Ultrasonographic gastric volume before unplanned surgery

We aimed to measure gastric antral cross‐sectional area with ultrasound and estimate the gastric volume of 300 patients before unplanned surgery, fasted for at least six hours. Measurements were successfully recorded in 263 semi‐recumbent patients. The median (IQR [range]) area was 333 (241–472 [28–1803]) mm² and the mean (SD) estimated volume was 45.8 (34.0) ml. The area exceeded 410 mm² in 92/263 (35%) measurements. Body mass index and morphine administration were associated with larger gastric areas on multivariable linear regression analysis, with beta coefficient (95%CI) 0.02 (0.01–0.04), p = 0.01, 0.23 (0.01–0.46), p = 0.04, respectively. Fasting time was not associated with gastric area and therefore could not substitute for ultrasound measurements in this cohort.     

Gastric Emptying After Pylorus-Preserving Gastrectomy in Comparison with Conventional Subtotal Gastrectomy for Early Gastric Carcinoma

(Received for publication on Oct. 14, 1996; accepted on May 12, 1997)     

胃结石并溃疡穿孔误诊胃癌穿孔1例

病人男性,62岁.因腹痛腹胀1d于2007-12-06急诊入院.无发热、黄疸、呕血,病后未解大便,小便正常,无明显消瘦,既往体健.体查:生命征平稳,痛苦表情,心肺无特殊,腹饱满,未见肠型蠕动波,无腹壁静脉曲张及疝,全腹压痛、反跳痛、肌紧张,尤以剑下为甚.     

腹腔镜胃间质瘤切除术23例

目的:探讨腹腔镜下胃间质瘤切除术的可行性及临床应用价值。方法:回顾分析23例腹腔镜下胃间质瘤切除术的手术方式、术中处理原则以及术后相关指标。结果:23例手术全部成功,平均手术时间(133±68)min,平均出血量40mL,术后平均肠道功能恢复时间(36.6±16.2)h,平均住院(8.1±3.0)d。结论:腹腔镜下胃切除术治疗胃间质瘤是安全、可行的,不同位置手术难易程度相差较大,位于后壁及近贲门部较大的间质瘤应格外慎重。     

Perforated marginal ulcer after gastric bypass for obesity: a systematic review

Marginal ulcers are a recognized complication of gastric bypass procedures for obesity. Perforated marginal ulcer (PMU) is a life-threatening complication of marginal ulcers. We performed a systematic review to understand the presentation, management, and outcomes of PMUs. PubMed, Google Scholar, and Embase databases were searched to identify all studies on PMUs after gastric bypass procedures. A total of 610 patients were identified from 26 articles. The mean age was 39.8±2.59 years, and females represented most of the cohort (67%). The mean body mass index was 43.2±5.67 kg/m². Most of the patients had undergone a Roux-en-Y gastric bypass (98%). The time gap between the primary bariatric surgery and the diagnosis of PMU was 27.5±8.56 months. The most common presenting symptom was abdominal pain (99.5%) and a computed tomography scan was the diagnostic modality used in 72% of the patients. Only 15% of patients were on prophylactic proton pump inhibitors or H2 blockers at the time of perforation, and 41% of patients were smoking at the time. Twenty-three percent of patients were on nonsteroidal anti-inflammatory drugs. Laparoscopic omental patch repair of the perforation (59%) was the most used technique; 18% of patients underwent open surgery, and 20% were managed non-surgically. Thirty-day mortality was 0.97%; it was 1.21% (n=5) and 0% (n=0) in those who were managed surgically and nonsurgically, respectively. Ulcers recurred in 5% of patients. In conclusion, PMU is a surgical emergency after gastric bypass that can result in significant morbidity and even mortality. This is the first systematic review in scientific literature characterizing this condition.     

Antral compensation after proximal gastric vagotomy

Proximal gastric vagotomy (PGV) has little impact on the normal pattern of solid gastric emptying, despite denervation of the proximal two thirds of the stomach and loss of the proximal gastric pump. In four healthy volunteers and four patients with PGV, we investigated the possible compensatory mechanisms that may come into play after proximal denervation of the stomach. We measured antropyloroduodenal motility with a 10-lumen sleeve/side-hole catheter for 180 minutes after ingestion of a dual-isotope radiolabeled mixed liquid/solid meal. Patients with PGV exhibited faster liquid emptying, but the rate of solid emptying was similar to that in healthy volunteers. The frequency of propagated antropyloric pressure waves was similar between the two groups, but patients with PGV exhibited less isolated pressure waves in the proximal antrum. The amplitude and duration of pressure waves recorded in the distal antrum were significantly increased in the PGV patients as compared to healthy volunteers. Although the pattern of propagated antral contractions and solid gastric emptying remains unchanged after PGV, there is an increase in the amplitude and duration of distal antral contractions, which may compensate for loss of proximal gastric pumping mechanisms.     

Propofol and gastric effects of morphine

OBJECTIVE: The purpose of this study was to evaluate whether propofol abolishes morphine-induced effects on gastric emptying and gastric tone. METHOD: The study was carried out before anesthesia in 40 patients (ASA I-II). Gastric tone was measured in 20 patients by an electronic barostat. Volume changes were thereby registered continuously in an intragastric flaccid bag with a constant preset pressure. All patients received i.v. morphine 0.1 mg x kg(-1) before the measurements and, in a randomized order, 10 of the patients also received a bolus dose of propofol 1 mg. kg-1 before morphine. Gastric emptying was studied with the paracetamol method in 20 patients. All patients received morphine 0.1 mg x kg(-1) i.v. 10 min before oral ingestion of 1.5 g paracetamol in 200 ml water and, in a randomized order, 10 of the patients also received propofol, a bolus dose of 0.3 mg x kg(-1) before morphine, followed by an infusion of 1 mg x kg(-1) x h(-1) during the whole study (2 h). RESULTS: The volume in the intragastric bag increased in all patients receiving morphine without propofol. In the group that received propofol before morphine, the volume in the intragastric bag decreased in all patients. The volume differences between the groups were statistically significant (P<0.01). There were no statistically significant differences of the AUC60, Cmax and Tmax of serum paracetamol concentrations between the morphine and propofol-morphine groups. CONCLUSION: Propofol did not abolish morphine-induced delay of gastric emptying even if propofol abolished the decrease of gastric tone induced by morphine.     

Carcinoma of the reconstructed stomach tube following esophageal resection for a benign stricture: Report of a case and review of the literature

We report herein the case of a 60-year-old woman who presented with dysphagia and anorexia and was subsequently diagnosed as having gastric cancer of the reconstructed stomach tube 36 years after undergoing surgery for a benign esophageal stricture. Reports on carcinoma of the reconstructed stomach tube are rarely found and interestingly, all of the previous cases, which were documented only in the Japanese literature, corresponded to metachronous double cancers after esophageal malignancies. To our knowledge, this is the first case of carcinoma of the reconstructed stomach tube following esophageal resection for a benign stricture, and it is thought that the carcinoma probably developed at the site of the anastomosis a long time after the first operation. We reviewed 30 cases of carcinoma of the reconstructed stomach tube for which the clinicopathological data was complete, and we believe that this new type of cancer needs more than 10 years to develop and should be defined as carcinoma of the gastric remnant.     

下丘脑室旁核对胃的调控

下丘脑室旁核（hypothalamic paraventricular nucleus，PVN）位于下丘脑的上端第三脑室两侧，是下丘脑前区最显著的核团之一，在下丘脑对内脏活动的调节中占有重要地位。哺乳类的室旁核大多由大细胞神经元和小细胞神经元共同组成。大鼠室旁核的大细胞神经元可分为三部分，即：前大细胞核、内侧大细胞核及后大细胞核。室旁核小细胞神经元可分为五部分：室旁核室周核、室旁核前小细胞核、室旁核内侧小细胞核、室旁核背侧小细胞核及室旁核外侧小细胞部。PVN有广泛的投射，与脑干、边缘系统、脊髓及垂体等均有密切的联系，能合成或分泌30种左右的神经递质和调质，如促皮质激素释放激素（CRF），加压素（AVP），催产素（OXT），血管紧张素Ⅱ（ANGⅡ），神经肽Y（NPY），胆囊收缩素（CCK），神经降压素（NT），脑啡肽等，以及近年来发现的脑肠肽如Ghrelin和Apelin等。     

Pediatric gastric adenocarcinoma: A National Cancer Data Base review

PurposeWe sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients.MethodsUsing the 2004 to 2014 National Cancer Database (NCDB), patients ≤ 21 years (pediatric) were retrospectively compared to > 21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences.ResultsOf the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73–1.15).ConclusionWhile gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable.Type of studyRetrospective cohort study.Level of evidenceIII     

The TANTALUS™ System for Obesity: Effect on Gastric Emptying of Solids and Ghrelin Plasma Levels

BACKGROUND: Gastric electrical stimulation (GES), using the implantable TANTALUS System, is being explored as a treatment for obesity. The system delivers nonstimulatory electrical signals synchronized with gastric slow waves, resulting in stronger contractions. We hypothesized that this GES may enhance gastric emptying and as a result affect plasma ghrelin and insulin homeostasis. The aim was to test the effect of GES on gastric emptying of solids and on ghrelin and insulin blood levels in obese subjects. METHODS: The system consists of 3 pairs of gastric electrodes connected to an implantable pulse generator. Gastric emptying test (GE) of solids was performed twice, on separate days, a few weeks after implantation, before and after initiation of stimulation. Blood samples for ghrelin and insulin were taken at baseline and at 15, 30, 60 and 120 min after the test meal. RESULTS: There were 11 females, 1 male, mean age 39.1 +/- 8.9 years, mean BMI 41.6 +/- 3.4. Data is available from 11 subjects; GE was normal in 9 subjects and accelerated in 2 subjects. GES significantly accelerated GE compared to control: percent retention at 2 hours 18.7 +/- 12.2 vs 31.9 +/- 16.4, respectively (P < 0.01). Overall, there was no significant change in ghrelin or insulin profile after food intake. Ghrelin levels fell significantly at 60 min compared to baseline during stimulation (P = 0.014) and control (P = 0.046). CONCLUSION: GES results in a significant acceleration of gastric emptying of solids in obese subjects. GES did not have a significant effect on postprandial ghrelin levels when compared to control.     

Neonatal gastric perforations; A diagnostic clue in pre-perforative phase

This paper is a retrospective analysis of the pre-perforative clinical picture in twenty-seven neonates with gastric perforations. In fifteen there was a remarkably consistent progressive pattern in the preperforative clinical course. We separated the clinical course of the disease into three distinct stages in relation to pathological changes in the gastric wall i.e. gastric ischemia and dysfunction, transmural peritonitis and paralytic ileus, and actual perforation. Emphasis was placed on the existance of a clinically detectable pre-perforative phase which, if interpreted correctly, should lead to earlier diagnosis and consequently more satisfactory therapeutic results.     

The significance of nm23 protein expression in human gastric carcinomas

The clinical significance of nm23 protein (nm23) expression was studied in tissue samples from 110 patients with primary gastric cancer by immunohistochemical staining with the anti-nm23 antibody. Primary carcinomas with either lymph node involvement or liver metastasis expressed significantly reduced levels of nm23 compared to those without metastasis. This relationship was clearer in the more differentiated adenocarcinomas than in the poorly differentiated adenocarcinomas. However, there was no correlation between nm23 expression and depth of invasion, quantity of stroma, infiltrating growth pattern, or macroscopic type. The cumulative 5-year survival rates based on nm23 immunoreactivity within the primary tumor were significantly higher in the nonreduced expression group (72%) than in the reduced expression group (45%). A multivariate analysis revealed that nm23 expression levels influence the outcome of patients as strongly as depth of invasion and more strongly than the other clinicopathological factors. These results suggest that the degree of nm23 expression is closely related to the metastatic potential of gastric carcinoma cells and can be used as a prognostic indicator independent of the clinicopathological features.     

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series

BackgroundReoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure.ObjectivesTo describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes.SettingThree hospitals in Australia with both private and public (government funded) patients.MethodsWe reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications.ResultsWe identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1–55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience.ConclusionIn our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.     

Laparoscopic Roux-en-"W" gastric bypass.

OBJECTIVES: Roux-en-Y gastric bypass is the gold standard for treating morbid obesity in this country. The totally laparoscopic performance of this procedure, although quite demanding and technically difficult, has revolutionized it; and the demand for it has skyrocketed. We describe 2 cases where it became necessary to convert the Y into a "W" while performing the procedure. METHODS: A laparoscopic Roux-en-Y gastric bypass was attempted on 2 patients, 1 male and 1 female, both with body mass indexes greater than 40. During creation of the side to side jejunojejunostomy, ie, the Y, it became obvious that stenosis or obstruction would result. This area was partially resected and an additional side to side anastomosis was formed, creating a "W." RESULTS: The operative time was 205 minutes and 180 minutes, respectively, which compared favorably with the average operative time of 151 minutes in that quartile of patients (patients #101-#150). Both patients had normal upper gastrointestinal and small bowel contrast x-rays the day following surgery and were started on clear liquids. They were discharged later that day. Weight loss of 119 lb at 8 months and 80 lb at 6 months was documented, respectively, with no gastrointestinal sequelae. CONCLUSION: If problems are encountered when creating the Y of a laparoscopic Roux-en-Y gastric bypass, a laparoscopic Roux-en-W may be performed. It appears safe, technically feasible, and with a postoperative course not unlike that of the standard approach.     

Gastric Peristalsis Control by Mono Situ Electrical Stimulation: a Preliminary Study

Background: This study was initiated 3 years ago when antral gastric electric stimulation was first used successfully to reduce free feeding in swine. Methods: Three swine weighing 45 kg each were implanted with one subserosal bipolar electrode, positioned in the antrum, close to the pylorus, at the anterior side of the lesser gastric curvature. Results: During 4 h of kethamine anaesthesia we paced the stomach by various patterns of electrical stimulation and obtained both forward and backward peristalsis, as well as gastric paresis. Conclusion: Variations in antral electrical stimulation produce characteristic patterns of forward and reverse peristalsis.     

Effect of preoperative paracetamol on gastric volumes and pH in children.

The effect preoperative paracetamol elixir has on gastric contents is unknown. Children presenting for elective adenotonsillectomy were randomized to receive either paracetamol elixir (40 mg x kg(-1)) 90 min before surgery or paracetamol suppositories (40 mg x kg(-1)) intraoperatively. Following induction of anaesthesia a 16 Fr multiple-oriface orogastric tube was passed into the stomach and measure taken of the residual gastric volume and pH. The children had a mean age of 8.5 years (SD 3.2) with a weight of 35 kg (SD 16.5). Children given elixir (n=41) had a mean residual gastric volume of 0.083 ml x kg(-1) (95% CI; 0.006, 1.24) and a pH of 1.83 (95% CI; 0.75, 4.49), while those given suppositories (n=40) had a mean residual gastric volume of 0.083 ml x kg(-1)(95% CI; 0.008, 0.9) and a pH of 2.07 (95% CI; 0.84, 5.12). There was no significant difference between these two groups. Paracetamol elixir is rapidly absorbed in the gastrointestinal system of children and preoperative administration has no effect on gastric contents. Given paracetamol's slow equilibration rate constant from the central to the effect compartment, children may be given this medication preoperatively for routine surgical procedures.     

Controversies in Bariatric surgery: Evidence-based discussions on laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric banding (LAGB) is a surgical option that involves placing a silicone band circumferentially around the uppermost aspect of the stomach. The band creates a small proximal pouch that empties slowly resulting in early satiety and a decreased appetite. The band is attached to an access port that is secured to the rectus muscle and can be accessed percutaneously in the office with a needle. Injection of saline into the port results in tightening of the band. This is performed on an individual basis according to weight loss and appetite. Band adjustments are required approximately 5–6 times in the first year and 2–3 times in the second year. Weight loss is gradual, averaging 1–2 lb/week during the first 2 years after surgery.     

Gastric ultrasound in the third trimester of pregnancy: a randomised controlled trial to develop a predictive model of volume assessment

Bedside gastric ultrasonography can be performed reliably by anaesthetists to assess gastric content in the peri‐operative period. We aimed to study the relationship between gastric cross‐sectional area, assessed by ultrasound, and volumes of clear fluids ingested by pregnant women. We recruited 60 non‐labouring third‐trimester pregnant women in a randomised controlled and assessor‐blinded study. A standardised scanning protocol of the gastric antrum was performed in the 45° semirecumbent and 45° semirecumbent‐right lateral positions. Subjects were randomly allocated to drink one out of six predetermined volumes of apple juice (0 ml, 50 ml, 100 ml, 200 ml, 300 ml, 400 ml). Qualitative and quantitative assessments at a baseline period after an 8‐h fast, and immediately after the drink, were used to establish the correlation between antral cross‐sectional area and volume ingested. A predictive model to estimate gastric volume was developed. Antral cross‐sectional area in the semirecumbent right lateral position significantly correlated with the ingested volume (Spearman rank correlation = 0.7; p < 0.0001). A cut‐off value of 9.6 cm² discriminated ingested volumes ≥ 1.5 ml.kg^?1 with a sensitivity of 80%, a specificity of 66.7%, and an area under the curve of 0.82. A linear predictive model was developed for gastric volume based only on antral cross‐sectional area (Volume (ml) = ?327.1 + 215.2 × log (cross‐sectional area) (cm²)). We conclude that in pregnant women in the third trimester of gestation, the antral cross‐sectional area correlates well with volumes ingested, and this cut‐off value in the semirecumbent right lateral position discriminates high gastric volumes.     

Gastro-gastric Fistula between Pouch and Fundus following Gastric Banding and Bypass

A complication observed with revisional surgery involving a fistula between the former pouch after gastric banding and the fundus is described. A 59-yearold man with BMI 41 kg/m² presented for Roux-en-Y gastric bypass (RYGBP). He had previously undergone an open gastric banding operation, with the band removed for obstruction 1 year later. He presented to our hospital with a third incisional hernia which was so large that he suffered from abdominal angina following meals. A RYGBP and a hernia repair with mesh were performed. The postoperative contrast xray study disclosed a fistula between the pouch and fundus. A procedure to close the fistula became necessary. The reason for the fistula may have been an erosion at the former connection between the pouch and the fundus after gastric banding, although a preoperative gastroscopy had not revealed this fistula.