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.

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.

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.

Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy

BACKGROUND： Enhanced recovery after surgery（ERAS） has improved postoperative outcomes particularly in colorectal surgery. This study aimed to assess compliance with an ERAS protocol and evaluate its effect on postoperative outcomes in patients undergoing pancreaticoduodenectomy. METHODS： Fifty patients who had received conventional peri operative management from 2005 to 2009（conventional group）were compared with 75 patients who had received perioperative care with an ERAS protocol（fast-track group） from 2010 to2014. Mortality, complications, readmissions and length of hospital stay were evaluated and compared in the groups.RESULTS： Compliance with each element of the ERAS pro tocol ranged from 74.7% to 100%. Uneventful patients had a significant higher adherence to the ERAS protocol（87.5% vs40.7%; P〈0.001）. There were no significant differences in de mographics and perioperative characteristics between the two groups. Patients in the fast-track group had a shorter time to remove the nasogastric tube, start liquid diet and solid food pass flatus and stools, and remove drains. No difference was found in mortality, relaparotomy, readmission rates and over all morbidity. However, delayed gastric emptying and length of hospital stay were significantly reduced in the fast-track group. The independent effect of the ERAS protocol in reduc ing delayed gastric emptying and length of hospital stay was confirmed by multivariate analysis.CONCLUSION： ERAS pathway was feasible and safe in improving gastric emptying, yielding an earlier postoperative recovery, and reducing the length of hospital stay.

Complete resection of the gastric antrum decreased incidence and severity of delayed gastric emptying after pancreaticoduodenectomy

Background:Delayed gastric emptying(DGE)is the main complication after pancreaticoduodenectomy(PD),but the mechanism is still unclear.The aim of this study was to elucidate the role of complete resection of the gastric antrum in decreasing incidence and severity of DGE after PD.Methods:Sprague-Dawley rats were divided into three groups:expanded resection(ER group),complete resection(CR group),and incomplete resection(IR group)of the gastric antrum.The tension(g)of remnant stomach contraction was observed.We analyzed the histological morphology of the gastric wall by different excisional methods after distal gastrectomy.Moreover,patients underwent PD at our department between January 2012 and May 2016 were included in the study.These cases were divided into IR group and CR group of the gastric antrum,and the clinical data were retrospectively analyzed.Results:The ex vivo remnant stomachs of CR group exhibited much greater contraction tension than others(P<0.05).The contraction tension of the remnant stomach increased with increasing acetylcholine concentration,while remained stable at the concentration of 10×10^(-5 )mol/L.Furthermore,174 consecutive patients were included and retrospectively analyzed in the study.The incidence of DGE was significantly lower(3.5%vs.21.3%,P<0.01)in CR group than in IR group.In addition,hematoxylin-eosin staining analyses of the gastric wall confirmed that the number of transected circular smooth muscle bundles were higher in IR group than in CR group(8.24±0.65 vs.3.76±0.70,P<0.05).Conclusions:The complete resection of the gastric antrum is associated with decreased incidence and severity of DGE after PD.Gastric electrophysiological and physiopathological disorders caused by damage to gastric smooth muscles might be the mechanism underlying DGE.

Study on Gastric Empty Disorder after the Gastric Ulcer Healing and Therapeutic Effect of Cisapride

Summary: Gastric emptying time of liquid meal was detected by using ultrasonography in 28 gas- tric ulcer patients with continual or recurrent dyspepsia symptoms after the ulcer healing. Sixteen out of 28 patients (57. 1 % ) with a delay of gastric emptying time (T1/2) were randomly divided into two groups: 8 cases were treated with cisapride 5 mg three times a day and & cases with cisapride 10 mg three times a day respectively. The results showed that cisapride could relieve the symptoms with the effective rate being 68. 8 % in the two groups. T1/2 in the patients after treatment with cisapride was significantly shorter than before treatment (P<0. 001 ). It was concluded that there is a delay of T1/2 in some patients with gastric ulcer healing. Cisapride could promote gastric empty of liquid meal and relieve the symptoms efficiently. The effect of lower dose of cisapride is similar to that of higher dose.

Risk factors for postoperative delayed gastric emptying in ovarian cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy(CRSHIPEC)has shown promising results in improving the survival of ovarian cancer patients.Although the safety profiles of CRS-HIPEC exist,more attention should be paid to gastrointestinal complications,as the procedure involves a considerable proportion of bowel resection and anastomosis.AIM To identify the risk factors for delayed gastric emptying in ovarian cancer treated with CRS-HIPEC.METHODS A cross-sectional study was conducted.According to the inclusion and exclusion criteria,we retrospectively analyzed 77 patients admitted between March 2014 and April 2018 with advanced and recurrent ovarian cancer treated with CRSHIPEC in Beijing Shijitan Hospital of Capital Medical University.Risk factors for delayed gastric emptying were analyzed using univariate analysis.All of the statistically significant variables in the univariate analysis were entered into the multivariable logistic regression model to determine factors independently associated with delayed gastric emptying.RESULTS Among the 77 included patients,36.4%(28/77)had delayed gastric emptying after CRS-HIPEC.The median age and body mass index of all patients were 59 years and 22.83 kg/m^(2),respectively.Preoperative chemotherapy was administered in 55 patients(71%).Sixty-two patients(81%)had a history of at least one previous pelvic surgery.The median operation time and intraoperative hemorrhage volume were 630 min and 600 mL,respectively.Omentectomy was performed in 32 cases of primary ovarian cancer and 24 cases of recurrence.The median peritoneal cancer index was 16.The risk factors for delayed gastric emptying from the univariate analysis were body mass index<23 kg/m2(X2=5.059,P=0.025),history of pelvic surgery(X^(2)=4.498,P=0.034),history of chemotherapy(X^(2)=4.334,P=0.037),operation time≥7 h(X2=4.827,P=0.047),and intraoperative hemorrhage≥800 mL(X^(2)=7.112,P=0.008).Multivariable analysis revealed that age≥70 years(HR=7.127;95%CI 1.122-45.264;P=0.037)and intraoperative hemorrhage≥800 mL(HR=3.416;95%CI 1.067-10.939;P=0.039)were independently associated with postoperative delayed gastric emptying after CRS-HIPEC.CONCLUSION Postoperative gastrointestinal management,including prolonged nasogastric intubation,should be promoted for patients over 70 years or those with intraoperative bleeding exceeding 800 mL.

EFFECTS AND MECHANISM OF STRESS AND OF CRF MICROINJECTION INTO PVN ON GASTRIC EMPTYING

Objective To study the effects of wrap-restraint stress and of CRF or CRF antagonist (a-belieal-CRF9-41 ) microinjection on gastric emptying, and the role of plasma motilin (Mot ). Methods The effects of wrap- restraint stress or CRF and CRF antagonist microinjection into paraventricular nucleus (PVN) on gastric empiring were determined by using dextran blue-2000 as a marker. The plasma level of Mot was determined by radioimmunoassay. Results Wrap-restraint stress inhibited gastric emptying. Microinjection of CRF into PVN inhibited gastric emptying dose-dependently. In normal condition, a-he- lical-CRF9-4l bilaterally microinjected into PVN didn’ t modify gastric emptying; however, a-belieal-CRF9-41 microinjection bilaterally into PVN 15min before wrap-restraint stress could significantly antagonize the effect of stress on gastric emptying. After 30min of stress or CRF microinjection into PVN, plasma levels of Mot significantly decreased, as compered with the normal control group. Conclusion Wrap-restraint stress can inhibit gastric emptying, and microinjection of CRF into PVN has the similar effect. The PVN is one of the speific sites for the action of CRF affecting on gastric emptying. Plasma Mot might partic ipate in the effects of stress and CRF-induced alteration of gastric emptying.

Extended Fasting Durations Delayed Gastric Emptying and Colonic Motility in Normal Male Rats

Background: Previous studies on fasting and gastrointestinal motility were reported with information lacking concerning prolonged continuous fasting and gastrointestinal motility. This study investigated the effect of prolonged fasting duration on gastrointestinal motility. Methods: Forty-five (45) male Wistar rats, with body weights between 180 - 200 g were used. They were randomly assigned into three (3) groups. Group1: control (rats fasted for 18 h—common duration of fasting for motility studies), groups 2 and 3 fasted for 48 and 72 h respectively. Five (5) rats per experiment and per group were considered. Blood glucose was determined by glucose oxidase method, gastric emptying was assessed by hydrated carbohydrate meal, intestinal motility by charcoal meal, and colonic motility was assessed using bead test. Data were reported in Mean ± SEM and analyzed with one-way ANOVA. Differences in results were considered significant at p ≤ 0.05. Results: There was no significant change in the blood glucose level (mmol/L) of rats in the 48 h group (2.94 ± 0.35) and 72 h group (3.20 ± 0.32) as compared with the control (3.62 ± 0.19). There was a significant decrease in the rate of gastric emptying (g) in the 72 h group (0.20 ± 0.08) compared with the control (0.64 ± 0.16). The intestinal transit (cm) in the 48 h group (67.54 ± 6.15) and 72 h group (72.10 ± 7.60) increased significantly when compared with the control (42.14 ± 3.14). There was a significant decrease in the colonic motility time (Sec.) in the 48 h group (2707 ± 864.1) and 72 h group (6363 ± 968.1) when compared with the control (263.8 ± 64.26). Conclusion: Extended fasting durations decrease the rate of gastric emptying and colonic motility. It suggests that extended fasting durations could be beneficial in intestinal spasms or where the gut is required to relax.

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.

Gastric emptying evaluation by ultrasound prior colonoscopy:An easy tool following bowel preparation

AIM: To investigate the gastric emptying after bowel preparation to allow general anaesthesia. METHODS: A prospective, non-comparative, and nonrandomized trial was performed and registered on Eudra CT database(2011-002953-80) and on www.trial.gov(NCT01398098). All patients had a validated indication for colonoscopy and a preparation using sodium phosphate(NaP) tablets. The day of the procedure, patients took 4 tablets with 250 mL of water every 15 min, three times. The gastric volume wasestimated every 15 min from computed antral surfaces and weight according to the formula of Perlas et al(Anesthesiology, 2009). Colonoscopy was performed within the 6 h following the last intake.RESULTS: Thirty patients were prospectively included in the study from November 2011 to May 2012. The maximum volume of the antrum was 212 mL, achieved 15 min after the last intake. 24%, 67% and 92% of subjects had an antral volume below 20 mL at 60, 120 and 150 min, respectively. 81% of patients had a Boston score equal to 2 or 3 in each colonic segment. No adverse events leading to treatment discontinuation were reported.CONCLUSION: Gastric volume evaluation appeared to be a simple and reliable method for the assessment of gastric emptying. Data allow considering the NaP tablets bowel preparation in the morning of the procedure and confirming that gastric emptying is achieved after two hours, allowing general anaesthesia.

Gastric emptying, postprandial blood pressure, glycaemia and splanchnic flow in Parkinson's disease

AIM: To determine gastric emptying, blood pressure, mesenteric artery blood flow, and blood glucose responses to oral glucose in Parkinson's disease. METHODS: Twenty-one subjects(13 M, 8 F; age 64.2 ± 1.6 years) with mild to moderate Parkinson's disease(Hoehn and Yahr score 1.4 ± 0.1, duration of known disease 6.3 ± 0.9 years) consumed a 75 g glucose drink, labelled with 20 MBq 99mTc-calcium phytate. Gastric emptying was quantified with scintigraphy, blood pressure and heart rate with an automated device, superior mesenteric artery blood flow by Doppler ultrasonography and blood glucose byglucometer for 180 min. Autonomic nerve function was evaluated with cardiovascular reflex tests and upper gastrointestinal symptoms by questionnaire. RESULTS: The mean gastric half-emptying time was 106 ± 9.1 min, gastric emptying was abnormally delayed in 3 subjects(14%). Systolic and diastolic blood pressure fell(P < 0.001) and mesenteric blood flow and blood glucose(P < 0.001 for both) increased, following the drink. Three subjects(14%) had definite autonomic neuropathy and 8(38%) had postprandial hypotension. There were no significant relationships between changes in blood pressure, heart rate or mesenteric artery blood flow with gastric emptying. Gastric emptying was related to the score for autonomic nerve function(R = 0.55, P < 0.01). There was an inverse relationship between the blood glucose at t = 30 min(R =-0.52, P < 0.05), while the blood glucose at t = 180 min was related directly(R = 0.49, P < 0.05), with gastric emptying. CONCLUSION: In mild to moderate Parkinson's disease, gastric emptying is related to autonomic dysfunction and a determinant of the glycaemic response to oral glucose.

Changes in patients' symptoms and gastric emptying after Helicobacter pylori treatment

AIM: To investigate the changes in clinical symptoms and gastric emptying and their association in functional dyspepsia(FD) patients.METHODS: Seventy FD patients were enrolled and divided into 2 groups Helicobacter pylori(H. pylori)-negative group(28 patients), and H. pylori-positive group(42 patients). Patients in the H. pylori-positive group were further randomly divided into groups: H. pylori-treatment group(21 patients) and conventional treatment group(21 patients). Seventy two healthy subjects were selected as the control group. The proximal and distal stomach area was measured by ultrasound immediately after patients took the test meal, and at 20, 40, 60 and 90 min; then, gastric half-emptying time was calculated. The incidence of symptoms and gastric half-emptying time between the FD and control groups were compared. The H. pylori-negative and conventional treatment groups were givenconventional treatment: domperidone 0.6 mg/(kg/d) for 1 mo. The H. pylori-treatment group was given H. pylori eradication treatment + conventional treatment: lansoprazole 30 mg once daily, clarithromycin 0.5 g twice daily and amoxicillin 1.0 g twice daily for 1 wk, then domperidone 0.6 mg/(kg/d) for 1 mo. The incidence of symptoms and gastric emptying were compared between the FD and control groups. The relationship between dyspeptic symptoms and gastric half-emptying time in the FD and control groups were analyzed. Then total symptom scores before and after treatment and gastric half-emptying time were compared among the 3 groups. RESULTS: The incidence of abdominal pain, epigastric burning sensation, abdominal distension, nausea, belching, and early satiety symptoms in the FD group were significantly higher than in the control group(50.0% vs 20.8%; 37.1% vs 12.5%; 78.6% vs 44.4%; 45.7% vs 22.2%; 52.9% vs 15.3%; 57.1% vs 19.4%; all P < 0.05). The gastric half-emptying times of the proximal end, distal end, and the whole stomach in the FD group were slower than in the control group(93.7 ± 26.2 vs 72.0 ± 14.3; 102.2 ± 26.4 vs 87.5 ± 18.2; 102.1 ± 28.6 vs 78.3 ± 14.1; all P < 0.05). Abdominal distension, belching and early satiety had an effect on distal gastric half-emptying time(P < 0.05). Abdominal distension and abdominal pain had an effect on the gastric half-emptying time of the whole stomach(P < 0.05). All were risk factors(odds ratio > 1). The total symptom score of the 3 groups after treatment was lower than before treatment(P < 0.05). Total symptom scores after treatment in the H. pylori-treatment group and H. pylori-negative group were lower than in the conventional treatment group(5.15 ± 2.27 vs 7.02 ± 3.04, 4.93 ± 3.22 vs 7.02 ± 3.04, All P < 0.05). The gastric half-emptying times of the proximal end, distal end, and the whole stomach in the H. pylori-negative and H. pylori-treatment groups were shorter than in the conventional treatment group(P < 0.05). CONCLUSION: FD patients have delayed gastric emptying. H. pylori infection treatment helps to improve symptoms of dyspepsia and is a reasonable choice for treatment in clinical practice.

Effect of DA-9701 on gastric emptying in a mouse model: Assessment by ^(13)C-octanoic acid breath test

AIM:To evaluate the effects of DA-9701 on the gastric emptying of a solid meal using the 13C-octanoic acid breath test in a mouse model. METHODS:Male C57BL/6 mice aged > 8 wk and with body weights of 20-25 g were used in this study. The solid test meal consisted of 200 mg of egg yolk labeled with 1.5 L/g 13C-octanoic acid. The mice were placed in a 130 mL chamber flushed with air at a flow speed of 200 mL/min. Breath samples were collected for 6 h. The half-emptying time and lag phase were calculated using a modified power exponential model. To assess the reproducibility of the 13C-octanoic acid breath test, the breath test was performed two times at intervals of one week in ten mice without drug treatment. To assess the gastrokinetic effects of DA-9701, the breath test was performed three times in another twelve mice, with a randomized crossover sequence of three drug treatments:DA-9701 3 mg/kg, erythromycin 6 mg/kg, or saline. Each breath test was performed at an interval of one week. RESULTS:Repeatedly measured half gastric emptying time of ten mice without drug treatment showed 0.856 of the intraclass correlation coefficient for the half gastric emptying time (P = 0.004). The mean cumulative excretion curve for the 13C-octanoic acid breath test showed accelerated gastric emptying after DA-9701 treatment compared with the saline control (P = 0.028). The median half gastric emptying time after the DA-9701 treatment was significantly shorter than after the saline treatment [122.4 min (109.0-137.9 min) vs 134.5 min (128.4-167.0 min), respectively; P = 0.028] and similar to that after the erythromycin treatment [123.3 min (112.9-138.2 min)]. The lag phase, which was defined as the period taken to empty 15% of a meal, was significantly shorter after the DA-9701 treatment than after the saline treatment [48.1 min (44.6-57.1 min) vs 52.6 min (49.45-57.4 min), respectively; P = 0.049]. CONCLUSION:The novel prokinetic agent DA-9701 accelerated gastric emptying, assessed with repeated measurements in the same mouse using the 13Coctanoic acid breath test. Our findings suggest that DA-9701 has therapeutic potential for the treatment of functional dyspepsia.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODS In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying(DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTS Technical success was achieved in all patients(100%). Early symptom improvement was observed in 15 of 20 patients(75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d(range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients(70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients(95%).CONCLUSION Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Influencing factors of postoperative early delayed gastric emptying after minimally invasive Ivor-Lewis esophagectomy

BACKGROUND The main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy(MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying(DGE).AIM To investigate the influencing factors of postoperative early DGE after MIILE.METHODS A total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group(n = 49) and a control group(n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic(ROC) curve was used to assess potential factors in predicting postoperative early DGE.RESULTS Age, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group(P < 0.05). Age, anxiety score, perioperative albumin level,and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant(P <0.05). The ROC curve analysis revealed that the area under the curve(AUC) foranxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L,and the sensitivity and specificity were 97.2% and 46.9%, respectively.CONCLUSION Advanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.

Right recumbent position on gastric emptying of water evidenced by ^(13)C breath testing

AIM:To compare the impact of the right recumbent position with the sitting position on gastric emptying of water. METHODS:In eight healthy male volunteers,the 13C acetate breath test was performed twice to assess gastric emptying of 100 mL tap water.Subjects were seated in one test and lying on their right side in the other.In both positions,pulmonary 13CO2 exhalation curves were obtained by plotting breath data against time.Percent gastric retention curves were created by analyzing data using the Wagner-Nelson protocol. RESULTS:No significant posture effect was found in pulmonary 13CO2 output curves(P=0.2150),whereas a significant effect was seen in gastric retention curves (P=0.0315).The percent retention values at 10 min and 15 min were significantly smaller when subjects were in the right recumbent position compared with the seated position(P<0.05).Our results verified the accelerating effect of the right recumbent position on gastric emptying of non-nutritive solutions.Concerning clinical implications,this study suggests that placing patients with acute pain on their right side after oral administration of analgesic drugs in solution is justified as an effective practice for rapid pain relief.For patients with gastrointestinal reflux symptoms,sleeping in the right recumbent position may reduce nocturnal symptoms,as delayed gastric emptying can cause reflux symptoms. CONCLUSION:Gastric emptying of water occurs more quickly when a subject lies on the right side compared with sitting.

Individual Differences in Blood Alcohol Concentrations after Moderate Drinking Are Mainly Regulated by Gastric Emptying Rate Together with Ethanol Distribution Volume

Blood alcohol concentration (BAC) differs greatly among individuals, even when people of the same sex and age drink alcohol under the same drinking conditions. In this study, we investigated the main factors involved in the internal reg-ulation of individual differences in BAC, focusing on the alcohol dehydrogenase 1B (ADH1B) genotype, blood acetal-dehyde concentration (BAcH), amount of habitual alcohol consumption, pharmacokinetic parameters of BAC, distribution volume of ethanol (Vd), and gastric emptying rate (GER) under the same drinking conditions. Twenty healthy Japanese males aged between 40 and 59 years old and having the aldehyde dehydrogenase 2 (ALDH2) genotype of ALDH 2*1/*2 were recruited for this study. The subjects were given 0.32 g ethanol/kg body weight in the form of commercially available beer (5%, v/v). The results showed that BAC-max differed greatly among individuals with a more than two-fold variation. When the BAC-time curve was compared among ADH1B genotypes (ADH1B*1/*1, *1/*2, and *2/*2), there were no differences in BAC among the genotypes. Although BAcH, monthly alcohol consumption, elimination rate of blood ethanol (β value) and ethanol disappearance rate from the body (EDR) can affect BAC, all of them had no correlations with BAC-max. However, Vd (liter/kg), ΔPlasma glucose concentration (ΔPGC = PGC30 min ? PGC0 min) and the serum concentration of gastric inhibitory polypeptide (GIP) did correlate with BAC-max. Model 2 in multiple linear regression analysis showed the optimal model for Vd and GIP with positive correlations with BAC-max. As GIP and ΔPGC are both reflected by gastric emptying rate (GER), we concluded that the individual differences in BAC after moderate drinking are mainly regulated by GER together with Vd. These findings demonstrate that together with body water content, the gastrointestinal tract plays an important role in the regulation of individual differences in BAC, involving first pass metabolism of ethanol.

Effect of Gongronema latifolium on gastric emptying in healthy dogs

AIM:To investigate sonographically the effect of Gonogronema latifolium (G.latifolium) on gastric emptying of semi-solid meals in healthy dogs.METHODS:In a randomized,placebo-controlled experiment,twenty-five clinically healthy dogs were randomly allotted into five groups of five dogs in each group.The placebo group served as the control,and the low,moderate and high dose groups ingested the methanolic leaf extract of G.latifolium in capsules at 100 mg/kg,250 mg/kg and 500 mg/kg,respectively,while the prokinetic group ingested 0.5 mg/kg capsules of metoclopramide.After a 12-h fast,each group ingested its treatment capsules 30 min before the administration of a test meal.Measurements of gastric emptying and blood glucoselevels were obtained 30 min before and immediately after the ingestion of the test meal and thereafter every 15 min for 4 h.This was followed by further measurements every 30 min for another 2 h.RESULTS:The gastric emptying times of the placebo,low dose,moderate dose,high dose and prokinetic dose groups were 127.0 ± 8.2 min,135.5 ± 3.7 min,155.5 ± 3.9 min,198.0 ± 5.3 min and 59.0 ± 2.5 min,respectively.Gastric emptying times of the moderate and high dose groups were significantly slower than in the placebo control group (155.5 ± 3.9 min,198.0 ± 5.3 min vs 127.0 ± 8.2 min,P=0.000).No significant difference in gastric emptying between the low dose and placebo control groups was noted (135.5 ± 3.7 min vs 127.0 ± 8.2 min,P=0.072).Gastric emptying of the prokinetic group was significantly faster than that of the control group (59.0 ± 2.5 min vs 127.0 ± 8.2 min,P=0.000).The hypoglycaemic effect of G.latifolium and gastric emptying were inversely related (r=-0.95,P=0.000).CONCLUSION:G.latifolium delays gastric emptying and lowers postprandial blood glucose in healthy dogs.It reduces the postprandial blood glucose by delaying gastric emptying.

Dual loop(Roux en Y) reconstruction with isolated gastric limb reduces delayed gastric emptying after pancreatico-duodenectomy

BACKGROUND Single loop reconstruction(SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy(PD). Roux-en Y reconstruction with an isolated gastric limb(RIGL) recently became the reconstruction of choice.AIM To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying(DGE).METHODS This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.RESULTS One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE(15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal(3 vs 5, P < 0.001), regain of normal diet(8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE(P < 0.001, OR 0.14)CONCLUSION The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.