Gastric emptying in deformed stomach

To evaluate the relationship between the onset of peptic ulcer and gastric emptying, some factors which were thought to regulate gastric emptying, i.e. the stage of the ulcer, the location of the ulcer and gastric acidity were studied in cases of gastric ulcer with deformed stomach and were proven to have little influence on gastric emptying. Further, the main cause of delayed gastric emptying was revealed to be the deformity itself, because the shortening of the distance from the gastric angle to the pyloric ring at the lesser curvature (sac-shaped stomach) and the indentation of the corpus ventriculi (hourglass-shaped stomach) significantly delayed gastric emptying. Moreover, it was found that the healing of gastric ulcer was delayed in cases of deformed stomach with delayed gastric emptying when the ulcer was at an active stage. Therefore the improvement of gastric emptying by some methods was thought to be necessary to promote ulcer healing and prevent ulcer recurrence in gastric ulcer patients who had a deformed stomach.     

Gastric cancer arising from the remnant stomach after distal gastrectomy: A review

Gastric stump carcinoma was initially reported by Balfore in 1922, and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology, carcinogenesis, Helicobacter pylori (H. pylori) infection, Epstein-Barr virus infection, clinicopathologic characteristics and endoscopic treatment. In particular, it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition, endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast, many issues concerning gastric stump carcinoma remain to be clarified, including molecular biological characteristics and the carcinogenesis of H. pylori infection. We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.     

Delayed gastric emptying after distal gastrectomy for gastric cancer

BACKGROUND/AIMS: Gastric surgery may potentiate delayed gastric emptying. The aims of the study were to determine the frequency and causes of delayed gastric emptying in patients who had undergone distal gastrectomy for gastric carcinoma and to assess which factors predispose to its development. METHODOLOGY: 209 patients, who had undergone gastrectomy, were evaluated. RESULTS: Delayed gastric emptying occurred in 4.3% of patients receiving a Billroth-I, and 15.5% of patients receiving a Roux-Y reconstruction (p = 0.01). The patients who had these consecutive symptoms following Roux-Y operation were all clinically diagnosed as having Roux stasis syndrome. The delayed gastric emptying after Roux-Y operation was more frequent in patients receiving extensive lymph node dissection than those receiving conventional dissection (p<0.05). The symptoms spontaneously subsided, and postoperative body weight loss was not significant. CONCLUSIONS: In spite of the strong association between delayed gastric emptying and the Roux-Y procedure, it enables a relatively early return to oral intake.     

Gastric emptying for liquids and solids after distal gastrectomy with Billroth-I reconstruction

BACKGROUND/AIMS: Although distal gastrectomy followed by Billroth-I reconstruction has been a standard surgical procedure for over 100 years, gastric emptying of liquid and solids after this procedure remains poorly understood, despite its contribution to postgastrectomy complications such as dumping syndrome and reflux esophagitis. A simple way to standardize measurement and generate normal values is needed. This study proposed a new, accurate and easy method, "dual phase method", for gastric emptying after distal gastrectomy. METHODOLOGY: Liquid- and solid-phase gastric emptying were measured using a combined test consisting of acetaminophen and sulfamethizole capsule ingestion, respectively. Data from 12 patients (B-I group) who had undergone distal gastrectomy with D2 lymph node dissection and truncal vagotomy followed by Billroth-I reconstruction were compared with those from 14 healthy volunteers (control group). RESULTS: A two-factor repeated measures ANOVA (analysis of variance) demonstrated a highly significant difference in the sequential changes in the serum acetaminophen concentration after ingestion between the two groups (p<0.0001). On the other hand, the sequential changes in the serum sulfamethizole concentration after ingestion was similar in the two groups (p=0.91). CONCLUSIONS: Gastric emptying of liquids is rapid after distal gastrectomy followed by Billroth-I reconstruction. However, emptying of solids is unchanged. The data obtained in this study can be a point of reference for comparing gastric emptying following gastrectomy.     

Prevalence of Helicobacter pylori in the residual stomach after gastrectomy for gastric cancer

BACKGROUND/AIMS: In recent years, the role of Helicobacter pylori in gastritis of the residual stomach has attracted much attention. We investigated the prevalence of Helicobacter pylori in the residual stomach after distal gastrectomy for gastric cancer, as well as the correlations between Helicobacter pylori positivity and clinical characteristics or the severity of gastritis in the residual stomach. METHODOLOGY: The subjects were 66 patients with gastric cancer who underwent distal gastrectomy with Billroth I reconstruction at our department. Helicobacter pylori was detected by the 13C-urea breath test, and patients were considered to be Helicobacter pylori-positive if the delta 13C value was > 2.5@1000. RESULTS: The overall Helicobacter pylori positivity rate of the gastrectomy patients was a high 80.3%, with the rate being especially high in patients under 60 years of age and in those tested less than 5 years after surgery. There was a close relationship between Helicobacter pylori positivity and the severity of gastritis. CONCLUSIONS: Helicobacter pylori infection appears to cause the development of gastritis. Helicobacter pylori eradication needs to be taken into consideration in the management of Helicobacter pylori-positive patients after gastrectomy.     

Gastric emptying after pylorus-preserving gastrectomy: assessment using the 13C-acetic acid breath test

BACKGROUND/AIMS: Gastric emptying after PPG is directly associated with postoperative QOL. Few studies have investigated gastric emptying after a gastrectomy for stomach cancer using carbon-labeled acetic acid breath test. METHODOLOGY: We analyzed gastric emptying in 28 patients who underwent a gastrectomy for gastric carcinoma. Among the patients, 14 underwent pylorus-preserving gastrectomy and 14 underwent distal gastrectomy. We recruited 15 healthy subjects as controls. Gastric emptying was evaluated with the 13C-Acetic acid breath test was performed. Postprandial breath samples were collected at a 15-min interval for 2 hours and at a 30-min interval thereafter. We calculated the ratio of (13)CO2 expired per hour and determined the time required to reach peak (13)CO2 expiration level. RESULTS: The time required to reach peak (13)C02 expiration level were 1.78 hours for the patients who underwent pylorus-preserving gastrectomy, 1.19 hours for the control group and 0.70 hours for the patients who underwent distal gastrectomy. CONCLUSIONS: Our 13C-Acetic acid breath test following an intake of solid foods showed that gastric retention can be preserved after a pylorus-preserving gastrectomy.     

Gastric mucosa after partial gastrectomy.

A partial gastrectomy of Billroth I or II type was performed in a series of 146 patients with peptic ulcer. Gastric biopsy was carried out two years later and the histology of the specimens compared with that of the body mucosa at the time of operation. In 138 patients without body atrophic gastritis (AG) before operation this condition was found in 74 (54%) two years after (46% of DU patients and 73% of GU patients). Those with antral or pyloric canal ulcers were particularly liable to develop AG (81%). Apart from site of ulcer various other factors possibly associated with the development of AG were examined: no positive correlations were found with the possible exception of anaemia. Gastric parietal cell antibodies were not found in any patient with AG tested. The cause of gastritis after partial gastrectomy and its possible relationship with gastric carcinoma are discussed.     

Segmental gastrectomy for early cancer in the mid-stomach.

BACKGROUND/AIMS: We modified the surgical procedure for segmental gastrectomy, which is normally used for peptic ulcers, to treat early gastric cancer of the mid-stomach. In this paper, we describe the surgical technique and its results. METHODOLOGY: The location of the tumor was confirmed by intra-operative endoscopic examination. An area 2 cm proximal and distal to the tumor was marked with sutures. Firstly, the lymph nodes were dissected from around the perigastric and along the left gastric and common hepatic arteries. Then, a segmental gastrectomy was performed. The greater omentum, omental sac, and vagal nerve, including the hepatic, pyloric and celiac rami, were left intact. An end-to-end gastrogastrostomy was performed using Gambee's sutures and 4-0 monofilament polydioxanone. Gastric drainage was not necessary. RESULTS: We performed segmental gastrectomies on 30 patients. Tumors less than 1 cm in diameter were found in 4 patients; 1.1-2 cm in 14, 2.1-5 cm in 11, and a tumor exceeding 5.1 cm in one patient. The cancer was confined to the mucosa in 23 patients; in the other 7, it had penetrated the submucosa. No lymph node metastases were found but 2 patients had microscopic invasion or permeation of the lymphatic vessels. One patient required post-operative balloon dilation of the pyloric sphincter for delayed gastric emptying. The remaining patients had no post-operative complications. To date, 29 patients, excluding one who died in a traffic accident, have survived disease-free for a mean of 30 months (range: 7-51). Their body weight and dietary volume returned to pre-operative levels within 12 months of surgery. CONCLUSIONS: Patients who underwent segmental gastrectomy have had a reasonably good quality of life in the post-operative follow-up to date.     

Role of Helicobacter pylori in stomach cancer after partial gastrectomy for benign ulcer disease.

OBJECTIVE: To determine the prevalence of Helicobacter pylori infection in patients having undergone gastrectomy for non-neoplastic disease who later developed gastric stump cancer. MATERIAL AND METHODS: Retrospective study of all patients with partial gastrectomy for non-malignant peptic disease who were submitted to an endoscopic exploration between 1995 and 2001. A comparison was made of major clinical and histological characteristics, and the presence of Helicobacter pylori among patients with and without gastric cancer in the stomach remnant. RESULTS: A total of 73 patients were studied in this period. Fifteen patients (20.5%) had remnant-stump gastric cancer. All but one were adenocarcinomas (71% intestinal and 29% diffuse, respectively). The average time between diagnosis of gastric cancer and previous gastrectomy was 32 (14-48) years. There was a higher detection rate of Helicobacter pylori in patients with cancer in the gastric remnant (100 vs. 81.5%, respectively, p < 0.07). No relationship was seen between type of gastric reconstruction (Billroth I or II) and rate of Helicobacter pylori detection. CONCLUSIONS: Helicobacter pylori infection is frequent in patients with previous gastrectomy for non-neoplastic disease. The results of the study suggest that Helicobacter pylori infection may play a role in gastric stump cancer.     

Gastric emptying rate for solid and for liquid test meals in patients with dyspeptic symptoms after partial gastrectomy and after vagotomy followed by partial gastrectomy

BACKGROUND/AIMS: Gastric emptying rate for solid and for liquid test meals was investigated retrospectively in patients with longstanding epigastric distress after partial gastrectomy, either as primary treatment or after failure of vagotomy for peptic ulcer in order to find an explanation for the postoperative symptoms. METHODOLOGY: Radionuclide-labeled liquid and solid test meals were used to evaluate gastric emptying rate, at least one year after surgery. RESULTS: The lag phase for liquid test meals disappeared in all operated patients. Partial gastrectomy usually lead to fast emptying but this resective procedure, if performed after vagotomy, lead to stasis in a significant number of patients. Gastric emptying rate for solids increased in only a few of these symptomatic patients. In most of them however, there was a normal to decreased emptying rate. If a vagotomy had preceded the resective procedure, gastric emptying rate decreased significantly. CONCLUSIONS: In all these symptomatic patients, gastric emptying had been disturbed for at least one type of test meal. This makes investigation for both meals necessary, especially since there is a lack of correlation. Furthermore, if vagotomy fails to prevent ulcer recurrence, one should carefully consider all options before performing partial gastrectomy since gastric emptying rate after these consecutive procedures worsens considerably.     

Gastric adenocarcinoma in the gastric stump after partial gastrectomy.

Carcinomas of the gastric stump are divided into two types. In the main group of patients (n = 18), carcinoma developed after resection for benign ulcer disease, and in the second group (n = 4) after resection for early gastric carcinoma. In the first group, the mean age of the patients was 63, and the male-to-female ratio of 17:1. The mean interval between the primary operation and the diagnosis of cancer was 27 years. Biopsies were positive in 16 out of 18 patients. The resectability rate was 72%, resection being performed with curative intent in 50%. Total gastrectomy was performed in 50% of the cases. There were no postoperative deaths. The 5-year survival rate was 33% for all patients and 50% after tumoral resection. Early detection was achieved by means of an endoscopic survey of the gastric stump. A comparison between gastric stump carcinomas and other gastric carcinomas in our series fails to reveal any major differences. Gastric stump carcinoma is not specific. In the second group, the mean age of the patients was 72.5 and the sex ratio 1:1. The mean interval between the two operations was 5 years. The resectability rate was 100%, and all the patients survived with follow-up ranging from 2 to 10 years. The second lesion could be considered a metachronous cancer, but it may have been present and overlooked at the time of the initial gastrectomy. Differentiating between synchronous and metachronous lesions is quite difficult.     

Proximal stomach and antrum in stomach emptying.

In a series of measurements of liquid-phase gastric emptying using a radionuclide marker on 35 subjects, five were identified in whom the proximal stomach and antrum were clearly distinguishable. Three of these subjects were normal controls and two suffered from systemic sclerosis. In the three normal subjects, analysis of the movement of the liquid showed the expected movement from fundus to antrum and thence through the pylorus. In the two patients with systemic sclerosis, there was, in contrast, evidence of mass retropulsion of the contents of the antrum into the fundus. In such cases, the measurement of stomach emptying based on the assumption of a single-compartment system in likely to be misleading.     

Undisturbed water gastric emptying in patients of stomach cancer

BACKGROUND/AIMS: Gastric cancer is an infiltrative disease involving deep layers of the stomach. It is of interest whether the stomach motility in gastric cancer patients may be altered. We employed a homemade applied potential tomographic system to study the features of water gastric emptying in gastric cancer patients. METHODOLOGY: Twelve electrodes were placed in a circular array around the upper abdomen of studied subjects. After drinking 500 mL of test water, paired electrodes injected an electrical current and another 9 paired electrodes recorded signals. This procedure was processed in a rotated order for 50 min while the serial changes in altered resistivity were constructed to display water gastric emptying curve. Before surgery, 27 histologically confirmed gastric cancer patients were enrolled to measure their gastric emptying parameters including half emptying time (T1/2) and area under the curve (AUC). Consequently, tumor parameters were obtained from their resected specimens. In addition, 28 healthy controls were recruited to compare water gastric emptying. RESULTS: The half emptying times of gastric cancer patients and controls were 15.51 +/- 2.21 (SE) and 16.82 +/- 2.13 min, respectively (NS). While their measured areas under the curve were also comparable (1719.5 +/- 169.4 vs. 1896.0 +/- 143.6 arbitrary unit, NS). Regarding with various patient factors to influence water gastric emptying among gastric cancer patients, those patients presenting nausea (T1/2: 8.3 +/- 1.44 vs. 18.5 +/- 2.8 min, P<0.05) or free of regional lymph node metastasis (9.98 +/- 2.53 vs. 22.7 +/- 3.84 min, P<0.05) had a rapid water gastric emptying. Other demographic and tumor characteristics including gender, age, smoking, body size, serum levels of tumor markers, cancer location/size, invasion layer, Helicobacter pylori colonization and histological subtype did not influence water gastric emptying. CONCLUSIONS: Water gastric emptying in non-obstructive gastric cancer patients is mainly undisturbed. However, some obvious dyspeptic symptom or tumor nature appears leading to a rapid water gastric emptying.     

Monitoring immunocompetent cells in the peripheral blood of stomach cancer patients after splenectomy and gastrectomy

Summary The status of lymphocyte subpopulations in splenectomized (Sx) stomach cancer patients (SCa-patients), assessed by monoclonal antibodies, has not been evaluated so far. Therefore subsets of peripheral white blood cells were monitored prior to and following surgical treatment in gastrectomized (Gx) and Sx (n=64) as well as in non-Sx patients (n=39).Postoperative surgical complications were more frequent in the Sx group. However, the 2-year survival rate of this group was higher than in non-Sx patients.Lymphocytes were significantly decreased in both groups of patients during the early postoperative period. Monocytes and polymorphonuclear cells (PMN) increased correspondingly. A significant loss of lymphocytes and their subsets in Sx patients was observed during the 1st-3rd postoperative days as compared to the Gx only patients. The OKT4/OKT8 ratios did not differ in either group of patients, whereas the OKT3/anti-B-Ly2 ratio was significantly increased in Sx patients 1 to 3 days postoperatively.The study was supported by the Boehringer-Ingelheim Fonds for Basic Research and the Weigand Grant