Manometric evidence of improved early gastric stasis by erythromycin after pylorus-preserving pancreatoduodenectomy

Body surface gastric mapping to determine gastric motility patterns associated with delayed gastric emptying after pancreaticoduodenectomy. Gastric Electric Mapping after Pancreatoduodenectomy study protocol

INTRODUCTION

Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Although often associated with postoperative pancreatic fistula, the precise pathogenesis in patients with no underlying complications remains unclear. There is evidence to suggest that, after surgery, aberrant electrical pathways are formed in the stomach which could contribute to the development of DGE.Gastric Alimetry is a novel technology which measures the electrical activity of the stomach non-invasively using an array of electrodes applied to the skin of the abdomen. This technique, termed body surface gastric mapping (BSGM), has been validated in normal controls and in patients with functional dyspepsia syndromes. This study will investigate the efficacy and feasibility of using BSGM to assess gastric motility in patients who undergo PD.

METHODS AND ANALYSIS

This prospective cohort study will be conducted at a single large volume hepatobiliary unit in the UK. 50 patients who are planned to undergo PD will be included. BSGM measurement will be performed at four timepoints viz: preoperatively, day 4 postoperatively, at discharge and 6 months postoperatively. Key parameters of BSGM measurement, including wave amplitude, frequency and directional vector, will be measured at each timepoint and compared between different patient subgroups. Symptoms will be self-reported by patients during the recording using an iPad application designed for this purpose. Quality of life and patient experience will be assessed using standardised questionnaires at the end of the follow-up period.

ETHICS AND DISSEMINATION

The protocol has been approved by the research ethics committees of Newcastle University and the Health Research Authority (HRA) of the UK (ethical approval IRAS ID 305302). Findings will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

This study will automatically be registered with the ISRCTN registry by the HRA as part of the ethics approval process.

Does the Ileal Brake Contribute to Delayed Gastric Emptying After Pancreatoduodenectomy?

Delayed gastric emptying (DGE) represents a significant cause for morbidity following pancreatoduodenectomy (PD). At a time when no specific and universally effective therapy exists to treat these patients, elucidating other potential (preventable or treatable) mechanisms for DGE is important. The aim of the manuscript was to test the hypothesis that ileal brake contributes to DGE in PD patients receiving jejunal tube feeding by systematically reviewing experimental and clinical literature. A series of clinically relevant questions were framed related to the potential role of the ileal brake in development of DGE post-PD and formed the basis of targeted literature searches. A comprehensive search of major reference databases from January 1980 to June 2015 was carried out which included human and animal studies. The ileal brake is a feedback loop neurally mediated by the vagus and sympatho-adrenergic pathways and hormonally by gut peptides including glucagon-like peptide-1, peptide YY (PYY), and neurotensin. The most potent stimulus for this inhibitory reflex is intra-ileal fat. There is evidence to indicate the role of an inhibitory reflex (on gastric emptying) mediated by PYY and CCK which, in turn, are stimulated by nutrient delivery into the distal small intestine providing indirect support to the role of ileal brake in post-PD DGE. The ileal brake is a likely factor contributing to DGE post-PD. While there has been no study to directly test this hypothesis, there is compelling indirect evidence to support it. Designing a trial that would answer such a question appears to be the most appropriate way forward.

Pylorus preserving pancreaticoduodenectomy for peri-ampullary carcinoma, is it a good option?

Pancreaticoduodenectomy (PD) is the standard surgical treatment for resectable peri-ampullary tumors. It can be performed with or without pylorus preservation. Many surgeons have a negative opinion of pylorus preserving PD (PPPD) and consider it an inferior operation, especially from an oncological point of view. This article reviews the various aspects of PD in the context of operative factors like blood loss and operation time, complications such as delayed gastric emptying and anastomotic leaks, and the impact on quality of life and survival. We aim to show that PPPD is at least as good as classic PD, if not better in some aspects.

Erythromycin establishes early oral feeding in neonates operated for congenital intestinal atresias

PURPOSE

The recovery of gastrointestinal function following surgery for congenital intestinal atresias can be prolonged and may increase morbidity and hospital stay. This study was conducted to investigate the prokinetic effect of erythromycin in neonates undergoing surgery for small bowel atresias.

METHODS

A randomized-controlled trial was conducted at the Departments of Paediatrics and Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January to December 2007 to study the prokinetic effect of erythromycin (3 mg/kg per dose 4 times daily). Thirty consecutive neonates undergoing primary anastomosis for congenital small bowel atresias were randomly divided into two groups: group I (erythromycin) and group II (control). The groups were similar in terms of gestational age, sex, mode of delivery, birth weight and types of atresias. Postoperative recovery of intestinal functions was measured as time taken to achieve full enteral feed (150 ml/kg per 24 h), duration of total parenteral nutrition (TPN) and hospital stay.

RESULTS

Neonates receiving oral erythromycin achieved full enteral feeding early (13.07 vs. 16.13 days) required TPN for shorter duration (10.53 vs. 13.73 days) and their hospital stay was less (16.2 vs. 18.0 days) as compared to the neonates in the control group who did not receive any erythromycin. The differences were statistically significant.

CONCLUSION

The administration of oral erythromycin following primary anastomosis for small intestinal atresias results in early recovery of intestinal function, fewer days on TPN and a trend for shorter hospital stay.

Gastrointestinal motility after digestive surgery

Gastrointestinal (GI) motility dysfunction is a common complication of any abdominal surgical procedure. During fasting, the upper GI tract undergoes a cyclic change in motor activity, called the interdigestive migrating motor contraction (IMC). The IMC is divided into four phases, with phase III having the most characteristic activity. After digestive surgery, GI motility dysfunction shows a lack of a fed response, less phase II activity, more frequent phase III activity of the IMC, and some phase III activity migrating orally. Postoperative symptoms have been related to motor disturbances, such as interrupted or retrograde phase III or low postprandial activity. The causes of GI disorder are autonomic nervous dysfunction and GI hormone disruptions. The administration of a motilin agonist can induce earlier phase III contractions in the stomach after pancreatoduodenectomy. For nervous dysfunction, an inhibitory sympathetic reflux is likely to be important in postoperative motility disorders. Until recently, treatment for gut dysmotility has consisted of nasogastric suction, intravenous fluids, and observation; however, more effective treatment methods are being reported. Recent discoveries have the potential to decrease postoperative gut dysmotility remarkably after surgery.

Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection

BACKGROUND/PURPOSE

The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated.

METHODS

We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy.

RESULTS

(1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05).

CONCLUSIONS

Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.

Advances in mechanisms of postsurgical gastroparesis syndrome and its diagnosis and treatment

Postsurgical gastroparesis syndrome (PGS) is a complex disorder characterized by post-prandial nausea and vomiting, and gastric atony in the absence of mechanical gastric outlet obstruction, and is often caused by operation at the upper abdomen, especially by gastric or pancreatic resection, and sometimes also by operation at the lower abdomen, such as gynecological or obstetrical procedures. PGS occurs easily with oral intake of food or change in the form of food after operation. These symptoms can be disabling and often fail to be alleviated by drug therapy, and gastric reoperations usually prove unsuccessful. The cause of PGS has not been identified, nor has its mechanism quite been clarified. PGS after gastrectomy has been reported in many previous studies, with an incidence of approximately 0.4-5.0%. PGS is also a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD), and the complication occurs in the early postoperative period in 20-50% of patients. PGS caused by pancreatic cancer cryoablation (PCC) has been reported about in 50-70% of patients. Therefore, PGS has a complex etiology and might be caused by multiple factors and mechanisms. The frequency of this complication varies directly with the type and number of gastric operations performed. The loss of gastric parasympathetic control resulting from vagotomy contributes to PGS via several mechanisms. It has been reported that the interstitial cells of Cajal (ICC) may play a role in the pathogenesis of PGS. Recent studies in animal models of diabetes suggest specific molecular changes in the enteric nervous system may result in delayed gastric emptying. The absence of the duodenum, and hence gastric phase III, may be a cause of gastric stasis. It was thought that PGS after PPPD might be attributable, at least in part, to delayed recovery of gastric phase III, due to lowered concentrations of plasma motilin after resection of the duodenum. The damage to ICC might play a role in the pathogenesis of PGS after PCC, for which multiple factors are possibly responsible, including ischemic and neural injury to the antropyloric muscle and the duodenum after freezing of the pancreatoduodenal regions or reduction of circulating levels of motilin. As the treatment of gastroparesis is far from ideal, non-conventional approaches and non-standard medications might be of use. Multiple treatments are better than single treatment. This article reviews almost all the papers related to PGS from various journals published in English and Chinese in recent years in order to facilitate a better understanding of PGS.

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

BACKGROUND

Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality.

METHODS

We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations.

RESULTS

A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported.

CONCLUSIONS

The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.

Early oral nutrition after major upper gastrointestinal surgery: why not?

PURPOSE OF REVIEW

To examine the available documentation addressing the introduction of early food after major upper gastrointestinal surgery.

RECENT FINDINGS

No high-quality trials, recent or old, have addressed this topic. A few attempts have been identified. Information is extracted from papers discussing other topics of postoperative care in this field. Generally, nasogastric tubes and nil-by-mouth prevail in the early postoperative period.

SUMMARY

The reluctance to allow early food at will is not evidence based, but neither is the safety of an alternative regimen. Early food at will should probably be allowed after hepatic resections, gastric resections, and total gastrectomies and maybe also after pancreaticoduodenectomies. Resections of the esophagus remain the most challenging issue. The need is urgent for high-powered and high-quality randomized controlled clinical trials.

Effects of motilin and ursodeoxycholic acid on gastrointestinal myoelectric activity of different origins in fasted rats

AIM: To investigate gastrointestinal migrating myoelectric complex (MMC) and the effects of porcine motilin and ursodeoxycholic acid (UDCA) on MMC of gastrointestinal tract of different origins in fasted rats.

METHODS: Three bipolar silver electrodes were chronically implanted on the antrum, duodenum and jejunum. Seven days later 24 experimental rats were divided into 2 groups. One group was injected with porcine motilin via sublingual vein at a dose of 20 μg/kg, the other group was perfused into stomach with UDCA. The gastrointestinal myoelectric activity was recorded 1 h before and 2 h after the test substance infusions into the rats.

RESULTS: In all fasted rats a typical pattern of MMC was observed. Among the totally 68 activity fronts recorded in fasted rats under control, 67% started in duodenum, and 33% in antrum. MMC cycle duration and duration of phase III of antral origin were longer than those of duodenal origin. Administration of 20 μg/kg porcine motilin induced a premature antral phase III of antral origin. But perfusion into stomach with UDCA resulted in shorter MMC cycle duration, longer duration of phase III of duodenal origin, which were followed with shorter cycle duration and duration of antral phase III.

CONCLUSION: In fasted rats, MMC could originate from antrum and duodenum respectively. The characteristics of MMC of different origins may contribute to the large variations within subjects. The mechanisms of different origins of phase III may be different. Porcine motilin and UDCA could affect MMC of different origins of the gastrointestinal tract in fasted state, respectively.

Analysis of multiple factors of postsurgical gastroparesis syndrome after pancreaticoduodenectomy and cryotherapy for pancreatic cancer

AIM: To explore the etiology, pathogenesis, diagnosis, and treatment of postsurgical gastroparesis syndrome (PGS) after pancreatic cancer cryotherapy (PCC) or pancreatico-duodenectomy (PD), and to analyze the correlation between the multiple factors and PGS caused by the operations.

METHODS: Clinical data of 210 patients undergoing PD and 46 undergoing PCC were analyzed retrospectively.

RESULTS: There were 31 (67%, 31/46) patients suffering PGS in PCC group, including 29 with pancreatic head and uncinate tumors and 2 with pancreatic body and tail tumors. Ten patients (4.8%, 10/210) developed PGS in PD group, which had a significantly lower incidence of PGS than PCC group (χ = 145, P < 0.001). In PCC group, 9 patients with PGS were managed with non-operative treatment (drugs, diet, nasogastric suction, etc.), and one received reoperation at the 16th day, but the symptoms were not relieved. In PD group, all the patients with PGS were managed with non-operative treatment. The PGS in patients undergoing PCC had close association with PCC, tumor location, but not with age, gender, obstructive jaundice, hypoproteinemia, preoperative gastric outlet obstruction and the type and number of gastric biliary tract operations. The mechanisms of PGS caused by PD were similar to those of PGS following gastrectomy. The damage to interstitial cells of Cajal might play a role in the pathogenesis of PGS after PCC, for which multiple factors were possibly responsible, including ischemic and neural injury to the antropyloric muscle and the duodenum after freezing of the pancreatico-duodenal regions or reduced circulating levels of motilin.

CONCLUSION: PGS after PCC or PD is induced by multiple factors and the exact mechanisms, which might differ between these two operations, remain unknown. Radiography of the upper gastrointestinal tract and gastroscopy are main diagnostic modalities for PGS. Non-operative treatments are effective for PGS, and reoperation should be avoided in patients with PGS caused by PCC.

Erythromycin induces pyloric relaxation accompanied by a contraction of the gastric body after pylorus-preserving gastrectomy

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery; however, long-term retention of food in the residual stomach is a frequent complication during the early postoperative period. We reported that gastric stasis after PPG was attributable to the delayed recovery of gastric phase III, in which pyloric relaxation accompanied a contraction of the gastric body. The objective of the present study is to determine whether erythromycin can induce phase III with pyloric relaxation after PPG.

METHODS

We studied gastrointestinal motility in dogs after PPG by using strain gauge force transducer. After randomized administration of either erythromycin or saline, interdigestive gastropyloroduodenal motility was recorded.

RESULTS

Erythromycin induced phase III with pyloric relaxation in the early postoperative period. Pyloric relaxation accompanied a contraction of the gastric body. Compared with the saline group (body: 87.2 +/- 16.7 mmHg x min, antrum: 69.7 +/- 13.7 mmHg x min, pylorus: 91.7 +/- 22.1 mmHg x min), the erythromycin group showed significantly increased gastropyloric motility indexes (body: 506.2 +/- 33.5 mmHg x min, antrum: 430.9 +/- 53.7 mmHg x min, pylorus: 589.5 +/- 59.5 mmHg x min).

CONCLUSIONS

Erythromycin can induce phase III, in which pyloric relaxation accompanied a contraction of the gastric body in the early postoperative period after PPG. Erythromycin might be used as a prokinetic agent for the treatment of early gastric stasis after PPG.

Gastric phase 3 motility after pylorus-preserving pancreatoduodenectomy

OBJECTIVE

To analyze factors affecting the recovery course of phase 3 activity of the gastric migrating motor complex after pylorus-preserving pancreatoduodenectomy (PPPD) and investigate effects of the recovery of gastric phase 3 on gastric emptying after feeding.

SUMMARY BACKGROUND DATA

Whether early recovery of gastric phase 3 during fasting would predict early recovery of the fed-state gastric emptying function after PPPD has not been well documented.

METHODS

Manometric recording from the gastric antrum was repeated at a weekly interval until the first appearance of gastric phase 3 in 57 patients after PPPD. Twenty-three clinical parameters were assessed as possible factors affecting the recovery course of gastric phase 3 by simple and multiple regression analyses. A gastric emptying study after feeding of a test meal was performed by the acetaminophen method and the values were compared between patients with and without gastric phase 3 after PPPD.

RESULTS

The mean period before the first appearance of gastric phase 3 was 38 days. Among 23 parameters, only lymph node dissection along the hepatoduodenal ligament significantly delayed recovery of gastric phase 3 after PPPD by univariate and multivariate analyses. The presence or absence of gastric phase 3 in the early postoperative period did not influence gastric emptying after feeding in the intermediate period after PPPD.

CONCLUSIONS

Avoiding lymph node dissection along the hepatoduodenal ligament, if applicable, may contribute to early recovery of gastric phase 3 after PPPD. The recovery state of gastric phase 3 during fasting, however, is not necessarily consistent with the degree of improvement of gastric emptying after feeding.