63 yr old female with the history of severe weight loss (40kg – weight now 71kg) and vomiting of food directly after meals for 8 months. The symtoms have been getting worse the 2 weeks prior to admission.
Laboratory and diagnostic studies
Gastroscopy was difficult, but a normal oesophagus was seen. In the stomach was food, and it was difficult to distend with air. A large ulcer was seen,but localisation of its position was difficult. Barium meal revealed a large paraesophageal hernia with organo-axial volvulus. Obstruction was noted just distal to the EG junction as well as distal to the pilorus.
At surgery the whole stomach was basically in the chest, but it reduced relatively easily.Gastrotomy was done to inspect the ulcer , and a large duodenal ulcer (3x3cm) was seen. The stomach did not have a ulcer. We did a gastro-enterostomy and vagotomy as we were afraid of having problems ( anastomosis, leakage, stenosis) with the duodenum if we did a gastrectomy. The hernia was closed without a anti-reflux procedure.
The questions I would like to ask:
1.Would you have added an anti-reflux procedure ?
2.Your opinion about the vagotomy & gasto-enterostomy.
3.When you eradicate H.pylori in this patient, will you add a proton-pump inhibitor to the antibiotics if you already did a vagotomy?