Proximal gastrectomy with jejunal interposition and TGRY anastomosis for proximal gastric cancer

AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).

Assessment of proximal gastric accommodation in patients with functional dyspepsia

Impaired gastric accommodation is one of the most important etiologic factors in the pathophysiology of functional dyspepsia.Ultrasound is a potential alternative method to study changes in gastric volume as a reflection of gastric accommodation.Ultrasound is suitable for patients because it is a non-invasive,easily repeated and non-radioactive procedure,and a previous study has demonstrated the feasibility of 3-dimensional ultrasound in examining functional dyspepsia.The brief article by Fan et al demonstrated that both the proximal gastric area and volume,measured by 2-and 3-dimensional ultrasound respectively,were significantly smaller in patients with functional dyspepsia than in healthy controls.These results are very interesting,but we raise the relevant point that it should have been mandatory to study both changes in gastric volume and their relationship with upper gastrointestinal symptoms in functional dyspepsia.In fact,the relationship between cardinal symptoms and several pathophysiologic mechanisms in functional dyspepsia remains a matter of debate.Moreover,further evaluation of distal gastric volume that has been previously implicated in the origin of functional dyspeptic symptoms is advisable.Therefore,impaired gastric accommodation does not serve as a clear marker of the cardinal symptoms experienced by patients with functional dyspepsia in daily life.

Proximal gastric motility in critically ill patients with type 2 diabetes mellitus

AIM： To investigate the proximal gastric motor response to duodenal nutrients in critically ill patients with longstanding type 2 diabetes mellitus.METHODS： Proximal gastric motility was assessed （using a barostat） in 10 critically ill patients with type 2 diabetes mellitus （59±3 years） during two 60-min duodenal infusions of Ensure （1 and 2 kcal/min）, in random order, separated by 2h fasting. Data were compared with 15 non-diabetic critically ill patients （48 ± 5 years） and 10 healthy volunteers （28 ±3 years）. RESULTS： Baseline proximal gastric volumes were similar between the three groups. In diabetic patients, proximal gastric relaxation during I kcal/min nutrient infusion was similar to non-diabetic patients and healthy controls. In contrast, relaxation during 2 kcal/ min infusion was initially reduced in diabetic patients （P 〈 0.05） but increased to a level similar to healthy humans, unlike non-diabetic patients where relaxation was impaired throughout the infusion. Duodenal nutrient stimulation reduced the fundic wave frequency in a dose-dependent fashion in both the critically ill diabetic patients and healthy subjects, but not in critically ill patients without diabetes. Fundic wave frequency in diabetic patients and healthy subjects was greater than in non-diabetic patients.CONCLUSION： In patients with diabetes mellitus, proximal gastric motility is less disturbed than nondiabetic patients during critical illness, suggesting that these patients may not be at greater risk of delayed gastric emptying.

Prognostic Factors for Patients after Curative Resection for Proximal Gastric Cancer

The factors influencing the long-term survival of patients with proximal gastric cancer (PGC) after curative resection were investigated. Data from 171 patients who underwent curative resection for PGC were retrospectively analyzed. The patients were grouped according to the clinicopathological factors and operative procedures. The tumor depth (T stage) and lymph node metastasis (pN stage) were graded according to the fifth edition of TNM Staging System published by UICC in 1997. The metastatic lymph node ratio (MLR) was divided into four levels: 0%, 30%. The data of survival rate were analyzed by Kaplan-Meier method (log-rank test) and Cox regression model. The 5-year overall survival rate of 171 patients was 37.32%. The univariate analysis demonstrated that the survival time of the postoperative patients with PGC was related to tumor size (χ2=4.57, P=0.0325), gross type (χ2=21.38, P30% (χ2=13.34, P=0.0003), TNM Ⅲ (χ2=14.05, P=0.0002) or TNM Ⅳ stage (χ2=4.37, P=0.0366); and combining splenectomy was beneficial to the cases of T3 (χ2=5.68, P=0.0171) or MLR >30% (χ2=6.11, P=0.0134). It was concluded that MLR, pN stage, TNM stage, T stage, and gross type had advantages in providing a precise prognostic evaluation for patients undergoing curative resection for PGC, in which MLR was the most valuable index. TG and combining splenectomy were useful to improve the prognosis to patients with PGC of TNM Ⅲ/Ⅲ stage, serosa invasion, or extensive regional lymph node metastasis.

Proximal gastric response to small intestinal nutrients is abnormal in mechanically ventilated critically ill patients

AIM： To determine the response of the proxima stomach to small intestinal nutrients in critically ill patients. METHODS： Proximal gastric motility was measured in 13 critically ill patients （49.3 ± 4.7 years） and 12 healthy volunteers （27.7 ± 2.9 years） using a barostat technique. Recordings were performed at baseline, during a 60-rain intra-duodenal infusion of Ensure^R （2 kcal/min）, and for 2 h following the infusion. Minimum distending pressure （MDP）, intra-bag volume and fundic wave activity were determined. RESULTS： The MDP was higher in patients （11.7 ± 1.1 vs 7.8 ± 0.7 mmHg; P 〈 0.01）. Baseline intrabag volumes were similar in the 2 groups. In healthy subjects, a ‘bimodal＇ proximal gastric volume response was observed. In patients, the initial increase in proximal gastric volume was small and delayed, but eventually reached a maximal volume similar to that of healthy subjects. In healthy subjects, the proximal gastric volume rapidly returned to baseline level after nutrient infusion （median 18 min）. In contrast, the recovery of volume to baseline was delayed in critically ill patients （median 106 min）. In 6 patients, the volume had not returned to baseline level 2 hours after nutrient infusion. In patients, fundic volume waves were less frequent （P 〈 0.05） and had lower amplitude （P 〈 0.001）, compared to healthy subjects. CONCLUSION： In critical illness, proximal gastric motor responses to small intestinal nutrient stimulation are abnormal.

Proximal gastric cancer： lymph node metastatic patterns according to different T stages dictate surgical approach

Background As a common form of gastric cancer migration,lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer.Surgery is the fundamental curative option for gastric cancer that varies depending on different stages.The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer.Methods In our retrospective study,the data of 328 patients of proximal gastric cancer with different T stages were analyzed.By comparing the differences of lymph node metastatic rate and ratio,we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes.Also,we were especially interested in the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage.Results The overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4％ and 23.3％,respectively.The tumors of different T stages were statistically significant in size and differentiation degree （P ＜0.05）,multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer （RR,12.025; 95％ CI,2.326 to 62.157; P=0.003）.The overall survival rate of patients with No.5,6 group lymph node metastasis and those without was significantly different,but the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage were not statistically significant.Conclusions Different T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis.D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare.Therefore the range of the lymph node dissection in radical gastrectomy for earty gastric cancer was considered reasonable.Moreover,to meet the requirements of the lymph node dissection,total gastrectomy plus D2 lymphadenectomy or more are supposed to be applied for the advanced proximal gastric cancer patients.Precise T staging larqely determines the range of gastrectomy and lymphadenectomy.

Postprandial proximal gastric acid pocket and its association with gastroesophageal acid reflux in patients with short-segment Barrett’s esophagus

Objective:To determine the characteristics of postprandial proximal gastric acid pockets(PPGAPs)and their association with gastroesophageal acid reflux in patients with Barrett’s esophagus(BE).Methods:Fifteen patients with BE(defined by columnar lined esophagus of≥1 cm)and 15 healthy individuals that were matched for age,gender,and body mass index,were recruited.The fasting intragastric p H and the appearance time,length,lowest p H,and mean p H of the PPGAP were determined using a single p H electrode pull-through experiment.For BE patients,a gastroesophageal reflux disease questionnaire(Gerd Q)was completed and esophageal 24-h p H monitoring was carried out.Results:The PPGAP was significantly longer(5(3,5)cm vs.2(1,2)cm)and the lowest p H(1.1(0.8,1.5)vs.1.6(1.4,1.9))was significantly lower in patients with short-segment BE than in healthy individuals.The PPGAP started to appear proximally from the gastroesophageal p H step-up point to the esophageal lumen.The acidity of the PPGAP was higher in the distal segment than in the proximal segment.In short-segment BE patients,there were significant correlations between the acidity and the appearance time and length of the PPGAP.The length and acidity of the PPGAP were positively associated with gastroesophageal acid reflux episodes.The acidity of the PPGAP was associated with the De Meester scores,the Gerd Q scores,and the fasting intragastric p H.Conclusions:In patients with short-segment BE,a PPGAP is commonly seen.Its length and acidity of PPGAP are associated with gastroesophageal acid reflux,the De Meester score,and the Gerd Q score in patients with short-segment BE.

Intra-gastric triacetin alters upper gastrointestinal motility in conscious dogs

AIM: To examine the effect of intra-gastric triacetin on both upper gastrointestinal motility and proximal gastric tone in conscious dogs.