P-O02 Management Experiences of Post-gastrectomy Severe Alkaline Reflux Oesophagitis

Background Alkaline reflux oeosphagitis is a recognized complication of procedures that compromise the lower oesophageal sphincter (LES), including gastrectomy. Incidence of reflux is dependent on the reconstructive procedure with Roux-en-Y esophagojejunostomy commonly accepted as the optimal method. The authors report their experience of 6 patients who underwent remedial intervention for severe alkaline reflux esophagitis following gastric surgery. Methods A retrospective review of 6 patients who had underwent a previous gastric procedure and developed symptoms of gastroesophageal reflux disease, over a 6-year period (2014-2020). Reflux symptoms were diagnosed by clinical history, radiology, endoscopy and esophageal manometry prior to proceeding to surgical reflux control. Post-operative outcomes following anti-reflux surgery were assessed by means of serial outpatient assessments and endoscopy. Results Six patients were included in this report, 4 males and 2 females with an average age of 73 years (range 58-91). Primary diagnoses encompassed; 4 gastric adenocarcinomas, 1 gastric neuroendocrine tumour and 1 patient with debilitating gastric antral vascular ectasia (GAVE) syndrome. Four patients underwent total gastrectomy and 2 subtotal gastrectomy with Roux-en-Y reconstruction. Onset of post-operative reflux symptoms ranged from 2-weeks to 3-years. Failing medical management, all patients underwent jejunojejunal anastomosis and Roux limb length revision with surgical jejunostomy. At follow up 5 patients had some degree of symptom resolution; 3 complete resolution, 2 initial resolution and 1 with unresolved symptoms. Conclusions Severe alkaline reflux oesophagitis is a recognized complication of gastric procedures compromising the LES. The authors report our experience of managing this complication following gastrectomy with jejunojejunal anastomosis and Roux limb length revision, with a majority of patients having improvement in if not complete resolution of reflux symptoms.

INFLUENCE OF PECTIN AND CHITOSAN ON THE PROPERTIES OF GELS PROTECTING THE OESOPHAGEAL MUCOSA

Among the diseases of the digestive tract, gastro-oesophageal reflux is one of the most troublesome ailments. It is estimated that in highly developed countries, reflux symptoms occur in about 5%-10% of people every day. It has also been found that about 20% of people experience such symptoms once a week. The incidence of this disease increases with age, regardless of gender. The aim of the study was to investigate the physicochemical properties of gels intended for the protection of the oesophageal mucosa. Preparations containing 3.0% pectin showed the lowest pH. These gels can be used in the treatment of advanced alkaline reflux. The addition of chitosan to all tested gels increased their pH and dynamic viscosity. The texture tests showed the effect of pectin concentration on the adhesion work of the tested gels.

Early outcome of “Modified Uncut Roux-En-Y” Technique in Gastric Reconstruction Surgery

Loop gastro-Jejunostomy and Roux-en-Y gastro- Jejunostomy, the commonest reconstructions in gastric surgery, are significantly associated with alkaline reflux gastritis and Roux stasis syndrome (RSS) respectively. The Modified Uncut Roux-en-Y (MUREY) technique could be an effective technique in preventing both the conditions. This prospective observational study was designed to evaluate the effectiveness of Modified UREY reconstruction to prevent RSS and Alkaline reflux gastro-esophagitis while avoiding “Staple- line dehiscence”. A total of 47 patients of gastric outlet obstruction, both benign and malignant, undergoing Modified Uncut Roux-en-Y reconstruction with/ without Gastrectomy at BMCH over the span of July 2014 to July 2016, were incorporated in this study. Patients were followed up from the immediate post-operative periods till discharge and postoperatively for 2 months. There was no incidence of bile reflux or bilious vomiting in the follow-up period. There were two (4.3%) incidences of RSS among the 47 patients (P<0.001). Postoperative endoscopy was carried out in 9 patients to assess the integrity of staple line occlusion which revealed normal looking mucosa of upper GIT with an intact staple line occlusion. There was significant decrease in the average Visick score, from 3.5±0.6 (SD) preoperatively to 1.2±0.4(SD) in the post-operative period. Average increase in the body weight at the time of final follow-up was 6.7%±5.1 kg. The Modified “Uncut Roux-En-Y” reconstruction technique is bothfeasible and safe. It is effective in preventing RSS and alkaline reflux gastritis while preventing Staple-line dehiscence and, can be a preferred technique of gastric bypass.J Bangladesh Coll Phys Surg 2018; 36(4): 139-144

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

Objective: to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction. Methods: twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases. Results: the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%. Conclusion: the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life

Significance of the Lower Esophageal Sphincter Preservation in Preventing Alkaline Reflux Esophagitis in Patients After Total Gastrectomy Reconstructed by Roux-en-Y for Gastric Cancer

To clarify the significance of the lower esophageal sphincter (LES) for prevention of alkaline reflux esophagitis (ARE) after total gastrectomy reconstructed by Roux-en-Y (TGRY) for gastric cancer, we investigated LES function and lower esophageal pH in TGRY patients with or without LES preservation. A total of 51 patients 5 years after TGRY were divided into groups A (26 patients without preserved LES) and B (25 patients with preserved LES) and compared with 22 control participants (group C). Manometric study and ambulatory 24-hour esophageal pH monitoring were performed on all patients. Symptomatic and endoscopic AREs in group A were significantly higher than those in group B (P &lt; 0.05). The length of LES and maximum LES pressure in group A were significantly shorter and lower, respectively, than in groups B and C (P &lt; 0.01). The length of LES and maximum LES pressure in patients with symptomatic ARE were significantly shorter and lower, respectively, than in patients without symptomatic ARE (P &lt; 0.01). Percentages of time with pH &gt;7 and pH &gt;8 within 24 hours in group A were significantly higher than those in groups B and C (P &lt; 0.01). Preservation of the LES may be necessary to prevent ARE after TGRY.