Afferent loop obstruction is an uncommon complication associated with Billroth-II distal gastrectomy. Inappropriate treatment may result in life-threatening events as perforation and peritonitis. For the benign afferent loop obstruction, Braun or Roux-en-Y reconstruction has been reported as the choice. However, the edematous afferent loop may result in anastomotic fistula. In this study, a less invasive technique was described for treatment of benign afferent loop obstruction. The aim of this study was to investigate the effectiveness and safety of endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction. We conducted a retrospective review of the data of 2548 gastric cancer patients who underwent distal gastrectomy from January 2002 to January 2018. Patients who developed benign afferent loop obstruction were treated by this procedure. Outcomes were recorded. Follow-up was scheduled at 3, 6, and 12 months after the treatment. Twenty-six patients (1.0%) developed afferent loop obstruction. The median age, consisting of 19 men and 7 women, was 60 years (range 36–69 years). Of these 26 patients, 23 underwent the endoscopic treatment. The obstructive symptoms had a rapid relief in all the 23 patients. No one died due to this procedure. However, 2 patients underwent surgical treatment due to intestinal obstruction because of adhesion at >4 and 7 months after the endoscopic drainage, respectively. Endoscopic nasogastric tube insertion is an effective and safe procedure for treatment of benign afferent loop obstruction. In addition, it could be considered as the first step in treatment, especially in high-surgical-risk patients.

Introduction: Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy. Patient concerns: Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula. Diagnosis : All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents. Interventions: With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin–somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed. Outcomes: All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments. Conclusion: The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin–somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.

Rationale:Occult small bowel bleeding is always difficult to locate by either radiological examination or endoscopy. When the site of bleeding cannot be found by nonsurgical measures, exploratory laparotomy becomes necessary.Patient concerns:A 63-year-old woman with a half-month history of occult gastrointestinal bleeding failed to many conservative therapies.Interventions:Intraoperative transillumination with water-filling of lumen was performed.Diagnoses:Small bowel bleeding was diagnosed intraoperatively.Outcomes:Segmental resection of the diseased small bowel with side-to-side anastomosis was performed while the histology showed no significant abnormality.Lessons:The technique of intraoperative transillumination with water-filling of lumen allows simple, accurate, and rapid localization of lesions in occult small bowel bleeding and facilitates precise and definitive surgery.

No abstract