Postoperative reorganization of gastric pacemaker activity in patients after an extended period following distal gastrectomy

We recorded and analyzed electrogastrograms (EGGs) from 12 patients following distal gastrectomy. The EGGs were recorded from between 3 and 262 months post-operatively. Gastric electrical activity, which showed a distinct repeating pattern with a frequency of 3 cycles per minute (cpm), was easily recognizable in subjects who were recorded 16-20 years postoperatively, but was not clearly evident in EGG running spectra of subjects with a shorter postoperative period. Although the postprandial instability factor of the 3-cpm components (standard deviation of mean spectral frequency of peak 3-cpm group/mean of the 3-cpm spectral frequency) of the epigastric and supraumbilical EGGs showed a significant negative linear correlation with postoperative months, no such correlation was seen in the postprandial to fasting power ratio (postprandial power / fasting power) of the 3-cpm activity component. Therefore, we hypothesized that the disorganized pacemaker activity of the remnant stomach following distal gastrectomy can be reorganized to work as a synchronized unit over a long postoperative recovery period of from 15 to 20 years. A greater degree of epigastric and supraumbilical fasting 6-cpm power seemed to result in a worse quality of life (QOL). Similarly, a larger ratio of the supraumbilical postprandial to fasting power ratio of the 6-cpm activity seemed to result in a worse QOL. In contrast a larger ratio of the infaraumbilical postprandial to fasting power content of the 6-cpm activity seemed to result in a better QOL.     

Electrogastrography: Current Issues in Validation and Methodology

In this review we present some current applications of electrogastrography, relationships between the electrogastrogram (EGG) and electrical and contractile activity of the stomach, EGG recording technique, and the current status of electrogastrography. The authors conclude the following: (1) The 3 cpm frequency of the EGG reflects the frequency of pacesetter potentials occurring at the serosal and mucosal surfaces of the stomach. (2) An increase in the contractile activity of the corpnsantrum is associated with an increase in the amplitude of the 3 cpm EGG signal. (3) Tachygastria (5–9 cpm waves) recorded with the EGG reflects identical frequencies recorded with mucosal electrodes from the gastric antrum. (4) Low frequency components (approximately 1 cpm) appear in the EGG signal but their physiological significance is unknown at this time.     

Motor and electrogastrographic activity of the gastric tube formed after esophagectomy.

In order to characterize the motor activity of a surgically constructed gastric tube, several hours of ambulatory intraluminal pressure recordings were performed in 6 patients following esophagectomy and gastric tube construction. Whole pressure waves were spectrally analyzed by Fast Fourier Transform (FFT). Simultaneous abdominal and thoracic electrogastrograms (EGGs) were recorded for about 20 min both before and after meals during ambulatory pressure recording. The pressure waves and EGGs for each 20 min recording were analyzed by the maximal entropy method (MEM). While the motility index of the pressure waves decreased after a meal, the 3 cpm component of these waves (2.4-3.7 cpm) increased significantly (n=6, P<0.05). Both bradygastria (0-2.4 cpm) and the duodeno-respiratory component (10-15 cpm) decreased, while the tachygastria component (3.7-10 cpm) increased, although these differences were not significant. The peak power of the gastric tube abdominal EGGs was significantly larger than that of control abdominal or thoracic EGGs in each of the 1 cpm (0-2.4 cpm), 6 cpm (5.0-7.4) and 8 cpm components (7.5-9.9). The thoracic EGG consisted mainly of the 3 cpm component, while the spectral amplitudes of the 1, 6, 8 and 10 cpm components were below 6% of the 3 cpm component. The peak spectral frequency both of the intraluminal pressure waves by FFT and of the thoracic EGGs by MEM occurred within the 3 cpm component. A cross correlation of about 0.2-0.3 occurred between the thoracic EGGs and the intraluminal pressure waves. Thus the gastric tube seems to preserve most of the original gastric motor characteristics and to contribute as a substitute for the original esophagus and stomach.     

胃大部切除术后残胃功能性排空障碍10例临床分析

目的:探讨胃大部切除术后残胃功能性排空障碍发生原因,诊断及治疗。方法:对1996年至2008年收治的108例胃大部切除术患者的临床资料进行回顾性分析。结果:本组共发生功能性胃排空障碍10例,发生9.2%,均发生于术后3～12天。所有患者均经保守治疗出院,均于35天内治愈。结论:术后残胃和远端空肠正常的运动功能破坏是发生功能性胃排空障碍的主要原因,上消化道造影及胃镜检查是诊断本病、鉴别机械性梗阻的重要方法。采取非手术治疗一般均可治愈,针对胃排空动力学机制的改变采用促胃肠动力药可能收到较好的疗效。     

Spectral analysis of colonic intraluminal pressure in patients who received a colonic replacement following radical esophagectomy.

The aim of this study was to evaluate the motor activity of the interposed colonic segment in patients who had received a colonic replacement following radical esophagectomy using spectral analysis and a 24 hr activity graph. The 24-hr ambulatory pressure waves were recorded in the replaced colon after esophagectomy (n=8) using a solid-state manometric catheter (MicroDigitrapper, Synetics). Motility and spectral analyses of the intraluminal pressure waves were performed by Multigram and Gastrosoft (Synetics). It was revealed that after a meal the 3 cpm (cycles per minute) component of the motility index increased but the 12-15 cpm component decreased. The diurnal rhythm showed that colonic motility was high in the daytime and low during sleep. In contrast, duodenal motility was relatively high even during sleep. The motility index increased as the postoperative period increased. The motility of the replaced colon was higher during the daytime and after meals. The higher motility after meals was characterized by an increase in the 3 cpm component. These motor characteristics may help the function of the replaced colon as a substitute for the esophagus.     

Correlations between the responses of electrogastrograms, heart rate and respiratory rate to the stress of the mirror drawing test in human subjects.

An electrogastrogram (EGG) recorded on the skin is believed to reflect the electrical activity of the gastrointestinal tract. In this study, linear correlations were calculated for the EGG spectral frequencies and the power ratios, changes in heart and respiratory rate before and during mirror drawing test (MDT) stress and after having meals, with the changes in the sympathetic tone indicator (LF/HF) and HADS anxiety and depression scores in human subjects (n=48). Depression scores had a negative linear correlation with the EGG resting frequencies of the epigastric and supraumbilical 6 cpm groups (5.0-7.4 cpm). Anxiety scores had a positive linear correlation with the EGG area power ratio of the resting to MDT stress responses of the epigastric and infraumbilical 6 cpm groups (6 cpm area during MDT/that during fasting rest). The resting LF/HF had a positive linear correlation with the EGG area power ratio of the resting to MDT stress responses of the epigastric and infraumbilical 3 cpm groups (2.5-4.9 cpm). The resting LF/HF ratio had a negative correlation with the area power ratio of the resting to postprandial responses (postprandial power/resting power) in the epigatric, supraumbilical and infraumbilical 6 cpm groups. The resting LF/HF ratio had a positive linear correlation with the heart rate at rest and during MDT-stress. In contrast, the resting LF/HF ratio had a negative linear correlation with the respiratory rate at rest and during MDT-stress. EGGs of the surface electrical activities of the gastrointestinal tract were influenced by acute MDT-stress and their frequencies and their response power ratios were correlated linearly with anxiety scores, depression scores and the sympathetic tone indicator, the LF/HF ratio.     

Esophagoduodenostomy: a neglected reconstructive procedure after total gastrectomy

Three types of esophago-enteric reconstruction are currently employed following total gastrectomy: end-to-end anastomosis, esophagus to duodenum; Roux-en-Y esophagojejunostomy; and interposition of jejunal or colonic segment between the esophagues and duodenum. For reasons not entirely clear, esophagoduodenostomy enjoys less popularity than the two alternative methods. A study of cases reviewed at the Jewish Hospital reveals equality of results in terms of mortality and morbidity. The procedure was found to have definite advantages over the others. Esophagoduodenostomy is recommended as the procedure of choice following total gastrectomy.     

Indirect evidence for increased mechanosensitivity of jejunal secretomotor neurones in patients with idiopathic bile acid malabsorption

Aim: The interdigestive motor rhythm, the migrating motor complex (MMC), is accompanied by active secretion of chloride during periods of distally propagating maximal motor activity (MMC phase III). We studied the behaviour of this system in bile acid malabsorption (BAM), a relative common cause of chronic diarrhoea. We measured motor activity and transmucosal potential difference (PD, reflecting active chloride secretion), in the proximal jejunum in healthy controls (n = 18) and in a group of patients with BAM (n = 11). The phase III‐generated voltage was related to the degree of BAM quantified by the ⁷⁵SeHCAT test. Methods: We used a multi‐channel intestinal infusion system to simultaneously measure jejunal pressure and PD. Saline passing calomel half‐cells was infused into the jejunum and subcutaneously. Pressure and PD were recorded in the fasting state and after a test meal. Results: In the absence of motor activity, jejunal PD was not significantly different from zero in either group. During MMC phase III, PD reached significantly higher mean and peak levels in BAM patients. The product of MMC phase III length multiplied by voltage, over 3 h, was also significantly higher in BAM patients (controls: median 307 mV × cm, range 70–398; BAM: median 511, range 274–2271, P < 0.01). This value was also significantly correlated with the degree of BAM as reflected by the ⁷⁵SeHCAT test (P < 0.05). Conclusion: Phase III induced jejunal secretion may be upregulated in BAM patients, resulting in overload of colonic reabsorption capacity.     

The effects of stress in response to mirror drawing test trials on the electrogastrogram, heart rate and respiratory rate of human subjects.

Electrogastrograms (EGGs), heart and respiratory rates were recorded simultaneously from human subjects and analyzed spectrally by the maximal entropy method. The stress of the mirror drawing test (MDT) significantly increased both the heart and respiratory rates with an associated increase in LF/HF ratios. MDT stress, however, increased (excited groups) or decreased (inhibited groups) the power amplitude and the power ratio, (peak power during MDT)/(peak power during rest), of the 1-cpm (0-2.4 cpm), 3-cpm (2.5-4.9), 6-cpm (5.0-7.4), 8-cpm (7.5-9.9) and 10-cpm (10.0-12.9) spectral group components of the EGG recording of the electrical activity of the gastrointestinal tract. The depression scores of the subjects in the MDT stress excited group were higher and their resting frequencies were significantly lower than those of the MDT stress inhibited groups in each of the epigastric, supra-umbilical and infra-umbilical 6-cpm frequency groups but not in the epigastric 1-cpm frequency group. Anxiety scores of the MDT stress excited groups were significantly higher and their power ratios were also significantly higher than those of the inhibited groups in each of the epigastric 10-cpm, the supra-umbilical 6-cpm and the infra-umbilical 1- and 3-cpm frequency groups. Therefore, depression scores appeared to have inhibitory effects on the resting EGG frequencies, while anxiety scores appeared to have facilitatory effects on the EGG power ratio during MDT stress. It is suggested that analysis of EGG under MDT stress would provide a measure of the stress sensitivity of the electrical activity of the human gastrointestinal tract.     

胃癌全胃切除后不同消化道重建术式对消化吸收功能的影响

目的探讨全胃切除术不同消化道重建方式对胃癌患者术后消化吸收功能的影响。方法 2012年1月至2013年1月我院收治114例胃癌患者,按手术方法的不同分为观察组和对照组,对照组58例行空肠食管Roux-en-y吻合术,观察组56例行"P"形空肠袢空肠食管Roux-en-Y吻合术,对2组患者并发症及术后营养状况进行比较。结果观察组RBC、HGB、TP、ALB水平明显高于对照组(P0.05),2组患者术中并发症、术后腹泻及反流性食管炎的发生率比较无明显差异(P0.05),但观察组患者术后倾倒综合征及腹胀的发生率明显低于对照组(P0.05)。结论 "P"形空肠袢空肠食管Roux-en-Y吻合术疗效明显优于空肠食管Roux-en-y吻合术。     

食管下段胃近端切除、回盲肠间置术治疗门静脉高压症术后再出血

目的探讨食管下段胃近端切除,回盲肠间置术治疗门静脉高压症术后再出血的疗效。方法1998~2004年广西医科大学附属第一医院采用食管下段胃近端切除,回盲肠间置术治疗断流术术后再出血5例。结果5例均获随访,最长6年,最短2年。随访期无食管静脉曲张,无复发出血。无术后近期死亡、并发症。结论食管下段胃近端切除、回盲肠间置术治疗门静脉高压症术后再出血止血确切,是一种比较理想的手术方法。     

Carcinoma in jejunal pancreatic heterotopia.

BACKGROUND: Although heterotopic pancreas in the gastrointestinal tract is not uncommon, jejunal pancreatic heterotopia is a rare finding, and malignant transformation in such a location is very unusual. METHODS: We encountered a case of jejunal carcinoma in pancreatic heterotopia and because of its rarity, we reviewed the Armed Forces Institute of Pathology experience as well as the literature. The clinical, histopathologic, and immunohistochemical features were studied. RESULTS: In 109 patients diagnosed as having pancreatic heterotopia in the gastrointestinal tract between 1970 and 1997 at the Armed Forces Institute of Pathology, 67 cases (62%) occurred in the stomach, 42 (38%) in the small intestine, and none in the large intestine. We found 2 patients with adenocarcinoma arising in pancreatic heterotopia. The 2 cases arose in the jejunum. One was of the ductal type, while the other was an acinar cell carcinoma with focal ductular differentiation. In both cases the nontumoral pancreatic tissue contained ducts, acini, and islets. Review of the literature yielded 26 reports of 28 cases of carcinoma arising in heterotopic pancreas; of these, 18 were well documented. Only 1 occurred in the jejunum, and none was of the acinar type. CONCLUSIONS: Carcinoma in pancreatic heterotopia is rare, and acinar cell carcinoma in pancreatic heterotopia is extremely rare. Recognition of carcinoma in pancreatic heterotopia is important to prevent its misinterpretation as a metastatic tumor.     

Immunoregulation of endometrial and jejunal epithelia sensitized by infection

The hypothesis was tested that the uterus of the rat orally infected with the parasite Trichinella spiralis becomes hypersensitized and that subsequent antigenic challenge affects functions in the endometrial epithelium. Results of experiments comparing the immunological responsiveness of isolated rat uterus with that of the jejunum supports our hypothesis. Antigenic challenge of uterus mounted in Ussing-type chambers causes an elevation in transuterine short circuit current (Isc) of 6.4 +/- 0.8 microA/cm2. The transduction of the antigenic signal to elicit the electrophysiological response involves 5-hydroxytryptamine (5-HT) working through a nerve-independent pathway. The antigen-stimulated rise in Isc peaks approximately 3 min after challenge. The uterine response is blocked by diisothiocyanostilbene-2,2'-disulfonic acid, an inhibitor of bicarbonate-chloride exchange. The antigen-evoked change in jejunal Isc is biphasic, peaking at 1.5 and approximately 4.0 min after challenge, and is about 10-fold greater in magnitude than the Isc in the uterus. The transductive pathway in the jejunum involves 5-HT, histamine and prostaglandin acting partly through intrinsic nerves. The jejunal response to antigen is inhibited by diphenylamine-2-carboxylate, a chloride channel blocker. Changes in net ion transport which are primed by infection and evoked by antigen are apparently triggered by local anaphylaxis in both the uterus and jejunum.     

全胃切除代胃空肠行抗返流术式预防食道返流的研究

目的 探讨近端胃癌行根治性全胃切除,空肠-空肠储袋胃、储袋胃的近、远端空肠行抗返流瓣术式、空场-空肠Roux-en-Y吻合术预食道返流的可行性。方法 将2003年1月~2012年12月我院收治的行近端胃癌根治手术的患者87例随机分为两组,对照组43例行全胃切除空肠储袋胃、空肠-空肠Roux-en-Y吻合的胃癌根治术,实验组44例行空肠储袋胃、储袋胃的近、远端空肠行抗返流瓣术式、空场-空肠Roux-en-Y吻合术预防食道返流,观察两组患者术后是否有吻合口狭窄、术后进食时间、肠道恢复时间、术后住院时间、钡剂停留时间。术后2个月随访营养状况,随访至6个月,根据Mettin标准评估两组患者食管黏膜组织学炎症改变、是否有反流性食管炎以及患者生存率。结果 术后两组患者恢复良好,均无吻合口狭窄。两组患者进食时间、肠道恢复时间、术后住院时间组间对比,差异无统计学意义（P＞0.05）。实验组钡剂停留时间长于对照组,差异具有统计学意义（P＜0.05）。术后2个月随访两组病例食欲良好,血红蛋白上升、体重无减轻,营养状况良好。对照组出现食管炎症改变的例数多于实验组,两组相比,统计学意义显著（P＜0.01）;对照组出现返流性食管炎例数多于实验组,差异具有统计学意义（P＜0.05）。所有患者均随访1年,1年内无患者死亡。结论 若严格的把握适应证,近端胃癌行根治性胃全切除行空肠-空肠储袋胃、储袋胃的近、远端空肠行抗返流瓣术式、空场-空肠Roux-en-Y吻合术能有效预防食道返流,可降低返流性食管炎的发生率,显著改善患者的生存质量。     

Immunohistochemical and statistical studies on the islets of Langerhans pancreas in autopsied patients after gastrectomy

We describe in detail the pathologic features of the islets of Langerhans in specimens of the pancreas from 75 autopsy specimens of patients who underwent gastrectomy and compare them with specimens from 22 patients not having gastrectomy with respect to the duration of the postoperative period and the operative procedure. In comparison with the control group, the islets of Langerhans from the gastrectomy patients showed hyperplasia and increased numbers of endocrine cells within 5 years of gastrectomy but atrophy and decreased numbers of endocrine cells thereafter. These changes are compatible with anti-insulin immunoreactivity (B-cells) in the islets of Langerhans, where B-cell counts correlated with the area of the islets. The proliferating cell nuclear antigen (PCNA)-positive cell ratio in the islets was higher during the early phase after gastrectomy, whereas the apoptotic cell ratio was not affected by the time after gastrectomy. Hyalinization of the islets of Langerhans was first recognized after 5 years postoperatively, and the percentage of hyalinization gradually increased. Amylin deposits, detected by immunostaining, increased progressively in the islets in relation to the duration of postoperative period, correlating inversely with B-cell count and PCNA positivity. These histologic changes suggest that B cells proliferated secondary to oxyhyperglycemia in the early phase after gastrectomy followed by the state of waste, finally resulting in atrophy and amylin deposits, which led to hypofunction of the islets of Langerhans with resultant glucose intolerance. HUM PATHOL 31:1368-1376.     

Coeliac disease: alpha-1-antitrypsin contents in jejunal mucosa before and after gluten-free diet

Biopsies of the jejunum from 10 patients suffering from coeliac disease were investigated by an immunohistochemical technique for alpha-I-antitrypsin. The biopsies obtained before treatment did not contain alpha-I-antitrypsin, but after a gluten-free diet alpha-I-antitrypsin was present in Paneth cells in the mucosal crypts. This finding suggests that the absence of alpha-I-antitrypsin in the jejunal mucosa might be a pathogenetic factor in coeliac disease.     

An investigation of human jejunal and ileal arteries

The arrangement of jejunal and ileal arteries varies along the length of the small bowel, but the reasons for this and the functional implications are uncertain. The aims of this anatomical and histological study were to investigate quantitative differences between jejunal and ileal arteries and to investigate their relative muscularity. Ten cadaver small bowels (five males, mean age 78 years) were analysed. In each specimen, the mesentery of two standardised 40-cm lengths of jejunum and ileum were dissected and measured. Representative arterial samples from a jejunal and ileal parent artery, first arcade artery and arteriae recta were examined histologically and their relative muscularity (proportion of arterial cross sectional area occupied by tunica media) compared. No consistent differences were found between jejunal and ileal parent artery lengths, but jejunal arteries tended to be larger (mean diameter 2.2 ± 0.2 mm vs. 2.0 ± 0.4 mm, p = 0.08). Compared to the jejunum, the number of arterial arcades was significantly greater in the ileum (p < 0.0001), and the arteriae recta were more numerous (p = 0.02), shorter (p = 0.007) and narrower (p = 0.004). There was no statistically significant difference between the muscularity of proximal jejunal versus distal ileal arteries or between parent, first arcade and arteriae recta within the proximal jejunum and distal ileum. These quantitative data clarify conflicting statements about jejunal and ileal arterial anatomy. However, the different arterial pattern in the jejunum and ileum does not appear to be associated with differences in the muscularity of these arteries.     

Leakage of jejunal end of roux limb after total gastrectomy: management with a placement of a covered metallic stent: case report

Postoperative leakage is a serious complication in patients after gastric surgery. It can lead to a rapid deterioration in the patient's condition and quality of life. Treatment is guided by the type of anastomosis and the patient's clinical status. The role of interventional radiology in gastrointestinal tract is evolving. Metallic stent placement has shown encouraging results for the palliation of gastrointestinal tract obstruction and fistula in malignant patients. We encountered a case of the leakage of jejunal end of Roux limb after total gastrectomy. This patient required a drainage procedure with long-term parenteral nutrition. We performed peroral placement of a covered metallic stent to avoid surgery and long-term parenteral nutrition, and he resumed adequate oral intake immediately after stent placement. This minimally invasive procedure is very promising for the treatment of a gastrointestinal fistula to avoid surgery and long-term parenteral nutritional support in selected cases.     

胃充水扩张对狗体表胃电活动的影响

本文旨在探讨餐后胃电活动（EGG）变化的可能机制,实验模拟狗进餐后胃的运动生理变化。先记录狗空腹基础状态体表胃电30min,然后胃内灌注水使胃扩张,并静脉注射阿托品阻断胃收缩或红霉素激发胃收缩,分别记录体表胃电活动30min。结果表明：狗基础状态胃电主频率为4．2－5．1counts/min;液体胃扩张后EGG功率（振幅）明显增加（P＜0．05）;阿托品不影响胃扩张所引起的EGG变化;红霉素则使EGG功率更进一步增加（P＜0．01）,主功率不稳定系数也增加。结果证明进餐后EGG功率增加与胃收缩增强和胃扩张使胃接近体表记录电极均有关。提示在临床上选择试餐时,在保证一定能量基础上,试餐的容量尽可能减少,以降低胃扩张对EGG的影响,EGG可能更好地反应胃收缩的信息。     

Usefulness of a developed four-channel EGG system with running spectrum analysis

Electrogastrography (EGG) is a method of measuring action potentials on the abdomen. It is noninvasive, inexpensive and easy to measure. However, the EGG signal has a very low frequency (0.05 Hz) and an extremely low amplitude (10-100 microV). Consequently, its measured waveform is difficult to analyze and it is not yet completely understood. In this study, a four-channel EGG measurement system was built to measure the action potential of the stomach. This system was compared with the commercially available one-channel Digitrapper EGG. The 3 cpm percentages were compared between the best channel of the four-channel system and channel 1, whose electrode position was similar to the commercially available one-channel system for normal subjects. The average 3 cpm percentage of the best channel and channel 1 for preprandial measurement was 89.5% and 83.2%, respectively, and this was statistically significant (p < 0.001). Also the average 3 cpm percentage of the best channel and channel 1 for postprandial measurement was 90.4% and 76.5%, respectively, and this was statistically significant (p = 0.003). From these results, it can be concluded that a multi-channel EGG system is required for better EGG measurement.