Pancreatic Fibrosis Correlates With Delayed Gastric Emptying After Pylorus-Preserving Pancreaticoduodenectomy With Pancreaticogastrostomy

OBJECTIVE: To show that residual pancreatitis delays gastric emptying, the authors used surgical specimens and studied gastric stasis after pylorus-preserving pancreaticoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying is a leading cause of complications after PPPD, occurring in 30% of patients. The pathogenesis of delayed gastric emptying remains unclear. METHODS: Surgical specimens of the pancreas from 25 patients undergoing PPPD and pancreaticogastrostomy were collected and examined by microscopy according to progressive pancreatic fibrosis and divided into three groups: no fibrosis, periductal fibrosis, and intralobular fibrosis. The authors then measured gastric output from the nasogastric tube, pancreatic output from the pancreatic tube, and the time until patients tolerated a solid diet. RESULTS: Pancreatic juice output was significantly related to the degree of pathologic findings, and gastric output was inversely related to them. A significant prolongation of postoperative solid diet tolerance correlated with increased pancreatic fibrosis and gastric fluid production. CONCLUSIONS: Pancreatic fibrosis and increased gastric fluid production correlate with delayed gastric emptying after PPPD with pancreaticogastrostomy.     

27例食管癌切除术后胃排空障碍

为探讨食管癌术后胃排空障碍合理的治疗方法及预防措施，对１９８２～１９９５年间２７例食管癌术后胃排空障碍病人的临床资料进行回顾性分析。食管胃颈部吻合者２２例，胸内吻合者５例。占同期食管癌手术２４２７例的１．１％。１８例功能性胃排空障碍病人中１５例经保守治愈，３例死亡；９例机械性胃排空障碍病人经手术治愈。结论：食管癌术后胃排空障碍好发于食管胃颈部吻合者，多为功能性，少数为机械性。因治疗方法不同需强调二者的鉴别诊断。术中精细适度各项操作，可减少机械性胃排空障碍的发生     

胃空肠吻合术后功能性胃排空障碍患者的护理

对10例胃癌术后及2例胰、十二指肠切除术后功能性胃排空障碍患者进行药物治疗及禁食、禁饮、胃肠减压、高渗盐水洗胃、营养支持及针刺、按摩。结果12例2～4周肠蠕动恢复，住院20～36d痊愈出院。提示功能性胃排空障碍诊断明确后，在积极治疗的基础上进行精心护理是确保患者康复的重要环节。     

胃空肠吻合术后功能性胃排空障碍患者的护理

对10例胃癌术后及2例胰、十二指肠切除术后功能性胃排空障碍患者进行药物治疗及禁食、禁饮、胃肠减压、高渗盐水洗胃、营养支持及针刺、按摩.结果12例2～4周肠蠕动恢复,住院20～36 d痊愈出院.提示功能性胃排空障碍诊断明确后,在积极治疗的基础上进行精心护理是确保患者康复的重要环节.     

Evaluation of Gastrectomy in Patients With Delayed Gastric Emptying After Antireflux Surgery or Large Hiatal Hernia Repair

Background

Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery.

Methods

Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome.

Results

The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (±SD) duration of 102 ± 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 ± 2.2 before gastrectomy to 5.4 ± 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile.

Conclusion

Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery.     

Factors Influencing Clinically Significant Delayed Gastric Emptying After Subtotal Stomach-Preserving Pancreatoduodenectomy

Background

Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD.

Methods

Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively.

Results

Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86–15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE).

Conclusions

DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.     

Delayed Gastric Emptying after Pancreatoduodenectomy

With pylorus-preserving pancreatoduodenectomy (PPPD) the goal is to reduce long-term morbidities such as gastric dumping, marginal ulceration or bile-reflux gastritis. Compared with the classical Whipple procedure, PPPD is affected by an equal postoperative morbidity but is known to induce delayed gastric emptying (DGE). It is difficult to evaluate the true incidence of DGE after PPPD (from 5 to 50% according to the literature).

Early and low doses of erythromycin in the postoperative period could prevent the onset of DGE and the administration of cisapride 15 mg/day improves gastric emptying up to 6 months after PPPD.     

Enteral Nutrition Reduces Delayed Gastric Emptying After Standard Pancreaticoduodenectomy with Child Reconstruction

Background  

Delayed gastric emptying (DGE) is a common complication following pancreaticoduodenectomy (PD). Our retrospective study aimed to evaluate the influence of enteral nutrition (EN) on DGE incidence after standard PD with antrectomy and Child reconstruction.     

Delayed Gastric Emptying After Sleeve Gastrectomy Is Associated with Poor Weight Loss

Obesity Surgery - Intermediate to long-term weight regain is a major challenge following sleeve gastrectomy (SG). Physiological changes that mediate the extent of weight loss remain unclear. We...     

Low-Dose Erythromycin Reduces Delayed Gastric Emptying and Improves Gastric Motility After Billroth I Pylorus-Preserving Pancreaticoduodenectomy

OBJECTIVE: To test the hypothesis that early and low doses of erythromycin reduce the incidence of early delayed gastric emptying (DGE) and induce phase 3 of the migratory motor complex in the stomach after Billroth I pylorus-preserving pancreaticoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying is a leading cause of complications after PPPD, occurring in up to 50% of patients. High doses of erythromycin (200 mg) accelerate gastric emptying after pancreaticoduodenectomy and reduce the incidence of DGE, although they induce strong contractions that do not migrate to the duodenum. METHODS: Thirty-one patients were randomly assigned to either the erythromycin or control groups. The patients received erythromycin lactobionate (1 mg/kg) every 8 hours, or H2-receptor antagonists and gastrokinetic drugs from days 1 to 14 after surgery. On postoperative day 30, gastroduodenal motility was recorded in 14 patients. RESULTS: Preoperative, intraoperative, and postoperative factors were comparable in the erythromycin and control groups. The erythromycin group had a shorter duration of nasogastric drainage, earlier resumption of eating, and a 75% reduction in the incidence of DGE. Erythromycin was an independent influence on nasogastric tube removal, and preservation of the right gastric vessels was a significant covariate. Low doses of erythromycin induced phase 3 of the migratory motor complex and phase 3-like activity, with the same characteristics as spontaneous phase 3, in 86% of patients: two had quiescent stomachs and the others had spontaneous phase 3 or phase 3-like activity. CONCLUSIONS: Low doses of erythromycin reduced the incidence of DGE by 75% and induced phase 3 of the migratory motor complex after Billroth I PPPD. Low doses of erythromycin are preferable to high doses in the unfed period after PPPD.     

Numerical Analysis of Pouch Filling and Emptying After Laparoscopic Gastric Banding Surgery

Background Previous studies have indicated that pouch volume and stoma size are two important factors related to weight loss after laparoscopic gastric banding in morbid obese patients. We hypothesized that there was association among the wall stress, pouch volume, and stoma size in a model for the filling and emptying phases of the pouch. Methods A numerical pouch model with variable pouch volume and stoma size was generated. Uniaxial tensile testing was performed on fundus strips from fresh pig stomach and the mass flow of filling and emptying of the pouch was simulated numerically. Results There was an overall qualitative agreement on the volume change between the simulated results and the clinical recording. Increasing the pouch volume size from 22 to 105 ml caused a decrease of the maximum circumferential stress from 14.14 to 11.80 kPa and the maximum longitudinal stress from 9.87 to 6.70 kPa in the pouch wall at the same degree of filling. Decreasing the stoma diameter from 27 to 10 mm caused an increase of the maximum circumferential stress from 11.46 to 12.78 kPa and a decrease of the maximum longitudinal stress from 10.34 to 8.69 kPa. Conclusion Both the pouch volume and stoma size are important determinants of mechanical wall stress, wall strain, and pouch emptying and hence may affect satiety and weight loss. This information may be important in understanding the mechanical behavior of pouches and for the development of more advanced numerical models in the clinical management of the surgery.     

Reconsideration of Delayed Gastric Emptying in Pancreaticoduodenectomy

Literature reports indicate that the incidence of delayed gastric emptying (DGE) is higher after pylorus-preserving pancreaticoduodenectomy (PPPD) than after conventional pancreaticoduodenectomy (CPD), but DGE is traditionally diagnosed from patient-reported subjective sensations. Our clinical radiological experience suggests higher rates for physiological DGE post-CPD. We therefore sought to quantify rates of subjective DGE (sDGE, based on patient complaint) verses objective DGE (oDGE, based on scintography) post-CPD and post-PPPD. Contractile motility of post-PPPD residual stomach was also studied. For 21 PPPD and 33 CPD patients between October 1997 and June 2000, sDGE and oDGE data were collected preoperatively, on postoperative day 14, and 6 months postoperatively, with cholescintography for pylorus ring competency on postoperative day 14. The incidence of sDGE was higher for PPPD (42%) than for CPD (15%) at 14 days, with zero sDGE for both at 6 months. The incidence oDGE was higher for CPD (91%) than for PPPD (76%) at 14 days, with a 6-month incidence of 4.7% in PPPD but ~33% for CPD. Solid-phase emptying in PPPD showed that residual stomach retained partial gastric emptying function at 14 days but not at 6 months. Cholescintography showed abnormal pylorus closure function in 2 of 21 PPPD patients but was not related to DGE. Literature reports of higher DGE incidence post-PPPD are true only for subjective symptoms. Radiological measurement of oDGE shows that both CPD and PPPD manifest ~80% incidence of DGE in the early postoperative period. At 6 months, ~33% of CPD show persistent oDGE. We concluded that (1) the concept of DGE should distinguish between subjective and objective symptoms; (2) loss of distal stomach mechanoreceptors in CPD reduces patients sensation of oDGE, producing “silent” DGE;(3) both CPD and PPPD have high and approximately equal rates oDGE;(4) the previously unnoticed silent oDGE in CPD may contribute to the higher rates of ulceration and related morbidity in association with CPD     

Accelerated Gastric Emptying but No Carbohydrate Malabsorption 1 Year After Gastric Bypass Surgery (GBP)

Background

Following gastric bypass surgery (GBP), there is a post-prandial rise of incretin and satiety gut peptides. The mechanisms of enhanced incretin release in response to nutrients after GBP is not elucidated and may be in relation to altered nutrient transit time and/or malabsorption.

Methods

Seven morbidly obese subjects (BMI?=?44.5?±?2.8?kg/m²) were studied before and 1?year after GBP with a d-xylose test. After ingestion of 25?g of d-xylose in 200?mL of non-carbonated water, blood samples were collected at frequent time intervals to determine gastric emptying (time to appearance of d-xylose) and carbohydrate absorption using standard criteria.

Results

One year after GBP, subjects lost 45.0?±?9.7?kg and had a BMI of 27.1?±?4.7?kg/m². Gastric emptying was more rapid after GBP. The mean time to appearance of d-xylose in serum decreased from 18.6?±?6.9?min prior to GBP to 7.9?±?2.7?min after GBP (p?=?0.006). There was no significant difference in absorption before (serum d-xylose concentrations?=?35.6?±?12.6?mg/dL at 60?min and 33.9?±?9.1?mg/dL at 180?min) or 1?year after GBP (serum d-xylose?=?31.5?±?18.1?mg/dL at 60?min and 27.2?±?11.9?mg/dL at 180?min).

Conclusions

These data confirm the acceleration of gastric emptying for liquid and the absence of carbohydrate malabsorption 1?year after GBP. Rapid gastric emptying may play a role in incretin response after GBP and the resulting improved glucose homeostasis.     

腹部手术后功能性胃排空障碍的营养支持

目的探讨腹部手术后功能性胃排空障碍的营养支持。方法对我院1997年1月至2004年2月收治的27例腹部手术后胃排空障碍患者的临床资料进行回顾性分析。结果单纯肠内营养支持8例（29．6％），肠内、肠外联合营养支持10例（37．0％），单纯肠外营养支持9例（33．3％）。分别于术后平均15、20及23d恢复胃动力。结论肠内营养在功能性胃排空障碍的治疗中具有重要作用。     

Delayed Intrathoracic Gastric Perforation After Obesity Surgery: A Severe Complication

We describe a case of a patient with an intrathoracic gastric perforation, 6 months after she underwent a gastric banding procedure for the treatment of morbid obesity. After an urgent laparotomy during which the stomach was replaced and oversewn, she recovered uneventfully. The possible mechanism of this severe complication is discussed.     

Impaired Emptying of the Retained Distal Stomach Causes Delayed Gastric Emptying after Pylorus-preserving Pancreaticoduodenectomy

Objective Delayed gastric emptying (DGE) is the major morbidity after pylorus-preserving pancreaticoduodenectomy (PPPD). Gastroscintigraphy was used to characterize food distribution in the proximal and distal stomach during emptying. Patients and Methods Between October 2000 and June 2003, 20 healthy volunteers and 23 PPPD patients underwent single-phase gastric emptying scintigraphy 14 days after surgery. Scintigraphic studies of the stomach were divided into proximal and distal regions, and the ratio of proximal to distal radiation counts (P/DR) was plotted. Momentary monitor-displayed images were compared to evaluate meal distribution during emptying. Results There were 21 eligible patients, 12 without symptoms of DGE (sDGE–) and 9 with symptoms of DGE (sDGE+). In healthy volunteers the mean P/DR value was maintained at a level of ≥ 2.5, and momentary images showed dilated proximal and constricted distal stomach throughout meal emptying. In both the solid and liquid phase tests, the average P/DR value for sDGE– patients was slightly lower than that for healthy volunteers, and momentary images showed early emptying of the solid meal. The mean P/DR value for sDGE+ patients was abnormally low and remained constant throughout the assessment. Momentary images showed significant dilatation of the distal stomach, with constant full size. The odds ratio for the change in P/DR per minute decreased after surgery, especially in sDGE+ patients, indicating a loss of contractility of the distal stomach. At the 6-month follow-up, the P/DR values exhibited a normal decreasing trend but were lower for sDGE+ patients than for healthy volunteers. Conclusions The P/DR curve provides new insight into normal and pathological gastric function. After surgery, temporary loss of contractility of the distal stomach causes symptoms of DGE.