Vertical Gastrectomy (VG) has quickly become the most performed bariatric surgery in the world. However, little is known about long-term results when compared to Roux-en-Y Gastric Bypass (RYGB).

In August 2022, an article was published in JAMA Surgery with the results of 10 years of follow-up of SLEEVEPASS, a randomized study comparing VG and RYGB. In this post, we will comment on the findings of this article.

Introduction

Vertical Gastrectomy already represents more than 60% of bariatric procedures performed in the USA and worldwide. Its long-term follow-up results are still unknown. Recent studies have shown a high incidence of GERD and even Barrett’s Esophagus.

The SLEEVEPASS trial showed equivalent results for both techniques in terms of weight loss, diabetes control, complications, and quality of life in the 5 and 7-year follow-ups.

Methods

A prospective multicenter randomized clinical study conducted in Finland from March 2008 to June 2010 with 240 patients with BMI > 40 or > 35  associated with comorbidities.  In relation to the initial protocol, an addendum was made for the 10-year study including the performance of upper digestive endoscopy.

The primary outcome was weight loss through the calculation of excess weight loss (%EWL). The secondary outcomes were remission of comorbidities, quality of life, postoperative morbidity, and mortality. For this 10-year analysis, there was a special focus on reflux-related outcomes, with symptoms, esophagitis, and Barrett’s esophagus.

Results

Of the 238 patients initially allocated to the study, 193 completed 10 years of clinical follow-up and 176 the endoscopic.

• Weight loss

The weight loss through %EWL was 43.5% for VG and 51.9% for RYGB. Despite a difference of 8.4% for RYGB, after imputing missing data in the analysis, the results were similar. Regarding weight regain, it was 35% for VG and 24.7% for RYGB, without statistical significance.

• GERD and Endoscopy

The prevalence of esophagitis was significantly higher in the sleeve than in the bypass, with 31% vs. 7%, respectively (p < 0.001). Patients in the VG group also had significantly more use of PPI (64% vs. 36%, p < 0.001), worse reflux-related quality of life score (10.5 vs. 0.0, p < 0.001), and more reflux symptoms than those in the RYGB group.

• Remission of comorbidities

Diabetes remission was seen in 26% of those who underwent sleeve and 33% of the bypass, with no statistical difference. There was also no difference in fasting blood glucose and glycated hemoglobin values between the groups in the 10-year follow-up.

Dyslipidemia was only in remission in 19% for VG and 35% for RYGB, without statistical significance. Regarding arterial hypertension, only 8% of those who underwent VG were without medication in the 10-year follow-up, while 24% of those who underwent RYGB (p = 0.04).

• Quality of life

Measured through the Moorehead-Ardelt score, the quality of life in 10 years significantly improved for both groups compared to the beginning of the study. There was no difference between the techniques.

• Morbidity and mortality

For the analysis of the 10 years of studies, all complications occurring between 30 days and 10 years were evaluated cumulatively. The rate of severe complication (Clavien-Dindo >= IIIb) was 15.7% for VG and 18.5% for RYGB (p = 0.57). Most of the sleeve reoperations were due to GERD and the bypass ones were due to internal hernia.

Discussion

The results of this 10-year comparative analysis between Sleeve and Bypass show that both techniques resulted in significant and sustained weight loss. There was no significant difference in the improvement of comorbidities, except for HAS, whose remission was superior in the bypass group.

The weight loss trajectories for VG and RYGB were consistent over the 5, 7, and 10-year follow-up periods. When analyzed together with another large trial (SM-BOSS), the bypass showed superior weight loss through the loss of excess BMI, despite there being no statistical difference in the trials separately.

Use of PPI, esophagitis, and reflux symptoms were significantly more frequent in VG compared to RYGB. However, Barrett’s Esophagus was equally uncommon (4%) in both groups, compared to alarming results published in other studies, which reached 17% of Barrett after Vertical Gastrectomy.

This is important considering the growing prevalence of obesity in the world and the large proportion of VG performed, which could impact a higher risk of Barrett and Esophageal Adenocarcinoma in the long term. Another recent study with 10.5 years of follow-up showed a 4% incidence of Barrett. This discrepancy in the results may be due to variability in the diagnostic criteria for Barrett, selection bias in cases submitted to endoscopy in smaller studies, or even population differences.

An important limitation of this study was the lack of criteria for analyzing reflux at the beginning of the study, considering symptoms, questionnaires, and endoscopy only in the long-term follow-up.

Conclusions

In 10 years of follow-up, the excess weight loss was superior in Bypass compared to Sleeve. There was no statistical difference in the remission of comorbidities, except for hypertension.

The cumulative incidence of Barrett’s Esophagus was much lower than reported in other studies, but symptoms of reflux, use of PPI, and diagnosis of esophagitis were significantly more prevalent after Vertical Gastrectomy, reinforcing the importance of GERD evaluation in the preoperative period for adequate patient selection and procedure choice.

Reference

Salminen P, Grönroos S, Helmiö M, Hurme S, Juuti A, Juusela R, Peromaa-Haavisto P, Leivonen M, Nuutila P, Ovaska J. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial. JAMA Surg. 2022 Aug 1;157(8):656-666. doi: 10.1001/jamasurg.2022.2229. PMID: 35731535; PMCID: PMC9218929.

How to cite this article

Dantas ACB,. Vertical Gastrectomy and Roux-en-Y Gastric Bypass. Is there a difference in long-term results? Gastropedia; 2022. Available at: gastropedia.com.br/surgery/obesity/vertical-gastrectomy-and-roux-en-y-gastric-bypass-is-there-a-difference-in-long-term-results

The American Society of Colon and Rectal Surgery and the American Society of Gastrointestinal and Endoscopic Surgery published in the first edition of the journal Diseases of Colon and Rectum in 2023 the updates (the last version was from 2017) of the guidelines for accelerated recovery in the postoperative period of colorectal surgery.

Advanced recovery protocols are a set of standardized perioperative processes, whose content can vary significantly, that are applied to patients undergoing elective surgeries. They are designed to improve patient outcomes, such as relieving nausea and pain, early return of intestinal function, and reducing wound infection rates and length of stay. Here, we will talk about the main measures mentioned to improve patient outcomes after elective colon and rectal resections.

As is known, colorectal surgery has always been associated with longer hospital stays, higher costs, and higher surgical site infection rates (about 20%) compared to procedures from other specialties. In addition, high rates of nausea and vomiting (80%), which also delay hospital discharge, and readmission (35%). It has been shown that the implementation of ERAS in colorectal surgery reduces morbidity rates and decreases the length of stay without increasing readmission rates.

PREOPERATIVE INTERVENTIONS

Pre-admission counseling

• Preoperative discussion about clinical objectives and discharge criteria should be conducted before surgery. Adherence to an advanced recovery protocol that includes preoperative patient education is associated with decreased length of stay and decreased complication rates.
• Patients who will undergo ileostomy creation should receive guidance on stoma management and advice on how to avoid dehydration, which reduces the length of stay and readmission rates.

Pre-Admission Nutrition and Colon Preparation

• Clear liquids can be continued up to 2 hours before general anesthesia. This intervention, according to several randomized clinical trials, is safe and improves patients’ sense of well-being.
• Intake of carbohydrate-rich beverages should be encouraged before surgery in non-diabetic patients to attenuate surgery and fasting-induced insulin resistance. The studies that evaluated this measure showed a reduction in the length of stay, but there were no differences in complication rates or other outcomes.
• Oral nutritional supplementation is recommended in malnourished patients before elective colorectal surgery, aiming for a protein intake of 1.2 to 1.5g/kg/d for a period of 1 to 2 weeks, which decreased postoperative complications. On the other hand, the efficacy of immunonutrition, supplementation containing immunomodulatory nutrients such as arginine, fish oil (omega-3 fatty acids), nucleotides, and glutamine, over standard high-protein oral nutritional supplements remains controversial.
• Mechanical colon preparation combined with preoperative oral antibiotics is usually recommended before elective colorectal surgery. A meta-analysis of seven randomized clinical trials including 1,769 patients comparing colon preparation with and without oral antibiotics, showed a reduction in surgical site and operative wound infection. In a retrospective analysis of a national database from the United States, colon preparation with oral antibiotics was associated with decreased overall morbidity, wound infection, anastomotic dehiscence, and intra-abdominal infections.

Pre-admission optimization

• Multimodal prehabilitation, which is the improvement of the patient’s general clinical conditions, before elective colorectal surgery, may be considered for patients with multiple comorbidities or with significant performance loss, especially in patients who will undergo open surgery.

PERIOPERATIVE INTERVENTIONS

Surgical Site Infection

• There should be a set of measures to reduce surgical site infection. There are several items described in the literature, but there is no universal standardization. The measures include chlorhexidine bath, colon preparation with oral antibiotic administration, intravenous antibiotics within one hour after incision, and standardization of surgical field preparation with chlorhexidine/alcohol. Surgical measures include the use of a wound protector, changing gowns and gloves before closing the aponeurosis, using an exclusive instrument box for closure, antimicrobial sutures, limiting traffic in the operating room, and maintaining controlled blood glucose and normothermia.

Pain Control

• A multimodal pain control plan, avoiding opioids, should be implemented before the induction of anesthesia. Several studies have shown that minimizing opioids after colorectal surgery is associated with an earlier return of intestinal function and a shorter length of stay. Measures include the use of simple analgesics (dipyrone, paracetamol) and non-hormonal anti-inflammatory drugs, especially selective ones (such as cyclooxygenase inhibitors) and ketorolac, analgesic blocks, such as lumbar square and transverse abdomen, and wound infiltration and spinal analgesia with intrathecal administration of morphine.
• Thoracic epidural analgesia, although not recommended for routine use in laparoscopic colorectal surgery, is an option for open colorectal surgery if a dedicated pain team is available for postoperative treatment.

Perioperative Nausea and Vomiting

• The use of prophylactic and multimodal antiemetics reduces perioperative nausea and vomiting. Risk factors for the development of postoperative vomiting include female sex, previous history of postoperative vomiting or nausea, non-smoker, young age, laparoscopic surgery, use of respiratory anesthesia, prolonged operative time, and opioid analgesia. Several prospective and observational studies show that combined therapy using two or more antiemetics to prevent nausea and vomiting is superior to a single agent. A meta-analysis of nine randomized clinical trials including 1,089 patients, showed that dexamethasone combined with other antiemetics provided significantly better prophylaxis than a single antiemetic, decreased the need for rescue therapy, and did not increase postoperative infections or significantly affect glycemic control.

Fluid Management

• Fluid administration should be adapted to avoid excessive fluid administration and volume overload or undue fluid restriction and hypovolemia. Both intravenous fluid overload and hypovolemia can significantly impair organ function, increase postoperative morbidity, and prolong hospital stay.
• Crystalloid solutions balanced with chloride restriction should be used for maintenance infusions and fluid boluses in patients undergoing colorectal surgery. There is no benefit in the routine use of colloid solutions for bolus fluids.
• Intraoperative hypotension should be avoided, as even short periods of mean arterial pressure <65 mmHg are associated with adverse outcomes, particularly myocardial injury and acute kidney injury.
• In high-risk patients and in patients undergoing colorectal surgery with anticipated significant intravascular losses, goal-directed hemodynamic therapy is recommended. Objective measures of hypovolemia, such as cardiac output, stroke volume, oxygen supply, oxygen extraction, and mixed venous oxygen saturation and dynamic indices of fluid responsiveness (for example, pulse pressure variation or stroke volume variation) can help decide whether intravenous fluids should be administered for resuscitation purposes.
• In the absence of surgical complications or hemodynamic instability, intravenous fluids should routinely be discontinued in the immediate postoperative period.

Surgical Approach

• A minimally invasive surgical approach should be used when available experience and when appropriate.
• The routine use of nasogastric tubes and intra-abdominal drains for colorectal surgery should be avoided.

POSTOPERATIVE INTERVENTIONS

Patient mobilization

• Early and progressive patient mobilization is associated with a shorter length of stay.

Prevention of Paralytic Ileus

• Patients should be offered a regular diet within 24 hours after elective colorectal surgery. Early feeding is associated with a decrease in hospital stay, a faster return of gastrointestinal tract function, and a shorter time to flatus and first bowel movement.
• Simulated feeding (i.e., chewing gum for ?10min 3–4× a day) after colorectal surgery is safe, results in small improvements in gastrointestinal recovery, and may be associated with a reduction in length of stay.

Urinary Catheters

• Urinary catheters should normally be removed within 24 hours after elective high colon or rectal resection, regardless of the use of thoracic epidural analgesia.
• Generally, urinary catheters should be removed within 24 to 48 hours after mid/lower rectal resection. Manipulation and dissection near the bladder and lateral pelvic nerves during proctectomy can increase the risk of postoperative urinary retention.

Discharge criteria

• Hospital discharge before bowel movement may be offered to selected patients. Traditional discharge criteria after colorectal surgery include the presence of bowel movement along with tolerance to oral intake, adequate pain control with oral analgesia, and the ability to mobilize in the absence of complications. Many patients meet these criteria on the first or second day after surgery. However, there are increasing reports of same-day discharge, which depends on the feasibility of discharging patients before the return of intestinal function for very selected patients, with the possibility of close follow-up and adequate home support. This is an area with limited but evolving evidence. Recommendations may change as more evidence becomes available.

References

1. Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023 Jan 1;66(1):15-40.
2. Chen M, Song X, Chen LZ, Lin ZD, Zhang XL. Comparing mechanical bowel preparation with both oral and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone for the prevention of surgical site infection after elective colorectal surgery: a meta-analysis of randomized controlled clinical trials. Dis Colon Rectum. 2016; 59:70–78.
3. Herbert G, Perry R, Andersen HK, et al. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev. 2019;7:CD004080.
4. Hogan S, Steffens D, Rangan A, Solomon M, Carey S. The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery—a systematic review and meta-analysis of randomised controlled trials. Eur J Clin Nutr. 2019; 73:1331–1342.
5. Liu Q, Jiang H, Xu D, Jin J. Effect of gum chewing on amelio- rating ileus following colorectal surgery: a meta-analysis of 18 randomized controlled trials. Int J Surg. 2017; 47:107–115.

How to cite this file

Camargo, MGM. Update of the American Guidelines for Enhanced Recovery After Surgery (ERAS) in Colorectal Surgery. Gastropedia; 2022. Available at: strongupdate-of-the-american-guidelines-for-emenhanced-recovery-after-surgery-em-eras-in-colorectal-surgery-strong

Insulinoma is the most frequent functioning pancreatic neuroendocrine tumor (55%), with its peak occurrence in patients in their fifth decade of life (between 40 and 50 years) and a slight predominance among women (1.4:1)¹.

The symptoms associated with the tumor are divided between adrenergic – anxiety, tremors and agitation – and neuroglycopenic such as disorientation, visual alterations and seizures². Due to frequent food intake to avoid severe hypoglycemia during fasting, it is common for patients to present with obesity/overweight at diagnosis.

In 1938, the Whipple triad was described: documented hypoglycemia (<50mg/dL), symptomatic and relieved after caloric intake. Currently, diagnostic confirmation is given with a clinical fasting test of 48 to 72 hours in which laboratory tests are collected periodically. The laboratory profile will show low blood sugar in opposition to high levels of insulin, pro-insulin and C-peptide³. It is essential for diagnosis to ensure that the patient does not use oral antidiabetics such as sulfonylureas or injectable insulin.

The relationship of insulinoma in endocrine syndromes (MEN-1 and tuberous sclerosis) is known and brings propaedeutic particularities due to a higher risk of multiple neuroendocrine tumors or malignant insulinomas⁴.

The recommended treatment is surgical excision of the tumor. Enucleation, as well as segmental pancreatectomies, are recognized treatments since the vast majority of tumors are benign. Thus, lymphadenectomy becomes less relevant than the preservation of pancreatic parenchyma in order to avoid exocrine or endocrine insufficiency¹.

Therefore, this article aims to bring an analysis of the different diagnostic tests used in insulinoma cases and their applications, in addition to a list of specific perioperative care for these patients.

Diagnostic methods by image

Axial methods with contrast are the most used for the anatomical study of the pancreas and its vascular relations. Among them, magnetic resonance, when available, has proven to be more sensitive to locate insulinomas that present as hypervascular nodules in the arterial phase, with hyperintensity in T2 and hypointensity in T1 in relation to the pancreatic parenchyma. Smaller lesions can be located more easily in diffusion phases⁵.

A specific exam for neuroendocrine tumors that uses their somatostatin receptors, the PET Gallium 68 can assist in cases of clinical suspicion without diagnosis by the methods above. It is an appropriate exam for the location of ectopic insulinomas that were not visualized in the upper abdomen⁵.

Invasive diagnostic methods

Echoendoscopy: Exam for evaluation of the pancreatic parenchyma in search of subcentimetric lesions, used by some authors as the first exam to locate the insulinoma. It offers even greater sensitivity in lesions of the head of the pancreas and uncinate process.

In the report of a suspected insulinoma, it is important to include, if possible, the measurement of the tumor, its location and the distance from relevant vascular structures (spleno-mesenteric junction), and the proximity of the main pancreatic duct (to assist the operative decision to enucleate the lesion).¹

Needle puncture is dispensable in the vast majority of cases. The symptomatic patient with sporadic lesion does not need histopathological confirmation for treatment. In endocrine syndromes, both functioning and non-functioning neuroendocrine tumors can express immunohistochemical markers for insulin. Thus, this exam is not suitable to differentiate them. ⁶

In non-peripheral or intrapancreatic lesions of difficult location, the surgeon may request a tattoo with methylene blue to facilitate intraoperative location.

Selective pancreatic arterial catheterization (SACS)

The exam consists of positioning a collector catheter in the right hepatic vein to collect the blood level of insulin after arterial stimuli.

Then, after selective arterial catheterization, calcium gluconate is injected into the peripancreatic arteries with the power to topograph the lesion if insulinemia doubles within 3 minutes after injection.

• Tumor in the body/tail of the pancreas: Positive after injection in the splenic artery
• Tumor in the pancreatic head or uncinate process: Positive after injection in the gastroduodenal or superior mesenteric artery
• Hidden hepatic metastasis: Positive after injection in the proper hepatic artery

The exam is used mainly in cases of endocrine syndromes and multiple neuroendocrine tumors in which it is desired to identify which lesion is metabolically active.¹

Surgical treatment

The definition of surgical route depends on the surgeon’s expertise. It is important to note that for laparoscopic access, especially for nodulectomies and distal pancreatectomies, a detailed planning of the location of the pancreatic section is necessary. Conversion to open surgery is justified in cases of imprecision.⁷

Intraoperative ultrasonography is an ally of the liver and pancreas surgeon and, in this context, certifies the tumor location and proximity to pancreatic ducts in cases where enucleation is considered. Thus, the exam provides greater safety to the procedure, reducing the risk of pancreatic fistula and allowing preservation of pancreatic parenchyma when possible.

A 65-year-old male patient, underwent Vertical Gastrectomy in 2017 for the treatment of Morbid Obesity. Lost follow-up during the COVID-19 pandemic, having only done a follow-up endoscopy in the first postoperative year.

Returns to the clinic with significant symptoms of heartburn and daily regurgitation, impacting quality of life and food tolerance. EDA requested, with the finding of a projection of columnar mucosa, salmon-pink in color in the distal third of the esophagus, measuring about 10 mm circumferentially. Biopsies were performed with confirmation of intestinal columnar metaplasia, compatible with the diagnosis of Barrett’s Esophagus.

Although uncommon in our environment, the diagnosis of Barrett’s Esophagus after VG has been increasingly reported in the literature. A recent meta-analysis showed a prevalence of 11.4%, with a grouped Barrett rate in patients with GERD symptoms of 18.2% (95% CI, 12.4% – 26%). Such a study also showed that there was no significant difference in the likelihood of having Barrett based on GERD symptoms.

Therefore, to make an early diagnosis of Barrett after Vertical Gastrectomy and maintain adequate clinical and endoscopic follow-up, we should follow the IFSO recommendation to perform upper digestive endoscopy annually in patients undergoing sleeve regardless of symptoms.

References

1. Qumseya BJ, Qumsiyeh Y, Ponniah SA, Estores D, Yang D, Johnson-Mann CN, Friedman J, Ayzengart A, Draganov PV. Barrett’s esophagus after sleeve gastrectomy: a systematic review and meta-analysis. Gastrointest Endosc. 2021 Feb;93(2):343-352.e2. doi: 10.1016/j.gie.2020.08.008. Epub 2020 Aug 14. PMID: 32798535.
2. Brown WA, Johari Halim Shah Y, Balalis G, Bashir A, Ramos A, Kow L, Herrera M, Shikora S, Campos GM, Himpens J, Higa K. IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg. 2020 Aug;30(8):3135-3153. doi: 10.1007/s11695-020-04720-z. PMID: 32472360.

How to cite this article

Dantas ACB, Vertical Gastrectomy and risk of Barrett’s Esophagus. Gastropedia; 2022. Available at: https://gastropedia.com.br/cirurgia/obesidade/gastrectomia-vertical-e-risco-de-esofago-de-barrett/

Gastroesophageal Reflux Disease (GERD) is quite common in the general population, with a prevalence of 10 to 20%. In patients with obesity, this prevalence can be double.

The mechanisms involved in the increased risk of GERD in obesity are due to increased abdominal pressure, leading to:

• Increased transient relaxation of the lower esophageal sphincter
• Hiatal hernia
• Decreased esophageal clearance

The prevalence of GERD is directly related to the severity of obesity and BMI (Body Mass Index). Patients with obesity (BMI > 30) have more episodes of reflux and worse DeMeester score than those who are overweight (BMI > 25). In candidates for bariatric surgery, those with BMI > 50 have erosive esophagitis with higher prevalence than those with BMI > 40 and so on. Despite this, it is uncommon to find severe esophagitis (C/D) or even the diagnosis of Barrett’s Esophagus.

How should GERD investigation be in the preoperative period of bariatric surgery?

Although it is routine in most bariatric services in Brazil, until recently there was great controversy in the international literature regarding Upper Digestive Endoscopy (EDA) in preparation for bariatric surgery.

The current recommendation according to international society consensus is as follows:

• EDA should be considered for all patients with gastrointestinal symptoms who plan to undergo bariatric surgery due to the frequency of findings that can change conduct
• EDA should also be considered for those without symptoms due to the chance of 25% of incidental endoscopic findings that can change conduct or even contraindicate bariatric surgery

How does the presence of GERD influence the technical choice of bariatric surgery?

Currently, Vertical Gastrectomy (GV) is the most performed bariatric surgery in the world. However, with long-term follow-up, we have seen more frequently cases with GERD postoperatively. In some situations, very symptomatic and refractory to clinical treatment, with the need for revision surgery for conversion to Roux-en-Y Gastric Bypass (BGYR).

There is no conduit, strong evidence regarding preoperative risk factors that can predict which patients will evolve with de novo reflux. We only know that those with pathological GERD, according to Lyon criteria, tend to worsen after GV.

For all this, the presence of GERD should be weighed in the joint decision with the patient between GV or Bypass. In general, but not necessarily, we should favor Gastric Bypass in case of:

• Los Angeles grades C or D Erosive Esophagitis
• Barrett’s Esophagus
• Hiatal hernia
• Esophageal motor alterations

How to cite this article

Dantas, A. Gastroesophageal reflux disease in the patient with obesity. Gastropedia; 2022 Available at: https://gastropedia.com.br/cirurgia/obesidade/doenca-do-refluxo-gastroesofagico-no-paciente-com-obesidade/

References:

1. Ayazi S, Hagen JA, Chan LS, DeMeester SR, Lin MW, Ayazi A, Leers JM, Oezcelik A, Banki F, Lipham JC, DeMeester TR, Crookes PF. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms. J Gastrointest Surg. 2009 Aug;13(8):1440-7.
2. Derakhshan MH, Robertson EV, Fletcher J, Jones GR, Lee YY, Wirz AA, McColl KE. Mechanism of association between BMI and dysfunction of the gastro-oesophageal barrier in patients with normal endoscopy. Gut. 2012 Mar;61(3):337-43.
3. Brown WA, Johari Halim Shah Y, Balalis G, Bashir A, Ramos A, Kow L, Herrera M, Shikora S, Campos GM, Himpens J, Higa K. IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg. 2020 Aug;30(8):3135-3153. doi: 10.1007/s11695-020-04720-z. PMID: 32472360.
4. Bolckmans, R., Roriz-Silva, R., Mazzini, G.S. et al. Long-Term Implications of GERD After Sleeve Gastrectomy. Curr Surg Rep 9, 7 (2021).
5. Sebastianelli L, Benois M, Vanbiervliet G, Bailly L, Robert M, Turrin N, Gizard E, Foletto M, Bisello M, Albanese A, Santonicola A, Iovino P, Piche T, Angrisani L, Turchi L, Schiavo L, Iannelli A. Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett’s Esophagus: Results of a Multicenter Study. Obes Surg. 2019 May;29(5):1462-1469.

Colon obstructions can be mechanical or non-mechanical and constitute about 25% of all intestinal obstructions. Among the mechanical causes, the most common are:

1. obstructive tumor in the colon or rectum (60%);
2. cicatricial stenosis from previous diverticulitis (10%);
3. colon volvulus (15 to 20%).

The colon volvulus is the twisting of a redundant segment of the colon in its mesentery that can lead to luminal occlusion of the twisted segment and ischemia by rotation of the mesocolon and, consequently, to perforation.

Although the colon volvulus can occur in any redundant segment, it most commonly involves the sigmoid (60%–75% of all cases) and cecum (25%–40% of all cases).

The sigmoid volvulus mainly occurs during the 6th to 8th decades of life, being more common in men, institutionalized patients, patients with chronic constipation, neuropsychological impairment or decompensated comorbidities. On the other hand, the cecal volvulus usually presents in younger patients and has a female predominance.

The acute pseudo-obstruction of the colon, or Ogilvie’s syndrome, is a non-mechanical functional cause of obstruction believed to be a consequence of the deregulation of the autonomic impulses of the colon’s innervation. There is great distension of the colon without an obstructive factor, but which can also evolve into ischemia and perforation. Clinical presentations vary according to the degree of distension, whether the ileocecal valve is competent or not, and the patient’s clinical condition. More commonly, Ogilvie’s syndrome affects elderly patients or patients hospitalized for unrelated reasons, including elective surgery, trauma, or treatment of an acute medical condition.

Here we present some recommendations from the guidelines of the American Society of Colorectal Surgery for the management of these cases.

Colon Volvulus

• Initial evaluation with history, physical examination, and basic laboratory tests. Symptoms may include cramps, nausea, vomiting, abdominal discomfort. The sigmoid volvulus usually has a more indolent presentation, while the cecal volvulus tends to have a more acute presentation. On physical examination, there is generally abdominal distension with varying degrees of pain on palpation, up to peritonitis. The rectal touch reveals an empty rectal ampulla. Presentation in the emergency room with peritonitis and signs of shock occurs in 25 to 35% of cases.

• In hemodynamically stable patients, an abdominal radiograph aids in the initial evaluation (finding of “coffee bean” and, in patients with incompetent ileocecal valve, distension of the small intestine). Tomography is used to confirm the diagnosis.

Sigmoid Volvulus

• Hemodynamically stable patients, without signs of peritonitis or evidence of perforation should undergo rectosigmoidoscopy to assess the viability of the sigmoid, undo the torsion and decompress the colon, effective therapy in 60 to 95% of cases. It is possible to maintain a probe for decompression after the rectosigmoidoscopy. The recurrence rate is 43 to 75% in cases that are not submitted to subsequent surgical intervention.

• Emergency sigmoidectomy is indicated when endoscopic distortion is not successful and in cases of colon suffering or perforation, as well as in patients with signs of peritonitis or septic shock. After resection of the twisted segment, the decision to perform a primary anastomosis, terminal colostomy or anastomosis with derivation should be individualized considering the patient’s clinical context at the time of surgery, the conditions of the remaining colon and comorbidities.

• Patients submitted to successful endoscopic distortion are candidates for segmental colectomy during the same hospital stay to avoid recurrent volvulus and its complications. Operations without resection, including only distortion, sigmoidopexy and mesosigmoidoplasty, are inferior to colectomy for the prevention of recurrent volvulus.

• Endoscopic fixation of the sigmoid can be considered in selected patients in whom surgical intervention has a prohibitive risk.

Cecal Volvulus

• Attempts at endoscopic reduction of cecal volvulus are not recommended.

• Segmental resection is the treatment of choice for patients with cecal volvulus. Unviable or ischemic cecum is present in 18% to 44% of patients with cecal volvulus and is associated with a significant mortality rate.

• In the case of cecal volvulus with viable intestine, the use of surgical procedures without resection should be limited to patients without clinical conditions for resection.

Acute Pseudo-Obstruction of the Colon (Ogilvie’s Syndrome)

• The initial evaluation should include history and physical examination, laboratory tests, and imaging diagnosis.
  In the absence of fever, leukocytosis, peritonitis, pneumoperitoneum or cecal diameter > 12?cm, the initial therapy consists of correcting hydroelectrolytic disorders, volume replacement, avoiding or minimizing the use of opioids, avoiding anticholinergic drugs and identifying and treating concomitant infections. Ambulation, fasting, positioning maneuvers (knee-chest or prone) to promote intestinal motility and decompression with nasogastric and rectal tubes are also recommended. Oral osmotic laxatives should be avoided as they can worsen colon dilation. Abdominal radiographs are part of the daily evaluation, accompanied by physical examination.

• The initial treatment is clinical support and includes the exclusion or correction of conditions that predispose patients to the condition or prolong its course.

• Pharmacological treatment with neostigmine is indicated when the condition does not resolve with supportive therapy.

• Endoscopic decompression of the colon should be considered in patients with Ogilvie in whom neostigmine therapy is contraindicated or ineffective.

• Surgical treatment is recommended in cases complicated by ischemia or perforation of the colon or refractory to pharmacological and endoscopic therapies.

Reading suggestion: also check out the American Guidelines for better postoperative recovery (ERAS)

How to cite this article

Camargo MGM., Treatment of Colon Volvulus and Acute Pseudo-Obstruction of the Colon (Ogilvie’s Syndrome). Gastropedia, 2022. Available at: https://gastropedia.com.br/cirurgia/colorretal/tratamento-do-volvo-de-colon-e-da-pseudo-obstrucao-aguda-do-colon-sindrome-de-ogilvie/

References:

1. Alavi K, Poylin V, Davids JS, Patel SV, Felder S, Valente MA, Paquette IM, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021 Sep 1;64(9):1046-1057. doi: 10.1097/DCR.0000000000002159. PMID: 34016826.
2. Yeo HL, Lee SW. Colorectal emergencies: review and controversies in the management of large bowel obstruction. J Gastrointest Surg. 2013;17:2007–2012.
3. Bauman ZM, Evans CH. Volvulus. Surg Clin North Am. 2018;98:973–993.
4. Quénéhervé L, Dagouat C, Le Rhun M, et al. Outcomes of first-line endoscopic management for patients with sigmoid volvulus. Dig Liver Dis. 2019;51:386–390.

Introduction

The incidence of neuroendocrine tumors of the pancreas is increasing, possibly due to more frequent imaging tests and the quality of these tests. However, their prevalence is fortunately still rare. This post from Therapeutic Endoscopy is intended to serve as a reference guide when we eventually come across one of these situations in our daily lives. If you want to know about duodenal neuroendocrine tumors check out this other article.

Important general concepts about neuroendocrine tumors of the gastrointestinal tract

The NETs correspond to a heterogeneous group of neoplasms that originate from neuroendocrine cells (enterochromaffin-like cells), with secretory characteristics.

All gastroenteropancreatic (GEP) NETs are potentially malignant and behavior and prognosis are correlated with histological types.

The NETs can be sporadic (90%) or associated with hereditary syndromes (10%), such as multiple endocrine neoplasia type 1 (MEN-1), SD von Hippel-Lindau, neurofibromatosis and tuberous sclerosis.

The NETs are mostly indolent, but can determine symptoms. Thus, they can be divided into functioning and non-functioning:

• Functioning: secretion of active hormones or neurotransmitters: serotonin, glucagon, insulin, somatostatin, gastrin, histamine, VIP or catecholamines. They can cause a variety of symptoms
• Non-functioning: they may not secrete any peptide/hormones or secrete non-active peptides or neurotransmitters, so as not to cause clinical manifestations.

Pancreatic neuroendocrine tumors (TNE-P)

The functioning TNEs of the pancreas are: insulinoma, gastrinoma, glucagonoma, vipoma and somatostatinoma.

Most TNE-Ps are malignant, except for insulinomas and TNE-NFs smaller than 2 cm.

Surgery is the only curative modality for sporadic TNE-P, and resection of the primary tumor in patients with localized, regional and even metastatic disease, can improve patient survival.

In general, functioning TNEs of the pancreas should be resected to control symptoms whenever possible. TNE-NF depends on size (see below).

Multiple pancreatic tumors are rare and should raise suspicion of MEN1.

NEXT WE WILL SEE THE MAIN CHARACTERISTICS OF EACH HISTOLOGICAL SUBTYPE

INSULINOMAS

• It is the most frequent TNE of the pancreatic islets.
• 90% are benign, but they are symptomatic even when small.
• About 10% are associated with MEN.
• They are hypervascularized and solitary lesions, often < 2 cm.
• Whipple’s triad:
  • hypoglycemia (< 50)
  • neuroglycopenic symptoms (blurred vision, weakness, fatigue, headache, drowsiness)
  • disappearance of symptoms with glucose replacement
• serum insulin > 6 IU/ml
• C-peptide > 0.2 mmol/l
• Pro-insulin > 5 IU/ml
• Positive prolonged fasting test (99% of cases)
• Learn more about insulinoma in this other article

GASTRINOMAS

• It is more common in the duodenum, but 30% of cases are in the pancreas
• They are the most frequent TNEs of the pancreas after insulinomas.
• They are associated with MEN 1 syndrome in 30%, and in these cases they present as small and multifocal lesions.
• They cause hypergastrinemia and Zollinger-Ellison syndrome.
• 60% are malignant.
• Treatment: surgical in sporadic cases (DPT).
• In MEN 1, there is controversy in the surgical indication, since gastrinemia may not be controlled even with DPT (tumors are usually multiple)

GLUCAGONOMAS

• Rare; most are sporadic.
• They are usually large and solitary, with a size between 3-7 cm occurring mainly in the tail of the pancreas.
• Symptoms: migratory necrolytic erythema (80%), DM, malnutrition, weight loss, thrombophlebitis, glossitis, angular cheilitis, anemia
• Slow growth and long survival
• Lymph node or hepatic metastasis occurs in 60-75% of cases.

VIPOMAS

• Extremely rare
• Like glucagonomas, located in the tail, large and solitary.
• Most are malignant and metastatic
• In 10% of cases it can be extra-pancreatic.
• Clinical picture related to VIP secretion (vasoactive intestinal peptide):
  • diarrhea (more than 3L liters per day) – rice washing water
  • Hydro-electrolyte disorders: hypokalemia, hypochloridria, metabolic acidosis
  • Blushing
• Excellent response to treatment with somatostatin analogues.

SOMATOSTATINOMAS

• It is the least common of all
• Somatostatin leads to inhibition of endocrine and exocrine secretion and affects intestinal motility.
• Solitary lesion, large, sporadic, mostly malignant and metastatic
• Clinical picture:
  • Diabetes (75%)
  • Gallstones (60%)
  • Steatorrhea (60%)
  • Weight loss

NON-FUNCTIONING PANCREATIC TNE

• 20% of all pancreatic TNEs.
• 50% are malignant.
• The main differential diagnosis is with adenocarcinoma

Well-differentiated TNE-NF smaller than 2 cm: two societies (ENETS and NCCN) suggest observation if it is well differentiated. However, the North American society NETS recommends observation in tumors smaller than 1 cm and individualized conduct, between 1-2 cm.

PANCREATIC TNE RELATED TO HEREDITARY SYNDROMES

• 10% of TNE-Ps are related to MEN-1
• Often multicentric,
• Usually affecting younger people.
• Usually of benign behavior, but they present malignant potential
• Gastrinoma 30-40%; Insulinoma 10%; TNE-NF 20-50%; others 2%
• Surgical treatment is controversial, because sometimes it does not control gastrinemia (multiple tumors)

The multiple endocrine neoplasia (MEN) syndromes comprise 3 genetically distinct familial diseases involving adenomatous hyperplasia and malignant tumors in several endocrine glands. They are autosomal dominant diseases.

MEN-1

• Autosomal dominant disease
• Predisposes to TU (3Ps): Parathyroid; Pituitary (pituitary); Pancreas,
• Usually of benign behavior, but they present malignant potential
• Gastrinoma 30-40%; Insulinoma 10%; TNE-NF 20-50%; others 2%
• Surgical treatment is controversial, because sometimes it does not control gastrinemia (multiple tumors)

MEN-2A:

• Medullary thyroid carcinoma,
• Pheochromocytoma,
• Hyperplasia or adenomas of the parathyroid glands (with consequent hyperparathyroidism).

MEN-2B:

• Medullary thyroid carcinoma,
• Pheochromocytoma
• Multiple mucous and intestinal neuromas

References:

1. Pathology, classification, and grading of neuroendocrine neoplasms arising in the digestive system – UpToDate ; 2021
2. Guidelines for the management of neuroendocrine tumours by the Brazilian gastrointestinal tumour group. ecancer 2017,11:716 DOI: 10.3332/ecancer.2017.716

How to cite this article:

Martins BC, de Moura DTH. Pancreatic neuroendocrine tumors. Gasstropedia. 2022; vol I. Available at: gastropedia.com.br/surgery/pancreatic-neuroendocrine-tumors