Page 42 - tmp

Gastric Outlet Obstruction Secondary to Spasmo-proxyvon Addiction
and gastrojejunostomy. All were male patients, median age was
36.5 years, and median duration of addiction was 25.5 months.
The mean operative time was 139.30 minutes. There was no
conversion to laparotomy. There was no intra and immediate
postoperative mortality. Two patients had delayed gastric emptying
in the immediate postoperative period. One patient was managed
conservatively with intravenous fluids and metoclopramide
therapy. Another patient did not respond to conservative
management and required feeding jejunostomy on postoperative
day ten for maintaining enteral nutrition. He showed improvement
with jejunostomy feeds and prokinetic agents and was gradually
started on oral diet. Mean duration of hospital stay was 7.81 days
(range 6–15 days). Median follow-up was 37.30 months. All the
patients had significant improvement in oral intake and weight
gain. One patient died due to severe anorexia, malnutrition, and
generalized anasarca secondary to resumption of drug abuse one
year after surgery.
Fig. 2: CT scan pyloric stenosis
dIscussIon
and contrast enhanced CT scan abdomen (Fig. 2). This was done Gastric outlet obstruction caused by peptic ulcer disease is a rare
to know the site of stricture and exclude any neoplastic etiology. disease; approximately 1–2% of peptic ulcer disease patient will
The inclusion criteria for the surgery were (1) symptomatic gastric require surgical therapy due to gastric outlet obstruction. The
8
outlet obstruction with postprandial vomiting; (2) narrowing of the chronic nonsteroidal antiinflammatory drug use is significantly
pyloric antrum or duodenum on endoscopy and CT scan abdomen; associated with gastric outlet obstruction. spasmo-proxyvon is
9
(3) complete abstinence from drug abuse (minimum 4 weeks); and antispasmodic analgesic that contains acetaminophen (400 mg),
(4) serum albumin ≥3.0 g/dL. Patients with significant malnutrition dicyclomine (10 mg), and dextropropoxyphene (400 mg). It is
and active drug abuse were managed with feeding jejunostomy of significant abuse in Punjab, India. 1,10 Pharmacologically none
with the intention of gastrojejunostomy later after optimizing of the salt composition in spasmo-proxyvon comes into the
nutritional status and achieving complete abstinence from drug category of NSAIDs. However, as shown in our study, significant
intake. The patient is placed in a supine reverse trendlenberg complications of peptic ulceration occurred in spasmo-proxyvon
position with legs far apart. The operating surgeon stands addict patients. Probably, it is the acetaminophen content and
between legs. Our standard procedure is 5 trocar approach—one dextropropoxyphene (opium derivative) contributing to peptic
4
10 mm supraumbilical camera port, one 12 mm port right upper ulceration. Piper et al. have shown strong positive association
quadrant mid clavicular line, and three 5 mm ports—one epigastric between heavy intake of acetaminophen and gastric ulcer with
6
port for left liver lobe retraction, and two left upper abdominal relative risk of 24.4. Appasani et al. and Aggarwal et al., in their
5
quadrant working ports in mid-clavicular and anterior axillary studies on gastric outlet obstruction, have also listed opium and
line, respectively. Harmonic scalpel was used for the division of its derivatives as one of the causes of gastric outlet obstruction.
gastrohepatic ligament and division of anterior and posterior Vagotomy and antrectomy have been regarded as the most
11
truncal vagotomy. After the division of gastrocolic omentum, effective operation for complications of peptic ulcer surgery. In
antecolic isoperistaltic posterior gastrojejunostomy was done using cases of peptic ulcers complicated by gastric outlet obstruction,
an Echelon Flex Endopath stapler using 60-mm (blue) cartridge, truncal vagotomy with pyloroplasy or gastrojejunostomy are
and common enterotomy was closed using an intracorporeal suggested alternatives. Radovanovic et al. and Csendes et al.
14
13
12
continuous polydixonane 2-0 suture. Postoperatively nasogastric have suggested highly selective vagotomy and gastrojejunostomy
tube was removed on day one. Oral liquid diet was started on day as the effective treatment for peptic ulcer-induced gastric outlet
two, which was gradually progressed to semisolid diet. Patients obstruction. Minimal access surgery is being used routinely for
were usually discharged by day five. Statistical analysis was done truncal vagotomy and gastrojejunostomy with the reduction in
using the statistical package for social sciences (SPSS) version 20.0 morbidity and mortality. 15,16 In our study, we have done stapler
for windows. posterior gastrojejunostomy with intracorporeal suturing of
common enterotomy with no mortality and minimal morbidity
(delayed gastric emptying in two cases). Similar results have been
results shown by other authors. 17
From January 2015 to May 2020, 27 patients of spasmo-proxyvon Endoscopic balloon dilatation is an alternative nonsurgical
18
addiction with complaints of abdominal pain, persistent vomiting, method to manage gastric outlet obstruction in peptic ulcer disease.
and bleeding were admitted in surgical ward of a tertiary hospital. The main drawback of endoscopic balloon dilatation is that it requires
Of these 27 patients, four cases presented with prepyloric multiple sessions compared to one time surgical procedure. Also,
perforation and two cases with persistent duodenal ulcer bleed long-term follow-up results of balloon dilatation therapy are scanty
after failure of endoscopic therapy. Five cases were managed with in the literature. In a series on endoscopic balloon dilatation therapy
19
feeding jejunostomy alone. These 11 patients were excluded from in gastric outlet obstruction by Noor et al. median follow-up
analysis. Remaining 16 patients with the feature of gastric outlet duration was only 12 months. Moreover, results of endoscopic
obstruction were managed with laparoscopic truncal vagotomy balloon dilatation vary with etiology of gastric outlet obstruction.

184 World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021)