars). The trauma creates a hiatal hernia that renders the antireflux mechanism useless and incapable of preventing GERD. Hypothesis 3: chronic trauma: The antireflux barrier in children and adults is gradually weakened over time as a result of chronic straining to defecate and straining in an unphysiologic position, both of which stem from our modern day habits of eating a low-fiber diet and living on the high-seated toilet. We suggest that the chronic traumatic hiatal hernia is (a) the cause of more than 90 percent of the GERD that stalks the Western world; (b) is a direct result of abandoning the popular and worldwide practice of squatting to socialize, eat and defecate; and (c) is our just reward for adopting the "civilized" high sitting position on chairs and modern toilets.
Topics: Abdominal Injuries; Esophagogastric Junction; Gastroesophageal Reflux; Hernia, Hiatal; History, 18th Century; History, 19th Century; History, 20th Century; History, Ancient; Humans; Thoracic Injuries
PubMed: 10780568
DOI: No ID Found -
Internal Medicine (Tokyo, Japan) Mar 2021
Topics: Carcinoma; Gastric Mucosa; Humans; Pyloric Stenosis; Stomach Neoplasms
PubMed: 33028778
DOI: 10.2169/internalmedicine.5924-20 -
The British Journal of Radiology Sep 2018To determine the clinical, radiographic, and endoscopic findings of sleeve stenosis after sleeve gastrectomy and to correlate treatment with outcomes.
OBJECTIVE
To determine the clinical, radiographic, and endoscopic findings of sleeve stenosis after sleeve gastrectomy and to correlate treatment with outcomes.
METHODS
We identified 43 patients who underwent barium studies to evaluate upper GI symptoms after laparoscopic sleeve gastrectomy. The clinical, radiographic, and endoscopic findings were reviewed and correlated with treatment and outcomes.
RESULTS
26 patients (60%) had sleeve stenoses. All stenoses appeared as short segments of smooth, tapered narrowing, with a mean length of 8.0 mm and mean width of 7.5 mm, and 24 (92%) were located in the proximal or distal third of the sleeve. 23 patients (88%) had upstream dilation, and 1 (4%) had retained food proximal to the stenosis. 23 (70%) of 33 patients with obstructive symptoms and 3 (30%) of 10 without obstructive symptoms had sleeve stenoses. Endoscopy revealed sleeve stenosis in 8 (67%) of 12 patients with radiographic stenosis. Endoscopic dilation resulted in improvement/resolution of symptoms in seven (88%) of 8 patients.
CONCLUSION
Sleeve stenosis after sleeve gastrectomy was characterized radiographically by a short segment of smooth, tapered narrowing, typically in the proximal or distal third of the sleeve. Approximately, 70% of patients with obstructive symptoms and 30% with non-obstructive symptoms had sleeve stenosis. One-third of radiographically diagnosed stenoses were not seen at endoscopy. The barium study, therefore, is a useful test for sleeve stenosis in patients with obstructive or nonobstructive symptoms after sleeve gastrectomy. Advances in knowledge: This article describes the appearance and location of sleeve stenoses after laparoscopic sleeve gastrectomy and the clinical presentation and treatment options for these patients.
Topics: Adolescent; Adult; Aged; Barium Radioisotopes; Constriction, Pathologic; Female; Gastrectomy; Gastric Stump; Gastroscopy; Humans; Laparoscopy; Male; Middle Aged; Postoperative Complications; Radiography; Retrospective Studies; Stomach; Young Adult
PubMed: 29227144
DOI: 10.1259/bjr.20170702 -
HPB : the Official Journal of the... Oct 2020Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and...
BACKGROUND
Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition.
METHODS
We reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012-December 2018.
RESULTS
We identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1-32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0-25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23-44.5 months), 12/15 (80%) reported symptom resolution or improvement.
DISCUSSION
Ampullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Common Bile Duct; Constriction, Pathologic; Female; Gastric Bypass; Humans; Male; Middle Aged; Retrospective Studies
PubMed: 32340857
DOI: 10.1016/j.hpb.2020.02.004