Ileocolic Interposition as a Gastric Substitute in Patients with Total Gastrectomy; Case Series and Literature Review

Background: The standard method for reconstruction after total gastrectomy is Roux-en-Y reconstruction, which has several negative points such as malabsorption. The most important reasons for weight loss in these patients are reserval insufficiency and reduction of food-digestive juice blending. We suggest that the creation of a food reserve with a natural conduit by ileocolic interposition may help the patient to have more normal diet habits and prevent severe weight loss. Methods: The study enrolled 8 patients with proximal gastric cancer, who underwent total gastrectomy with omentectomy and D2 lymphadenectomy. Then, the ileocolic segment with its vasculature was prepared and the anastomosis was done like right colon interposition between esophagus and duodenum. Intraoperative and postoperative events and also nutritional conditions were recorded. Results: Among 8 patients enrolled in the study, not an intraoperative bad event nor anastomotic site leakage, abscess formation, or other significant post-operative complication were seen. Except for the first two patients, the rest did not suffer from dysphagia. None of the patients suffered from delayed, chronic, or uncontrolled vomiting. All patients experienced weight loss postoperatively but after 2 months, they gained weight. Barium examination and also upper endoscopy revealed that the patients had normal reserval volume, no evidence of erosion or ulceration, no evidence of biliary esophagitis or reflux, and absence of tumor relapse. Conclusions: Because of the nutritional benefits of ileocolic interposition after total gastrectomy in gastric cancer treatment, it can be used as an acceptable alternative method of reconstruction in a subgroup of selected patients.

Delayed Awareness of the History of Barium Examination: Perforated Barium Appendicitis

A 41-year-old man presented to our hospital with lower abdominal pain and a high-grade fever. Physical examination revealed rebound tenderness and guarding in the lower abdomen. Abdominal X-ray examination showed a radiopaque object in the right lower quadrant of the abdomen. Abdominal computed tomography (CT) demonstrated that the object had a strong artifact with over 10,000 Hounsfield units, as well as ascites around the terminal ileum. We diagnosed acute peritonitis with a suspicion of the perforation due to unknown foreign body and performed an emergency laparotomy. Operative findings showed a contained perforation of a phlegmonous appendicitis, and appendectomy was performed. The resected specimen demonstrated that the appendix contained a fecalith, and histopathological examination showed the crystal structure of barium sulfate in the lumen of the appendix. Unfortunately, we did not obtain the history of screening for gastric cancer using a barium examination one month prior to our appendectomy. Our experience demonstrates the importance of establishing a history of barium examinations of the gastrointestinal tract in a patient with a radiopaque object in the right lower quadrant of the abdomen for early diagnosis of barium appendicitis. Additionally, early diagnosis of barium appendicitis may affect the selection of surgical procedures.

Small Intestine Obstruction in Patients due to Phytobezoar: Case Report of Four Patients

ABSTRACT Introduction: Bezoars are rare cause of small-bowel obstruction and lead to intraluminal obstruction. The other causes are foreign bodies, gall stones, and enteroliths. Phytobezoars are collection of non-digestible materials, usually of vegetable origin, and are most commonly found in patients with impaired gastric emptying, on high-fiber diet and with abnormal food habits.We present a case report of four patients who presented with acute intestinal obstruction, and the etiology in all these four cases was found to be a phytobezoar. The complaints of diffuse pain abdomen, vomiting, and constipation were common in all four cases. One patient had undergone a gastric pull-up surgery for carcinoma esophagus and one female had undergone bilroth1 for peptic ulcer disease. One patient was a known case of diabetes mellitus and had undergone surgery for perforated peptic ulcer few years back. Conclusion: Diagnosis of bezoars is usually confirmed by barium examination or endoscopy, and definitive treatment is surgery in case of obstruction with the removal of bezoar.

Barium Appendicitis 1 Month After a Barium Meal

Because barium sulfate (BaSO4) is not harmful to the mucosa, it is widely used for gastrointestinal imaging. Barium appendicitis is a very rare complication of barium meals and barium enema. We report a case of acute appendicitis associated with retained appendiceal barium. A 47-year-old man presented with right lower abdominal pain after upper gastrointestinal imaging was performed using barium 1 month earlier. The abdominal plain roentgenogram showed an area of retained barium in the right lower quadrant. Multiplanar reconstruction of computed tomography scans showed barium retention in the appendix. Emergency appendectomy was performed. A cross section of the specimen revealed the barium mass. Barium-associated appendicitis is a very rare clinical entity but we should be cautious of this uncommon disease when we encounter barium deposits in the appendix after barium examination. This report is significant because barium was identified both macroscopically and microscopically.