Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis

AIM: To evaluate whether antecolic reconstruction for duodenojejunostomy (DJ) can decrease delayed gastric emptying (DGE) rate after pylorus-preserving pancreaticoduodenectomy (PPPD) through literature review and meta-analysis.METHODS: Articles published between January 1991 and April 2012 comparing antecolic and retrocolic reconstruction for DJ after PPPD were retrieved from the databases of MEDLINE (PubMed), EMBASE, OVID and Cochrane Library Central. The primary outcome of interest was DGE. Either fixed effects model or random effects model was used to assess the pooled effect based on the heterogeneity.RESULTS: Five articles were identified for inclusion: two randomized controlled trials and three non-randomized controlled trials. The meta-analysis revealed that antecolic reconstruction for DJ after PPPD was associated with a statistically significant decrease in the incidence of DGE [odds ratio (OR), 0.06; 95% CI, 0.02-0.17; P < 0.00 001] and intra-operative blood loss [mean difference (MD), -317.68; 95% CI, -416.67 to -218.70; P < 0.00 001]. There was no significant difference between the groups of antecolic and retrocolic reconstruction in operative time (MD, 25.23; 95% CI, -14.37 to 64.83; P = 0.21), postoperative mortality, overall morbidity (OR, 0.54; 95% CI, 0.20-1.46; P = 0.22) and length of postoperative hospital stay (MD, -9.08; 95% CI, -21.28 to 3.11; P = 0.14).CONCLUSION: Antecolic reconstruction for DJ can decrease the DGE rate after PPPD.     

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy？ Prevention and management

INTRODUCTION Pylorus-preserving pancreaticoduodenectomy (PPPD) was first reported by Watson in 1944[1] and reintroduced by Traverso and Longmire in 1978[2]. For the sake of functional preservation of the stomach and improvement of life quality, it has bee…     

Determinants of symptom pattern in idiopathic severely delayed gastric emptying: gastric emptying rate or proximal stomach dysfunction?

BACKGROUND: Idiopathic gastroparesis is a syndrome characterised by severely delayed gastric emptying of solids without an obvious underlying organic cause. Although delayed gastric emptying is traditionally considered the mechanism underlying the symptoms in these patients, poor correlations with symptom severity have been reported. AIMS: To investigate proximal stomach function and to study the correlation of delayed gastric emptying and proximal stomach dysfunction with symptom pattern and severity in idiopathic gastroparesis. METHODS: 58 consecutive patients (19 men, mean (standard deviation) age 41 (2) years) with severely delayed solid gastric emptying (gastric half-emptying time (t(1/2))>109 min) without an organic cause were recruited. They filled out a symptom-severity questionnaire and underwent a gastric barostat study for assessment of gastric sensitivity and accommodation. Correlation of these mechanisms with symptom pattern and overall symptom severity (sum of individual symptoms) was analysed. RESULTS: At two different cut-off levels for gastric emptying (upper limit of normal t(1/2) up to 1.5 and 2 times), no significant change in symptom pattern occurred. 25 (43%) patients had impaired accommodation, and this was associated with higher prevalence of early satiety (p<0.005) and weight loss (p = 0.009). 17 (29%) patients had hypersensitivity to gastric distension, and this was associated with higher prevalences of epigastric pain (p = 0.005), early satiety (p = 0.04) and weight loss (p<0.005). Overall symptom severity was not correlated with gastric emptying or accommodation, but only with sensitivity to gastric distension (R = -0.3898, p = 0.003) and body weight (R = -0.4233, p = 0.001). CONCLUSIONS: In patients with idiopathic gastroparesis, the symptom pattern is determined by proximal stomach dysfunction rather than by the severity of delayed emptying.     

Does delayed gastric emptying shorten the H pylori eradication period？ A double blind clinical trial

INTRODUCTION H pylori has been implicated as a predisposing factor in gastric cancer, chronic active gastritis, duodenal ulcer, gastric ulcer and gastric lymphoma[1]. The incidence rate of stomach cancer in Iran is high, well above the world average; it i…     

Can symptoms discriminate among those with delayed or normal gastric emptying in dysmotility-like dyspepsia?

OBJECTIVE: Different subgroups can be identified in functional dyspepsia based on symptom type or severity, and may correlate with pathophysiological disturbances. In particular, female sex and severe fullness and vomiting have been reported to be strong independent predictors of slow solid gastric emptying. We aimed to determine if symptom patterns or severity could identify those with abnormal gastric emptying among patients with dysmotility-like functional dyspepsia and, for comparison, type I diabetes mellitus. METHODS: Patients with postprandial symptoms and documented functional dyspepsia by endoscopy (n = 551) and patients with type I diabetes who had postprandial dyspepsia (n = 247) enrolling in two separate randomized controlled trials were evaluated at baseline. Patients were assigned to either the delayed or normal gastric emptying strata, based on a validated C13 octanoic acid breath test with sampling over 4 h. A self-report questionnaire measured the presence and severity of eight symptoms on visual analog scales. The validated Nepean Dyspepsia Index measured the frequency, severity, and bothersomeness of 15 upper GI symptoms on Likert scales. RESULTS: Gastric emptying was definitely delayed (t1/2 > 192 min) in 24% of patients with functional dyspepsia and 28% with diabetes. Delayed gastric emptying was associated with female gender but not age or Helicobacter pylori status. The age- and sex-adjusted risk (odds ratio) of delayed gastric emptying for the upper GI symptoms ranged from 0.99 to 1.0 (all p values > or =0.2). The results were very similar in functional dyspepsia and diabetes. There was also no correlation between t1/2 and number of symptoms or symptom severity scores. CONCLUSIONS: Symptom prevalence and severity were similar in dyspeptic patients with and without delayed gastric emptying. Specific symptoms do not seem to be of predictive value in dysmotility-like dyspepsia for identifying alterations of gastric emptying.     

Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose?

STUDY OBJECTIVE: Because the ability of gastrointestinal decontamination to alter drug absorption varies inversely with time, we compared the time from arrival in the emergency department to gastrointestinal decontamination (gastric lavage or activated charcoal) for patients transported by ambulance with patients transported by other means after overdose. METHODS: A retrospective chart review was conducted in an academic university ED with an annual volume of 56,000 visits. Consecutive cases of oral overdose treated by gastrointestinal decontamination between December 1, 1995, and May 31, 1996, were identified from International Classification of Diseases, ninth revision, billing codes. ED charts were reviewed to determine the patient's age, sex, mode of transportation, disposition, and time interval to gastrointestinal decontamination with either gastric lavage or activated charcoal. RESULTS: Two hundred eighty-one patient visits were identified. Complete data were available for 173 visits. Six patients were excluded because the diagnosis of overdose was not made on presentation, leaving 167 cases for analysis. The median age for all patients was 27 years; 95 (57%) were female. Overdose patients were transported by ambulance in 105 (67%) cases. Admission rates were similar for patients transported by ambulance and those who arrived by other means. The median interval from arrival to any gastrointestinal decontamination (lavage or charcoal) for patients transported by ambulance was shorter than patients who arrived by other means at 55 and 73 minutes, respectively (95% confidence interval for difference 2.5 to 30.5 minutes, P =.03). Subgroup analysis showed this difference was largely the result of gastric lavage. CONCLUSION: Overdose patients transported by ambulance have a shorter time interval from ED arrival to gastrointestinal decontamination than patients arriving by other means. This difference was largely related to more rapid gastric lavage.     

β-Endorphins are not responsible for delayed gastric emptying of digestible solids after exercise in professional cyclists. A preliminary study

ObjectiveIt has been reported that professional cyclists had an accelerated solid gastric emptying which decreased by increasing the exercise intensity. That could be explained by a predominance of stress-dependent motility inhibitors such gastrointestinal hormones, neurotransmitters and or the predominance of the gastric inhibitory vagal motor circuit. The aim of this preliminary study was to evaluate the role of β-endorphins, inhibitors of gastric motility, in these findings.MethodsGastric emptying of solids marked with Tc⁹⁹ while resting and plasmatic levels of β-endorphins were evaluated in 27 healthy controls and 19 professional cyclists (day 1). Besides, gastric emptying of solids was also assessed in cyclists when they reached 50% (day 1) and 75% (day 2) of the maximum oxygen consumption (low and high, respectively), during exercise on the cycle-ergometer. The third day, naloxone was administered in cyclists in order to block the β-endorphins receptors and gastric emptying was measured when they reached 75% of the maximum oxygen consumption.ResultsBasal β-endorphin levels were lower in cyclists vs controls (p < 0.05) and they increased with the exercise intensity (p < 0.001). There were no significant differences in gastric emptying of solids with or without naloxone when 75% of the maximum oxygen consumption was reached.ConclusionsThe inhibitory effect of the exercise in the gastric emptying of solids does not seem to be secondary to the action of β-endorphins, that leaves the gastric inhibitory vagal motor circuit a more likely predominant role.     

Does extended lymphadenectomy influence prognosis of gastric carcinoma after curative resection?

BACKGROUND/AIMS: It is unclear whether gastric cancer prognosis is improved by extended lymph node dissection more than by lymph node dissection limited to the contiguous N1 perigastric lymph nodes. METHODOLOGY: Four hundred and thirty-eight patients treated by curative gastrectomy were evaluated. Outcomes of D1/D1.5 lymphadenectomy, limited lymph node dissection and of D2/D2.5 lymphadenectomy, extended lymph node dissection and histopathological prognostic factors as in the 1993 TNM staging classification supplement were analyzed. RESULTS: Estimated overall 5-year survival was 54.9%. Five-year survival was 58.4% in the limited lymph node dissection group and 54% in the extended lymph node dissection (P n.s.). Stage I 5-year survival was 59% after D2.5 lymph node dissection, 58% after D1.5 and 50% after D2 dissection (P n.s.). Stage II 5-year survival was 86% in D2.5 group and 56% in D1.5 group (P = 0.041). Stage IIIa survival was 61% in the D2.5 group and 22% in the D1.5 group (P = 0.001). Stage IIIb 5-year survival was 42% after D2.5 resection and 0% in D1.5 group (P = 0.001). In the pT3 group 5-year survival was 72% after D2.5 dissection and 33% after D2 dissection (P = 0.001). In the positive N1 lymph nodes group 5-year survival was better after extended lymph node dissection than after limited lymph node dissection. In pN2a patients 5-year survival was 57% after D2.5 resection and 0% after D2 resection (P < 0.001). In pN2b and pN2c patients extended lymph node dissection did not statistically improve survival. CONCLUSIONS: Even if no statistical differences were found in overall survival, prognosis was improved by extended lymph node dissection in stage II and III, particularly in T2 and T3 subgroups and in N1 and N2a subgroups. When large numbers of positive nodes were found, improved survival was dependent upon resection of extragastric nodes distal to the uppermost echelon of positive nodes.     

Effects of gastric pacing on gastric emptying and plasma motilin

AIM:To investigate the effects of gastric pacing on gastricemptying and plasma motilin level in a canine model of gastricmotility disorders and the correlation between gastricemptying and plasma motilin level.METHODS:Ten healthy Mongrel dogs were divided into:experimental group of six dogs and control group of fourdogs.A model of gastric motility disorders was establishedin the experimental group undergone truncal vagotomycombined with injection of glucagon.Gastric half-emptyingtime (GEt_(1/2)) was monitored with single photon emissioncomputerized tomography (SPECT),and the half-solid testmeal was labeled with an isotope-~(99m)mTc sulfur colloid.Plasmamotilin concentration was measured with radioimmunoassay(RIA) kit.Surface gastric pacing at 1.1-1.2 times the intrinsicslow-wave frequency and a superimposed series of highfrequency pulses (10-30 Hz) was performed for 45 rnin dailyfor a month in conscious dogs.RESULTS:After surgery,GEt_(1/2) in dogs undergone truncalvagotomy was increased significantly from 56.35±2.99 minto 79.42±1.91 rain (P<0.001),but surface gastric pacingmarkedly accelerated gastric emptying and significantlydecreased GEt_(1/2) to 64.94 1.75 min (P<0.001) in animalsundergone vagotomy.There was a significant increase ofplasma level of motilin at the phase of IMCⅢ(interdigestivemyoelectrical complex,IMCⅢ) in the dogs undergone bilateraltruncal vagotomy (baseline vsvagotomy,184.29±9.81 pg/mlvs 242.09±17.22 pg/ml;P<0.01).But plasma motilinconcentration (212.55±11.20 pg/ml;P<0.02) was decreasedsignificantly after a long-term treatment with gastric pacing.Before gastric pacing,GEt_(1/2) and plasma motilin concentrationof the dogs undergone vagotomy showed a positivecorrelation (r=0.867,P<0.01),but after a long-term gastricpacing,GEt_(1/2) and motilin level showed a negative correlation(r=-0.733,P<0.04).CONCLUSION:Surface gastric pacing with optimal pacingparameters can improve gastric emptying parameters andsignificantly accelerate gastric emptying and can resumeor alter motor function in a canine model of motilitydisorders.Gastric emptying is correlated well with plasmamotilin level before and after pacing,which suggests that motilin can modulate the mechanism of gastric pacing byaltering gastric motility.     

Are there changes in gastric emptying during the menstrual cycle?

BACKGROUND: The questions of whether gastric emptying of solids and liquids differs in men and women and whether emptying is influenced by the action of sex hormones on gastric smooth muscle remain unresolved. METHODS: We analysed the gastric emptying of digestible solids (GES), liquids (GEL), and radiopaque indigestible solids (GER) in three groups of healthy volunteers: 50 women in the follicular phase of the menstrual cycle, 50 women in the luteal phase, and 100 men. [99mTc]-labelled diethylenetriamine pentaacetic acid (DTPA) was used as the radioactive marker for digestible solids, and [111In]DTPA was used as the marker for liquids, to time gastric motility after a solid and a liquid meal. GER was evaluated on a different day in abdominal roentgenograms. RESULTS: GES and GEL were slower in women than in men (P < 0.05), but GER was similar in the two sexes. However, there were no significant differences in GES, GEL, or GER between women in the follicular and those in the luteal phase, between plasma concentrations of oestradiol and progesterone and the variables used to characterize gastric emptying. CONCLUSIONS: Evidence of postprandial 'physiologic gastroparesis' was found in women, although no differences were found between men and women in gastric motility during fasting. The rate of emptying was not related to changes in plasma concentrations of sex hormones during the menstrual cycle.     

Thallium reinjection after stress-redistribution imaging. Does 24-hour delayed imaging after reinjection enhance detection of viable myocardium?

BACKGROUND. Thallium reinjection immediately after conventional stress-redistribution imaging improves the detection of viable myocardium, as many myocardial regions with apparently "irreversible" thallium defects on standard 3-4-hour redistribution images manifest enhanced thallium uptake after reinjection. Because the 10-minute period between reinjection and imaging may be too short, the present study was designed to determine whether 24-hour imaging after thallium reinjection provides additional information regarding myocardial viability beyond that obtained by imaging shortly after reinjection. METHODS AND RESULTS. We studied 50 patients with chronic stable coronary artery disease undergoing exercise thallium tomography, radionuclide angiography, and coronary arteriography. Immediately after the 3-4-hour redistribution images were obtained, 1 mCi thallium was injected at rest, and images were reacquired at 10 minutes and 24 hours after reinjection. The stress, redistribution, reinjection, and 24-hour images were then analyzed qualitatively and quantitatively. Of the 127 abnormal myocardial regions on the stress images, 55 had persistent defects on redistribution images by qualitative analysis, of which 25 (45%) demonstrated improved thallium uptake after reinjection. At the 24-hour study, 23 of the 25 regions (92%) with previously improved thallium uptake by reinjection showed no further improvement. Similarly, of the 30 regions determined to have irreversible defects after reinjection, 29 (97%) remained irreversible on 24-hour images. These findings were confirmed by the quantitative analysis. The mean normalized thallium activity in regions with enhanced thallium activity after reinjection increased from 57 +/- 13% on redistribution studies to 70 +/- 14% after reinjection but did not change at 24 hours (71 +/- 14%). In regions with irreversible defects that were unaltered by reinjection, mean regional thallium activity did not differ from the reinjection to the 24-hour studies (57 +/- 17% and 58 +/- 17%, respectively). Twenty-four-hour imaging after reinjection showed improvement in only four of 35 irreversible regions (involving three of the 50 patients). CONCLUSIONS. These data indicate that thallium reinjection at rest after 3-4 hours of redistribution provides most of the clinically relevant information pertaining to myocardial viability in regions with apparently irreversible thallium defects. Hence, thallium reinjection may be used instead of 24-hour imaging in most patients in whom a persistent thallium defect is observed on conventional redistribution images.