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A Clinical Study of Gastric Outlet Obstruction in Adults''
A Clinical Study of Gastric Outlet Obstruction in Adults''
OBSTRUCTION IN ADULTS
Submitted by
Dr. M.S. SUSHRUTA, M.B.B.S.
Post Graduate in General Surgery
Under the guidance of
Dr. ABINASH HAZARIKA
MB.B.S., M.S.,
ASSOCIATE PROFESSOR
Department of General Surgery
SAH & R.C., B.G.NAGARA.
2.
3.
4.
5.
6.
6.1
APPENDIX I
APPENDIX IA
APPENDIX IB
APPENDIX IC
APPENDIX II
APPENDIX IIA
APPENDIX IIB
7.
APPENDIX IIC
APPENDIX IID
8.
LIST OF REFERENCES
APPENDIX III
9.
11.
No
11.2 SIGNATURE
12
12.2 SIGNATURE
APPENDIX - I
6. BRIEF RESUME OF INTENDED WORK
APPENDIX - IA
6.1 NEED FOR THE STUDY:
Gastric outlet obstruction (GOO, also known as pyloric obstruction) is not a single entity;
it is the clinical and pathophysiological consequence of any disease process that produces
a mechanical impediment to gastric emptying.
Clinical entities that can result in GOO generally are categorized into 2 well-defined
The incidence of gastric outlet obstruction has been reported to be less than 5% in
patients with peptic ulcer disease which is the leading benign cause of the problem.
To understand and study the trends in the incidence of various factors responsible for
APPENDIX - IIB
6.2 REVIEW OF LITERATURE
The stomach is a remarkable organ with important digestive, nutritional, and endocrine
functions.2
During the fifth week of gestation the stomach arises as a dilatation in the tubular
embryonic foregut2
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by epigastric
defense mechanisms.3
Ulcers within the pyloric channel and first portion of the duodenum usually are
The most common, Johnson type I gastric ulcer, is typically located near the angularis
incisura on the lesser curvature. These patients usually have normal or decreased acid
secretion.2
Type II gastric ulcer is associated with active or quiescent duodenal ulcer disease, and
Type III gastric ulcer is prepyloric. Both type II and type III gastric ulcers are associated
insufficiency. 4
Patients present with intermittent symptoms that progress until obstruction is complete.
Vomiting is the cardinal symptom. Initially, patients may demonstrate better tolerance to
to exclude malignancy.4
Peptic ulcer disease is now more commonly treated by antrectomy or distal gastrectomy
followed by gastrojejunostomy.
Endoscopic balloon dilation has been used successfully in patients obstruction due to
peptic ulcer disease. The use of balloon is preferred because it provides an even radial
force, which has an advantage over the longitudinal shearing force associated with the use
of conventional dilators.
Carcinoma stomach is the fourth-most common cancer worldwide. Its the second most
Gastric ulcers, adenamatous polyps and intestinal mataplasia have associated with a
subtypes:10
Intestinal-type cancers (30%) are glandular and arise from the gastric mucosa
Diffuse-type cancers (70%) arise from the lamina propria and are associated with an
Presentation of gastric cancer generally involves nonspecific signs and symptoms such as
epigastric abdominal pain, unexplained weight loss, nausea, vomiting, anorexia, early
satiety, and fatigue. Gastric outlet obstruction
patients (1% to 4%) Classic physical findings in gastric cancer represent metastatic and
incurable disease and include the following:
a. Cachexia.
b. Hepatosplenomegaly with ascites and jaundice.
c. Enlarged supraclavicular nodes (Virchow's node).
d. Fullness in the pelvic cul-de-sac (Blumer's shelf).
e. Enlarged ovaries on pelvic examination (Krukenberg's tumor).
f. Infiltration of the umbilicus (Sister Mary Joseph's node).
In the acute or chronic phase of obstruction, continuous vomiting may lead to dehydration
and electrolyte abnormalities.
When obstruction persists, patients may develop significant and progressive gastric
dilatation. The stomach eventually loses its contractility. Undigested food accumulates
and may represent a constant risk for aspiration pneumonia.
Abdominal pain is not frequent and usually relates to infiltration to the posterior bedpancreas and celiac ganglia or due to the liver metastasis.
Tissue diagnosis and anatomical localization of the primary tumuor are best obtained by
upper gastrointestinal endoscopy.3
tomography scan, peritoneal tumuor spread and occult liver and lymph node metastasis
are only intraoperatively in many patients.11
Gastrectomy is the most widely used approach for therapy of invasive gastric cancer.
Distal subtotal gastrectomy with resection of adjacent lymph nodes appears to sufficient
for lesions in the distal lower two thirds of the stomach.12
Billroth was the first surgeon to successfully resect the distal stomach. The patient,
Therese Heller, had distal gastric cancer, and continuity was re-established with a
gastroduodenostomy (Billroth I) using interrupted silk suture2.
The draining lymph nodes basins for the stomach can be divided into 16 stations: stations
1-6 are perigastric, and the remaining 10 are located adjacent to major vessels, behind the
pancreas, and along the aorta.13,14
An extended (D2) resection includes removal of nodes along the left gastric, hepatic,
splenic, and celiac arteries (stations 1-11)
Although the results of major trials attempting to answer this question have yielded
confounding results, it is generally agreed on that, at high-volume centers, D2
lymphadenectomies that preserve the distal pancreas and spleen can be performed without
increased morbidity, improve staging accuracy, and yield a survival advantage in patients
with stage II and III gastric cancer.
Maximum less than 2cm when lesion is slightly elevated and less than 1cm when lesion is
flat or slightly depressed.
Endoscopic mucosal dissection enables allows en bloc dissection of tumuor more than
2cm.
The epirubicin, cisplatin, infusion 5-FU (ECF) and docetaxel, cisplatin, infusional 5-FU
(DCF) combinations have emerged as the standard regimens for first line treatment.
Recent advances include SEMS (Self Expanding Metallic Stents) for palliative care
malignancy or benigm strictures.
APPENDIX - IC
6.3 AIMS AND OBJECTIVES
1. To analyse the occurrence of benign, malignant and any other causes encountered
as a cause of gastric outlet obstruction.
2. To analyse the various signs and symptoms of gastric outlet obstruction with
reference to specific features of benign, malignant and any other causes.
3. To analyse the various modalities of investigations and treatment and their results.
APPENDIX - II
7. MATERIALS AND METHODS
APPENDIX - IIA
7.1 SOURCE OF DATA:
This study is conducted in the Department of General Surgery at Sri Adichunchanagiri
Hospital and Research Centre, B.G.Nagara, Mandya district.
Sample size of a minimum of 50 patients fulfilling the inclusion criteria will be a part
of this study conducted for a duration of 18 months.
Study design: Clinical study.
APPENDIX - IIB
7.2 METHOD OF DATA COLLECTION:
Data will be collected from patients who are admitted in surgical wards of SAH &
RC, with a provisional diagnosis of gastric outlet obstruction.
Treatment modality will be planned once the definitive diagnosis of gastric outlet
obstruction is arrived at.
INCLUSION CRITERIA :
1. All patients admitted to the surgery wards with a clinical diagnosis of gastric
outlet obstruction.
2. Endoscopic evidence of gastric outlet obstruction.
10
APPENDIX - IIC
7.3 Does the study require any investigations or interventions to be conducted on
patients or other animals; if so describe briefly:
YES
INVESTIGATIONS:
1. Routine investigations
a. Haemoglobin percentage
b. Total count
c. Differential count
d. Erythrocyte sedimentation rate
e. Bleeding time
f. Clotting time
g. Urine for protein, sugar and microscopy
h. Random blood sugar
11
i. Blood urea
j. Serum creatinine
k. Serum electrolytes
l. HIV/ HbsAG
m. Blood grouping
n. Chest radiograph
o. Electrocardiogram
2. Specific investigations
a. Ultrasound abdomen and pelvis
b. Upper gastrointestinal endoscopy and biopsy
c. Liver function test
d. PT, aPTT, INR
e. CT Scan
INTERVENTION
1.
2.
3.
4.
5.
6.
APPENDIX II D
7.4 PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL
SECTION A
12
Principle investigator
(Name and Designation)
Co-investigator
(Name and Designation)
YES
APPENDIX I
APPENDIX IC
APPENDIX IIB
SAH & RC, B.G.NAGARA
18 MONTHS
YES
NO
NO
NO
NO
NO
II.
NA
13
III.
NA
IV.
NA
session?
E Is the study a part of multi central trial?
NO
NO
NO
NA
NA
NA
NA
NA
indication.
Phase one and two clinical trials
Experimental use in-patients and healthy
volunteers.
Hospital supplies
14
NA
None
Amount
Source
To whom payable
NA
NO
NO
The researcher?
YES
NO
NO
NA
NA
the study?
If Yes give details of
I.
Designation
II.
Qualification
III.
Number
IV.
Duration of Employment
NA
NO
NA
NA
NA
NA
reason:
15
APPENDIX II
Chairman,
P.G Training Cum-Research Institute,
A.I.M.S., B.G.Nagara.
Date :
PS : NA Not Applicable
16
APPENDIX III
LIST OF REFERENCES
1.
2.
and management.
Brunucardi.C, Andersen K, Billiar.R, Dunn.L, Hunter.G, Pollock.E, Schwartz Principles
3.
4.
5.
6.
7.
hepatogastroenterology 56:1219-1221.
Noyan T, Guducuoglu H, Ilhan M,(2009); A study of oxidative stress parameters in antihelibacter pylorus immunoglobulin g positive and negative gastric cancer patients,
8.
9.
10.
11.
17
12.
13.
18:89-195
Topaloglu U, Dulundu E, Ozkan E,Kahayan N, Ozel Y (2009); Extended
Lymphadenectomy for
14.
gastric
Hepatogastroenterology 56:266-269.
Asoglu O, Karanlik H, Parlak M, Kecer M, Muslumanoglou M, Igci Yu J; Xin F(2009)
A
study
on
the
association
of
histological
types
and
TNM
stages,
16.
18