Jianqu,a traditional Chinese medicine,alleviates functional dyspepsia in high-calorie and high-protein diet mice

Background:Jianqu has been used to alleviate symptoms in patients with functional dyspepsia,but its specific anti-functional dyspepsia effect is still unclear.Therefore,our study aimed to investigate the impact of Jianqu on functional dyspepsia in mice.Methods:The phytochemical profile of Jianqu was analyzed by UPLC-Q-TOF-MS.Subsequently,Kunming mice were fed a high-calorie or high-protein diet(HCHP)for 7 days,and then orally treated with vehicle or Jianqu(1.62 g/kg body weight(b.w.)and 3.25 g/kg b.w.)for 10 days.A carbon powder solution was used to detect the gastric emptying and intestinal transit rate.The pathological changes in stomach and duodenum were evaluated by hematoxylin-eosin staining.The occludin,claudin-1,ZO-1 and CD45 expression was measured by immunocytochemical staining.Importantly,the serum gastrointestinal hormones were detected by ELISA.In addition,the gut microbiota composition was determined using 16S rRNA gene sequencing.The cecal short chain fatty acids were assessed by gas chromatography.Results:In general,17 phytochemical compounds were identified from Jianqu,which significantly improved the gastric emptying rate and intestinal transit rate(p<0.01),increased the body weight and food intake(p<0.0001)in HCHP mice as well.Though HCHP did not cause significant pathological lesions in the gastrointestinal tract,increased the expression of CD45 in the duodenum(p<0.05)was observed.Notably,Jianqu attenuated this abnormal expression of CD45(p<0.05).The levels of serum gastrointestinal hormones were significantly normalized by Jianqu intervention(p<0.05).Moreover,Jianqu increased the relative abundance of Roseburia as well as short chain fatty acids levels in cecum(p<0.05).Conclusion:The present results showed that Jianqu alleviated dyspeptic symptoms in HCHP mice possibly through reducing the duodenal leukocyte infiltration,and regulating the expression of gastrointestinal hormones.These effects may be partly related to the increasing cecal short chain fatty acids levels probably via gut microbial modulation.

Glucagon-like-peptide-1 receptor agonists and the management of type 2 diabetes-backwards and forwards

This editorial is stimulated by the article by Alqifari et al published in the World Journal of Diabetes(2024).Alqifari et al focus on practical advice for the clinical use of glucagon-like-peptide-1(GLP-1)receptor agonists(GLP-1RAs)in the management of type 2 diabetes and this editorial provides complementary information.We initially give a brief historical perspective of the development of GLP-1RAs stimulated by recognition of the‘incretin effect’,the substantially greater insulin increase to enteral when compared to euglycaemic intravenous glucose,and the identification of the incretin hormones,GIP and GLP-1.In addition to stimulating insulin,GLP-1 reduces postprandial glucose levels by slowing gastric emptying.GLP-1RAs were developed because native GLP-1 has a very short plasma half-life.The majority of current GLP-1RAs are administered by subcutaneous injection once a week.They are potent in glucose lowering without leading to hypoglycaemia,stimulate weight loss in obese individuals and lead to cardiovascular and renal protection.The landscape in relation to GLP-1RAs is broadening rapidly,with different formulations and their combination with other peptides to facilitate both glucose lowering and weight loss.There is a need for more information relating to the effects of GLP-1RAs to induce gastrointestinal symptoms and slow gastric emptying which is likely to allow their use to become more effective and personalised.

Preoperative and postoperative complications as risk factors for delayed gastric emptying following pancreaticoduodenectomy: A single-center retrospective study

BACKGROUND Mortality rates after pancreaticoduodenectomy(PD)have significantly decreased in specialized centers.However,postoperative morbidity,particularly delayed gastric emptying(DGE),remains the most frequent complication following PD.AIM To identify risk factors associated with DGE after the PD procedure.METHODS In this retrospective,cross-sectional study,clinical data were collected from 114 patients who underwent PD between January 2015 and June 2018.Demographic factors,pre-and perioperative characteristics,and surgical complications were assessed.Univariate and multivariate analyses were performed to identify risk factors for post-PD DGE.RESULTS The study included 66 males(57.9%)and 48 females(42.1%),aged 33-83 years(mean:62.5),with a male-to-female ratio of approximately 1.4:1.There were 63 cases(55.3%)of PD and 51 cases(44.7%)of pylorus-preserving pancreatoduodenectomy.Among the 114 patients who underwent PD,33(28.9%)developed postoperative DGE.Univariate analysis revealed significant differences in four of the 14 clinical indexes observed:pylorus preservation,retrocolonic anastomosis,postoperative abdominal complications,and early postoperative albumin(ALB).Logistic regression analysis further identified postoperative abdominal complic-ations[odds ratio(OR)=4.768,P=0.002],preoperative systemic diseases(OR=2.516,P=0.049),and early postoperative ALB(OR=1.195,P=0.003)as significant risk factors.CONCLUSION Postoperative severe abdominal complications,preoperative systemic diseases,and early postoperative ALB are identified as risk factors for post-PD DGE.

Christian Sin and Buddhist Emptiness： The Angry God vs. a Smiling Buddha

Starting from a reading of Jonathan Edwards＇ famous sermon ＂Sinners in the Hands of an Angry God＂, this paper first analyzes the powerful image of ＂sinner＂ in the sermon, then goes on to give a definition of a Christian conception of sin. It is found that while sin is a central conception in the religious system of Christianity, Emptiness is a central idea in Buddhist＇s doctrine. Understanding this conception is a key step on one＇s road to the enlightenment. Buddha＇s emphasis on emptiness is to warn people not to hold everything tight in this world, to stop their craving and grasping, finally to end people＇s suffering in life. Human beings get salvation through the redemption of their sin in a Christian doctrine, while in a Buddhist doctrine, people can only get enlightened and salvation when they are aware of the empty nature of this world, the universe, and themselves

Inter-relationships between gastric emptying and glycaemia:Implications for clinical practice

Gastric emptying(GE)exhibits a wide inter-individual variation and is a major determinant of postprandial glycaemia in health and diabetes;the rise in blood glucose following oral carbohydrate is greater when GE is relatively more rapid and more sustained when glucose tolerance is impaired.Conversely,GE is influenced by the acute glycaemic environment acute hyperglycaemia slows,while acute hypoglycaemia accelerates it.Delayed GE(gastroparesis)occurs frequently in diabetes and critical illness.In diabetes,this poses challenges for management,particularly in hospitalised individuals and/or those using insulin.In critical illness it compromises the delivery of nutrition and increases the risk of regurgitation and aspiration with consequent lung dysfunction and ventilator dependence.Substantial advances in knowledge relating to GE,which is now recognised as a major determinant of the magnitude of the rise in blood glucose after a meal in both health and diabetes and,the impact of acute glycaemic environment on the rate of GE have been made and the use of gut-based therapies such as glucagon-like peptide-1 receptor agonists,which may profoundly impact GE,in the management of type 2 diabetes,has become commonplace.This necessitates an increased understanding of the complex inter-relationships of GE with glycaemia,its implications in hospitalised patients and the relevance of dysglycaemia and its management,particularly in critical illness.Current approaches to management of gastroparesis to achieve more personalised diabetes care,relevant to clinical practice,is detailed.Further studies focusing on the interactions of medications affecting GE and the glycaemic environment in hospitalised patients,are required.

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

Background: Delayed gastric emptying(DGE) is one of the most common complications after pancreaticoduodenectomy(PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. Data sources: Studies were identified by searching Pub Med for relevant articles published up to December 2022. The following search terms were used: “pancreaticoduodenectomy”, “pancreaticojejunostomy”, “pancreaticogastrostomy”, “gastric emptying”, “gastroparesis” and “postoperative complications”. The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. Results: In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. Conclusions: Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.

Management of gestational diabetes mellitus via nutritional interventions:The relevance of gastric emptying

Gestational diabetes mellitus(GDM)represents one of the most common medical complications of pregnancy and is important to the well-being of both mothers and offspring in the short and long term.Lifestyle intervention remains the mainstay for the management of GDM.The efficacy of nutritional approaches(e.g.calorie restriction and small frequent meals)to improving the maternal-neonatal outcomes of GDM was attested to by Chinese population data,discussed in two articles in recent issues of this journal.However,a specific focus on the relevance of postprandial glycaemic control was lacking.Postprandial rather than fasting hyperglycaemia often represents the predominant manifestation of disordered glucose homeostasis in Chinese women with GDM.There is now increasing appreciation that the rate of gastric emptying,which controls the delivery of nutrients for digestion and absorption in the small intestine,is a key determinant of postprandial glycaemia in both health,type 1 and 2 diabetes.It remains to be established whether gastric emptying is abnormally rapid in GDM,particularly among Chinese women,thus contributing to a predisposition to postprandial hyperglycaemia,and if so,how this influences the therapeutic response to nutritional interventions.It is essential that we understand the role of gastric emptying in the regulation of postprandial glycaemia during pregnancy and the potential for its modulation by nutritional strategies in order to improve postprandial glycaemic control in GDM.

Effects of Polygala fallax Hemsl Water Extract on a Mouse Model of Gastric Motility Disorders

[Objectives]To explore the effects of Polygona fallax Hemsl water extract on gastrointestinal motility in normal mice and gastric motility disorder model mice and approximate mechanism.[Methods]Using normal mice and mice with gastric motility disorders(modeled with atropine),the effects of different mass concentration groups of P.fallax Hemsl water extract(0.125,0.250,0.500 g/mL)and domperidone groups on gastric residual rate,small intestine propulsion rate,serum motilin(MLT),vasoactive intestinal peptide(VIP),and tissue morphology were studied.[Results]There was a highly significant difference(P<0.01)in the small intestine propulsion rate of liquid in normal mice among the different concentration groups of P.fallax Hemsl water extract compared to the blank group.The small intestine propulsion rate and gastric residue rate of semi-solid paste were statistically significant compared to the blank group(P<0.05).Among them,there was a highly significant difference between the high concentration group(67.75%±7.65%,46.5%±10.62%)and the medium concentration group(60.90%±5.87%,59.27%±7.82%)(P<0.01).There was statistical significance in normal mouse serum MLT content in the high concentration group(P<0.05).There was no effect on serum VIP levels in normal mice;no effect on the morphology of stomach and intestinal tissues of normal mice.The small intestine propulsion rate and gastric residue rate of liquid and semi-solid paste in mice with gastric motility disorders were statistically significant compared to the atropine group,with extremely significant differences(P<0.01).[Conclusions]P.fallax Hemsl water extract has a promoting effect on gastrointestinal motility.One of the specific mechanisms by which P.fallax Hemsl promotes gastrointestinal motility in normal mice may be related to the content of MLT in mouse serum.The mechanism of action in atropine induced gastric paresis mice may be related to the reactivation of M receptors,and the action mechanism of P.fallax Hemsl does not change the original histological basis.It can be inferred that P.fallax Hemsl water extract has a synergistic effect on promoting gastrointestinal motility through other mechanisms,but it is not fully understood and further in-depth research is needed.

Effect of amitriptyline on gastrointestinal function and brain-gut peptides: A double-blind trial

AIM: To study the effects of low-dose amitriptyline (AMT) on gastrointestinal function and brain-gut peptides in healthy Chinese volunteers. METHODS: This was a double-blind, randomised, placebo-controlled, two-period cross-over trial. Twentyeight healthy volunteers were randomised and administered 1-wk treatments of AMT (12.5 mg tid) or placebo. Before and during the final two days of treatment, gastric emptying, proximal gastric accommodation and visceral sensitivity were measured by drinkingultrasonography test; the orocecal transit time (OCTT) was measured by lactulose hydrogen breath test, and fasting blood was collected. Plasma levels of ghrelin, motilin and neuropeptide Y (NPY) were measured by enzyme-linked immunosorbent assay kits.RESULTS: AMT slowed the OCTT (109.2 ± 29.68 min vs 96.61 ± 23.9 min, P = 0.004) but did not affect liquid gastric emptying and had no effect on proximal gastric accommodation. AMT resulted in decreases in the visual analogue scale (VAS) for difficulty in drinking 600 and 800 mL of water (3.57 ± 0.94 vs 2.98 ± 0.85, 5.57 ± 0.82 vs 4.57 ± 0.98, P < 0.01 for both), although it had no significant effect on the VAS for difficulty in drinking 200 mL and 400 mL of water. AMT significantly increased the plasma ghrelin level (442.87 ± 176.79 pg/mL vs 526.87 ± 158.44 pg/mL, P = 0.04) and the neuropeptide-Y level (890.15 ± 131.46 pg/mL vs 965.64 ± 165.63 pg/mL, P = 0.03), whereas it had no effect on the MTL level. CONCLUSION: Low-dose AMT could slow OCTT, make the stomach less sensitive and increase the plasma levels of ghrelin and NPY. Thus, we recommend the use of low-dose AMT for functional gastrointestinal disorders.

Gastrointestinal hormone abnormalities and G and D cells in functional dyspepsia patients with gastric dysmotility

AIM: To investigate the relationship between gastric dysmotility,gastrointestinal hormone abnormalities, and neuroendocrine cells in gastrointestinal mucosa in patients with functional dyspepsia (FD).METHODS: Gastric emptying was assessed with solid radiopaque markers in 54 FD patients, and the patients were divided into two groups according to the results, one with delayed gastric emptying and the other with normal gastric emptying. Seventeen healthy volunteers acted as normal controls. Fasting and postprandial plasma levels and gastroduodenal mucosal levels of gastrointestinal hormones gastrin, somatostatin (SS) and neurotensin (NT)were measured by radioimmunoassay in all the subjects.G cells (gastrin-producing cells) and D cells (SS-producing cells) in gastric antral mucosa were immunostained with rabbit anti-gastrin polyclonal antibody and rabbit anti-SS polyclonal antibody, respectively, and analyzed quantitatively by computerized image analysis.RESULTS: The postprandial plasma gastrin levels, the fasting and postprandial plasma levels and the gastric and duodenal mucosal levels of NT were significantly higher in the FD patients with delayed gastric emptying than in those with normal gastric emptying and normal controls. The number and gray value of G and D cells and the G cell/D cell number ratio did not differ significantly between normal controls and the FD patients with or without delayed gastric emptying.CONCLUSION: Our findings suggest that the abnormalities of gastrin and NT may play a role in the pathophysiology of gastric dysmotility in FD patients, and the abnormality of postprandial plasma gastrin levels in FD patients with delayed gastric emptying is not related to the changes both in the number and gray value of G cells and in the G cell/D cell number ratio in gastric antral mucosa.

Modified B-ultrasound method for measurement of antral section only to assess gastric function and guide enteral nutrition in critically ill patients

AIM To establish a modified B-ultrasound method of measuring the antral section only to assess gastric motility in healthy people,and evaluate its application in guiding enteral nutrition(EN) in critically ill patients. METHODS First,30 healthy volunteers were selected. The modified B-ultrasound method and the traditional B-ultrasound method were applied to assess gastric function. The correlation of indices of gastric function between the two groups was analyzed statistically. In addition,64 critically ill patients were selected,and the modified B-ultrasound method and the gastric juice withdrawal method were applied to guide the implementation of EN. Daily caloric value,the time required to achieve complete EN,ICU stay,hospitalization time,and serum prealbumin and albumin levels were recorded and compared between the two groups. Kaplan-Meier survival curve was used to compare the complications of EN between the two groups. RESULTS In healthy subjects,there was a good correlation among gastric emptying time,antral contraction frequency andantral motility index between the two groups(r = 0.57,0.61 and 0.54,respectively). The study on critically ill patients also revealed that a better effect of EN was achieved in the modified B-ultrasound method group,in which patients had shorter ICU stay and hospitalization time and higher levels of serum prealbumin and albumin. The Kaplan-Meier survival analysis revealed that the improved B-ultrasound method was associated with significantly fewer EN complications(P = 0.031).CONCLUSION The modified B-ultrasound method can provide a good real-time assessment of gastric function and has a better effect than the traditional method in guiding EN in critically ill patients.

Capsule endoscopy: Improving transit time and image view

AIM： To evaluate the effect of various methods of small bowel preparation on the transit time and the quality of visualization of the entire small bowel mucosa. METHODS： Ninety-five patients underwent capsule endoscopy （CE） by easily swallowing the capsule. They were divided into three study groups according to the preparation used： group A （n = 26） by polyethylene glycol （PEG） liter or with sodium phosphate （SP） 12 h prior to the CE study; group B （n = 29） by erythromycin 1 h prior to the CE study; and group C （n = 40） without any preparation. Visualization ranged from good to satisfactory to poor. RESULTS： The gastric emptying time in the group prepared with erythromycin was shorter but without statistical significance and the small bowel transit time was unaffected. In elderly subjects prepared by PEG or SP, the gastric emptying time was significantly longer （163.7 rain, P = 0.05）. The transit times of the three sub-groups were not affected by gender or pathology. The grade of cleaning of the entire study group was 3.27±1.1. The erythromycin group presented significantly the worst quality of images （P = 0.05） compared to the other sub-groups. Age, gender, and pathology had no effect on the quality of the cleaning of the small bowel in the sub-groups. One （1.05%） case had no natural excretion. CONCLUSION： Erythromycin markedly reduces gastric emptying time, but has a negative effect on the quality of the image in the small bowel. The preparation of elderly subjects with PEG or SP has a negative effect on the small bowel transit time.

Role of cholecystokinin and central serotonergic receptors in functional dyspepsia

Symptoms of functional dyspepsia are characterized by upper abdominal discomfort or pain, early satiety, postprandial fullness, bloating, nausea and vomiting. It is a chronic disorder, with symptoms more than 3 mo per year, and no evidence of organic diseases. Dysfunctional motility, altered visceral sensation, and psychosocial factors have all been identified as major pathophysiological mechanisms. It is believed that these pathophysiological mechanisms interact to produce the observed symptoms. Dyspepsia has been categorized into three subgroups based on dominant symptoms. Dysmotility-like dyspepsia describes a subgroup of patients whose symptom complex is usually related to a gastric sensorimotor dysfunction. The brain-gut peptide cholecystokinin （CCK） and serotonin （5-HT） share certain physiological effects. Both have been shown to decrease gastric emptying and affect satiety. Furthermore the CCK induced anorexia depended on serotonergic functions probably acting via central pathways. We believe that abnormalities of central serotonergic receptors functioning together with a hyper responsiveness to CCK or their interactions may be responsible for the genesis of symptoms in functional dyspepsia （FD）.

Effect of ginger on gastric motility and symptoms of functional dyspepsia

AIM:To evaluate the effects of ginger on gastric motility and emptying,abdominal symptoms,and hormones that influence motility in dyspepsia.METHODS:Eleven patients with functional dyspepsia were studied twice in a randomized double-blind manner.After an 8-h fast,the patients ingested three capsules that contained ginger(total 1.2 g) or placebo,followed after 1 h by 500 mL low-nutrient soup.Antral area,fundus area and diameter,and the frequency of antral contractions were measured using ultrasound at frequent intervals,and the gastric half-emptying time was calculated from the change in antral area.Gastrointestinal sensations and appetite were scored using visual analog questionnaires,and blood was taken for measurement of plasma glucagon-like peptide-1(GLP-1),motilin and ghrelin concentrations,at intervals throughout the study.RESULTS:Gastric emptying was more rapid after ginger than placebo [median(range) half-emptying time 12.3(8.5-17.0) min after ginger,16.1(8.3-22.6) min after placebo,P ≤ 0.05].There was a trend for more antral contractions(P = 0.06),but fundus dimensions and gastrointestinal symptoms did not differ,nor did serum concentrations of GLP-1,motilin and ghrelin.CONCLUSION:Ginger stimulated gastric emptying and antral contractions in patients with functional dyspepsia,but had no impact on gastrointestinal symptoms or gut peptides.

Implication of neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function in diabetic gastroparesis

Recently, diabetic gastroparesis(DGP) has received much attention as its prevalence is increasing in a dramatic fashion and management of patients with DGP represents a challenge in the clinical practice due to the limited therapeutic options. DGP highlights an interrelationship between the gastric emptying and pancreatic secretory function that regulate a wide range of digestive and metabolic functions, respectively. It well documented that both gastric emptying and pancreatic secretion are under delicate control by multiple neurohormonal mechanisms including extrinsic parasympathetic pathways and gastrointestinal(GI) hormones. Interestingly, the latter released in response to various determinants that related to the rate and quality of gastric emptying. Others and we have provided strong evidence that the central autonomic nuclei send a dual output(excitatory and inhibitory) to the stomach and the pancreas in response to a variety of hormonal signals from the abdominal viscera. Most of these hormones released upon gastric emptying to provide feedback, and control this process and simultaneously regulate pancreatic secretion and postprandial glycemia. These findings emphasize an important link between gastric emptying and pancreatic secretion and its role in maintaining homeostatic processes within the GI tract. The present review deals with the neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function that implicated in DGP and this provides new insights in our understanding of the pathophysiology of DGP. This also enhances the process of identifying potential therapeutic targets to treat DGP and limit the complications of current management practices.

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy:A review of the literature and critical reappraisal of the implicated pathomechanism

Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND:A number of definitions have been used for delayed gastric emptying(DGE) after pancreatoduodenectomy and the reported rates varied widely.The International Study Group of Pancreatic Surgery(ISGPS) definition is the current standard but it is not used universally.In this comprehensive review,we aimed to determine the acceptance rate of ISGPS definition of DGE,the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.DATA SOURCE:We searched PubM ed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition,DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.RESULTS:Out of 435 search results,178 were selected for data extraction.The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7%(range:0-100%;median:18.7%) and 14.3%(range:1.8%-58.2%;median:13.6%),respectively.Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates.Although pyloric dilatation,Braun’s entero-enterostomy and Billroth Ⅱ reconstruction were associated with significantly lower DGE rates,pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.CONCLUSIONS:ISGPS definition of DGE has been used in majority of studies published after 2010.Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications.Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

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.

Gastric motor effects of ghrelin and growth hormone releasing peptide 6 in diabetic mice with gastroparesis

AIM:To investigate the potential therapeutic significance of ghrelin and growth hormone releasing peptide 6 (GHRP-6) in diabetic mice with gastric motility disorders. METHODS: A diabetic mouse model was established by intraperitoneal (ip) injection of alloxan. Diabetic mice were injected ip with ghrelin or GHRP-6 (20-200 μg/kg), and the effects on gastric emptying were measured after intragastric application of phenol red. The effect of atropine, NG-nitro-L-arginine methyl ester hydrochloride (L-NAME) or D-Lys3-GHRP-6 (a growth hormone secretagogue receptor (GHS-R) antagonist) on the gastroprokinetic effect of ghrelin or GHRP-6 (100 μg/kg) was also investigated. The effects of ghrelin or GHRP-6 (0.01-10 μmol/L) on spontaneous or carbachol-induced contractile amplitude were also investigated in vitro, in gastric fundic circular strips taken from diabetic mice. The presence of growth hormone secretagogue receptor 1a transcripts in the fundic strips of diabetic mice was detected by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: We established a diabetic mouse model with delayed gastric emptying. Ghrelin and GHRP-6 accelerated gastric emptying in diabetic mice with gastroparesis. In the presence of atropine or L-NAME, which delayed gastric emptying, ghrelin and GHRP-6 (100 μg/kg) failed to accelerate gastric emptying. D-Lys3-GHRP-6 also delayed gastric emptying induced by the GHS-R agonist. Ghrelin and GHRP-6 increased the carbachol-induced contractile amplitude in gastric fundicstrips taken from diabetic mice. RT-PCR confirmed the presence of GHS-R mRNA in the strip preparations. CONCLUSION: Ghrelin and GHRP-6 increase gastric emptying in diabetic mice with gastroparesis, perhaps by activating peripheral cholinergic pathways in the enteric nervous system.

Prevalence and determinants of delayed gastric emptying in hospitalised Type 2 diabetic patients

AIM: To determine the prevalence of delayed gastric emptying (GE) in older patients with Type 2 diabetes mellitus. METHODS: One hundred and forty seven patients with Type 2 diabetes, of whom 140 had been hospitalised, mean age 62.3 ± 8.0 years, HbA1c 9.1% ± 1.9%, treated with either oral hypoglycemic drugs or insulin were studied. GE of a solid meal (scintigraphy), autonomic nerve function, upper gastrointestinal symptoms, acute and chronic glycemic control were evaluated. Gastric emptying results were compared to a control range of hospitalised patients who did not have diabetes. RESULTS: Gastric emptying was delayed (T50 > 85 min) in 17.7% patients. Mean gastric emptying was slower in females (T50 72.1 ± 72.1 min vs 56.9 ± 68.1 min, P = 0.02) and in those reporting nausea (112.3 ± 67.3 vs 62.7 ± 70.0 min, P < 0.01) and early satiety (114.0 ± 135.2 vs 61.1 ± 62.6 min, P = 0.02). There was no correlation between GE with age, body weight, duration of diabetes, neuropathy, current glycemia or the total score for upper gastrointestinal symptoms. CONCLUSION: Prolonged GE occurs in about 20% of hospitalised elderly patients with Type 2 diabetes when compared to hospitalised patients who do not have diabetes. Female gender, nausea and early satiety areassociated with higher probability of delayed GE.