Esophageal and jejunal motor function after total gastrectomy and Roux-Y esophagojejunostomy

Roux-en-Y limb motility after total gastrectomy

The Roux-en-Y stasis syndrome is a troublesome postgastrectomy syndrome. Although the era of gastric resection for peptic ulcer disease has almost come to an end, the increasing incidence of proximal gastric cancer and the outbreak of bariatric operations make the study of the motility of the Roux-en-Y limb (RYL) after gastric resection or gastroplasty very relevant.This study aims to evaluate the motility of the RYL after total gastrectomy using high-resolution manometry (HRM). We performed an HRM on 8 patients after total gastrectomy for proximal gastric cancer and Roux-en-Y reconstruction, 74 ± 111 months after the operation. At the time of the study, all patients were asymptomatic without evidence of cancer recurrence.Peristaltic waves were noticed at the RYL in 3 (37%) of the patients. The mean wave amplitude of the peristaltic waves was 63 ± 29 (37-94) mmHg and 83 ± 35 (42-104) mmHg at 3 and 7 cm below the esophagojejunal junction, respectively. Simultaneous waves were noticed in 6 (75%) of the patients in 80 ± 32 % (30-100) of the swallows of these patients. No patient presented with absence of motor activity detectable at the HRM. Our results show that: (1) esophageal motility is normal after total gastrectomy with Roux-en-Y reconstruction; (2) motor activity is always detectable at the proximal RYL, but peristalsis is abnormal in most patients; and (3) absence of peristalsis does not translate into symptoms.

A mechanistic pharmacokinetic model to assess modified oral drug bioavailability post bariatric surgery in morbidly obese patients: interplay between CYP3A gut wall metabolism, permeability and dissolution

Objectives

Due to the multi-factorial physiological implications of bariatric surgery, attempts to explain trends in oral bioavailability following bariatric surgery using singular attributes of drugs or simplified categorisations such as the biopharmaceutics classification system have been unsuccessful. So we have attempted to use mechanistic models to assess changes to bioavailability of model drugs.

Methods

Pharmacokinetic post bariatric surgery models were created for Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch, sleeve gastrectomy and jejunoileal bypass, through altering the ‘Advanced Dissolution Absorption and Metabolism’ (ADAM) model incorporated into the Simcyp® Simulator. Post to pre surgical simulations were carried out for five drugs with varying characteristics regarding their gut wall metabolism, dissolution and permeability (simvastatin, omeprazole, diclofenac, fluconazole and ciprofloxacin).

Key findings

The trends in oral bioavailability pre to post surgery were found to be dependent on a combination of drug parameters, including solubility, permeability and gastrointestinal metabolism as well as the surgical procedure carried out.

Conclusions

In the absence of clinical studies, the ability to project the direction and the magnitude of changes in bioavailability of drug therapy, using evidence-based mechanistic pharmacokinetic in silico models would be of significant value in guiding prescribers to make the necessary adjustments to dosage regimens for an increasing population of patients who are undergoing bariatric surgery.

Long-term and short-term evaluation of esophageal reconstruction using the colon or the jejunum in esophageal cancer patients after gastrectomy

For esophageal cancer patients, the gastric tube is the first choice as an esophageal substitute, with the colon or the jejunum being used when the stomach cannot be used. We retrospectively compared these two methods from the viewpoint of peri-operative complications and long-term bodyweight alteration. From 1998 to 2005 53 patients who had undergone subtotal esophagectomy due to thoracic esophageal cancers were given reconstruction with the colon (28 cases) or the jejunum (25 cases). Both intestines were reconstructed via the subcutaneous route and were anastomosed to the internal mammalian artery and vein for a supercharged blood supply. There was no difference in operating time and blood loss. Compared with the colon reconstruction group, the hospital stay of the jejunum reconstruction group was significantly shorter (65 days vs 45 days, P = 0.0120) and the incidence of anastomotic leakage tended to be less (13 cases, 46%vs 6 cases, 24%, P = 0.1507), while other operative morbidity did not differ between the two groups. Bodyweight loss, which is a serious postoperative sequela after esophagectomy, was less in the jejunum group than in the colon group, showing a significant difference at 12 months after surgery. Our retrospective study revealed the jejunum to be superior to the colon for the reconstruction after esophagectomy along with gastrectomy, with respect to anastomotic leakage and bodyweight loss. The next step will be to conduct a prospective large cohort study.

Studies on gastrointestinal hormone and jejunal interdigestive migrating motor complex in patients with or without early dumping syndrome after total gastrectomy with Roux-en-Y reconstruction for early gastric cancer

BACKGROUND

There has been no report concerning fasting Roux limb motilities and gut hormone in patients with early dumping syndrome (EDS) after total gastrectomy with Roux-en-Y reconstruction. The present study investigated interdigestive migrating motor complex, phase III (IMMC-pIII) in the Roux limb, changes in the plasma gut hormone levels, and the relationships among those parameters and EDS.

METHODS

Forty-eight patients (35 men, 13 women; aged 33 to 69 years, mean, 59.8) 1.5 to 2.0 years (mean 1 year, 8 months) after total gastrectomy with Roux-en-Y reconstruction for early gastric cancer were allocated to two groups based on the presence or absence of EDS. The occurrence of IMMC-pIII was compared and changes in the plasma levels of both motilin (MT) and somatostatin (SOM) were monitored.

RESULTS

None of the patients with EDS (n = 8) were recognized as having IMMC-pIII. In the IMMC-pIII positive group, MT and SOM increased sequentially from phase I through IMMC-pIII. In the IMMC-pIII negative group, MT and SOM were significantly lower than in the IMMC-pIII positive group during phases I, II, and IMMC-pIII (P <0.05, P <0.01, P <0.01, respectively).

CONCLUSIONS

There is an absence of IMMC-pIII in patients with EDS, and both MT and SOM might be necessary for IMMC-pIII generation.

Oral erythromycin improves gastrointestinal motility and transit after subtotal but not total gastrectomy for cancer

BACKGROUND

Erythromycin has been shown to be a powerful prokinetic of the gastrointestinal tract. Little is known about its value to improve motility and transit in gastrectomized patients.

METHODS

Thirteen disease-free patients subjected to subtotal gastrectomy and 11 subjected to total gastrectomy for gastric cancer entered the study. Gastrointestinal transit of a standard 99mTc-labelled meal and fasting motility were studied before and after oral erythromycin.

RESULTS

In patients who had subtotal gastrectomy mean(s.d.) gastric half-emptying time was 42(14) min before and 26(11) min after erythromycin (P = 0.011). Before erythromycin prolonged rhythmical contractions (3 per min) were recorded in eight patients, sporadic non-organized contractions in two and prolonged bursts of waves in one. After erythromycin, clustered waves resembling a migrating motor complex (MMC) appeared in eight patients, while rhythmic motor activity was unchanged in three. In patients who had total gastrectomy jejunal half-emptying time was 39(18) min before and 45(12) min after erythromycin. In eight patients, frequent MMCs were recorded, peristaltic in four, synchronous in one, antiperistaltic in two, with clusters of non-propagated waves in one. After erythromycin, longer peristaltic MMCs were recorded in three, antiperistaltic MMCs persisted in two, synchronous in one and clusters of non-propagated waves in two.

CONCLUSION

Oral erythromycin improves gastrointestinal transit and motility after subtotal gastrectomy. The findings after total gastrectomy are controversial.

Gastrointestinal motility of patients with Roux-en-Y reconstruction

The electromyographic activity of the gastrointestinal tract was studied in 28 patients undergoing gastric, biliary, and pancreatic operations with reconstruction of the gastrointestinal tract with a Roux-en-Y limb. The Roux-en-Y limb was constructed 1 to 5 years before the study in 8 patients (chronic Roux-en-Y) and at the operation in which the electrodes were implanted in 20 patients (recent Roux-en-Y). All four phases of the migrating motor complex (MMC) were identified in the gastrointestinal tract, including in the Roux-en-Y limb. The duration of the MMC was 82.4 +/- 22.3 min in the patients with chronic Roux-en-Y and 89.0 +/- 25.1 min in the patients with recent Roux-en-Y. Food ingestion converted the MMC to the fed pattern in the entire gastrointestinal tract, including the Roux-en-Y limb in 16 (76.2%) of 21 recordings of the patients with chronic Roux-en-Y and in 27 (84.4%) of 32 recordings of the patients with recent Roux-en-Y. The duration of the fed pattern was 170 +/- 34 min in the patients with chronic Roux-en-Y and 154 +/- 26 min in the patients with recent Roux-en-Y. The findings of this study indicate that the electromyographic activity of the Roux-en-Y limb is normal during both fasting and fed states, even many years after the construction of the Roux-en-Y.