Patients with reflux esophagitis and H. pylori infection who are treated with omeprazole are at increased risk of atrophic gastritis.

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Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

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Esophageal perforations are surgical emergencies with high mortality rates. A variety of treatment strategies have been advocated. No single strategy has however, been fully applicable to deal with most situations. The aim of this study was to investigate if treatment with covered expandable metallic stents could offer a feasible option for the management of a leaking esophagus regardless of cause. Twenty-two consecutive patients with perforation or leakage from the intrathoracic esophagus were endoscopically treated with placement of a covered expandable metallic stent. Nine patients had esophageal cancer and 13 had benign underlying disease of whom two had a leakage from a surgical anastomosis. The leakage could be sealed in all but one patient. This patient died after an open esophageal diversion procedure. Twelve patients had an uneventful recovery, whereas three patients needed percutaneous drainage of abscesses and one drainage of the pleural cavity through a small thoracotomy. One patient required a conventional thoracotomy to drain the mediastinum. In total five (23%) patients died from the perforation within 30 days. Two of the deaths were unrelated and three (14%) related to the perforation. In patients with benign disease stents were removed or replaced after 3 weeks. In total 17 stents were successfully removed. Leakage from a damage esophagus can be effectively covered by expandable metallic stents seemingly regardless of the underlying cause and is likely to offer a good chance of survival even in severely ill patients.

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.

To elucidate mechanisms involved in weight development after gastrectomy we have prospectively determined changes in body composition during the first year after similar operations. A total of 75 patients were enrolled who had a "curative operation" for gastric carcinoma; 42 were randomized to have a total gastrectomy, 23 total gastrectomy with a gastric substitute, and 10 subtotal gastrectomy. All reconstructions were done with a Roux-en-Y loop of the jejunum. Body composition was assessed preoperatively and at 6 and 12 months after gastrectomy by determining total body potassium and total body water. From these estimates, body cell mass, extracellular water, fat-free extracellular solids, and body fat were calculated with knowledge of the actual body weight and length. Triceps skinfold, arm muscle circumference, and grip strength were also measured. Weight loss (10% of preoperative weight) occurred early after the operations, after which body weight stabilized. Body cell mass remained essentially unchanged over the entire study period in contrast to body fat, which decreased by 40% during the first 6 months after gastrectomy. In accordance with the selective loss of body fat, we recorded a significant decrease in triceps skinfold figures and only a minor decrease of arm muscle circumference without obvious deterioration in hand grip strength. Weight loss after gastrectomy seems to be characterized by selective loss of body fat in contrast to other known clinical situations associated with impaired nutritional intake. Our observations form a basis for future clinical research aimed at preventing weight loss after these operations.