24 year old female consumed corrosive along with food 3 and 1/2 weeks ago. OGD shows esophagitis but no strictures, gastritis and duodenal obstruction. 320 Slice CT shows Esophagitis, Gastritis, Gastric outlet obstruction and Duodenal scarring. Barium meal study showed signs of esophagitis, but the flow is normal, massively dilated stomach with duodenal obstruction. Stomach thickness is slightly more than normal. She is able to consume about 20-30 ml/hour.
Considering the age of the patient do we offer GJ or Lower Partial Gastrectomy?
We had a 18 yr old girl with similar presentation with loss of arnd 20 kg weight due to GOO and not tolerating even liquids. We did a roux-en-Y gastrojejunostomy for her and she has gained approx 24 kgs and I was not even able to recognize her at first.
Laparoscopic GJ is completely enough as a procedure in such case.
This question raises a lot of very interesting options. Many of the potential options will depend upon the degree and location of the duodenal scarring. If the scarring involves a significant portion of the descending duodenum, as well as the pancreatic and biliary entrance at that level, then early surgery with diversion of both the stomach as well as biliary and pancreatic drainage would probably be the best option and offer the most definitive approach. However, if there is no significant compromise to biliary or pancreatic outflow, then there are more flexible options. I would break my decision points based upon whether this is an acute stricturing or whether you're seeing the result of chronic scarification. In the more acute case, as there has been little time for significant fibrosis to develop, early balloon dilation with repetitive reevaluation and repeat dilation if needed may be all that is needed. If on the other hand, dense scarring has already begun you could consider the use of a completely covered SEMS. This would provide short as well as long-term gentle continuous dilation and could potentially avoid surgery. Then at some point the stent could be removed potentially restoring and maintaining a viable lumen.
Laparoscopic antecolcic post GJ was done.Duodenanal scarring and antral Edelman was present,mucosa was edematous at the antrum otherwise normal.Choosing the site for anastomosis is important.Thankyou all for your valuable suggestions. You
Roux en Y gastrojejunostomy is the ideal course of treatment in such cases
I thought 3 and 1/2 week is short time to decide on surgery vs endotherapy. At least 6-8 weeks should be allowed for the stomach to reach its final status. Then according to the degree of obstruction, endoscopic dilatation, stenting or surgery can be chosen
At that stage, corticosteroids may be beneficial. decision about surgery needs re evaluation after a couple of weeks.
Dear Dr Reddy and other authors. I agree with a laparoscopic Roux en Y gastrojejunostomy as has been performed. I have just some small points to add.
I presume you have also dealt with the circumstances surrounding the cause of the ingestion which is often complicated and may involve social services. When patients present late or have already malnutrition before the ingestion of corrosives, you may have a very weak patient with a higher risk of complications from surgery. In that case I would consider adding a laparoscopic feeding jejunostomy during the lap gastro- jej procedure as a safety backup. Corrosive strictures result in longterm inflammation and oedema of the tissues which may result in anastomotic leak/temporary oedema/re-stricturing in which case a functioning feeding jejunostomy is very helpful and allows further conservative management. Thank you for bringing up this interesting case.
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