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

Thyroid hormone activated upper gastrointestinal motility without mediating gastrointestinal hormones in conscious dogs

This study was conducted to clarify the relationship between thyroid function and gastrointestinal motility. We established an experimental configuration in which the feedback of thyroid function was completely removed using conscious dogs. With hypothyroidism, time of phase I of interdigestive migrating contractions (IMC) was longer, time of phase II and phase III was significantly shortened, and both the continuous time of strong tetanic contraction at antrum and 10-h frequency of phase III counted from the first IMC after meal significantly decreased. Whereas, hyperthyroidism caused the opposite events to those with hypothyroidism. Furthermore, We found giant migrating contractions (GMC) occurred from the upper gastrointestinal tract when we administrated high dose of thyroid hormone. One GMC occurred from anal sides propagated to cardiac, and this propagation was similar to the emesis-like interdigestive motor activity, the other GMC occurred from oral sides propagated to anal sides and this was similar to the diarrhea-like interdigestive motor activity. We examined the relationship between thyroid function and gastrointestinal hormones including of ghrelin, GLP-1, and cholecystokinin (CCK). However, we could not find significant differences under different thyroid hormone status. This is the first report that thyroid hormone activated upper gastrointestinal motility without mediating gastrointestinal hormones.

Impact of gastropyloric motor activity on the genesis of reflux esophagitis after an esophagectomy with gastric tube reconstruction

BACKGROUND

Reflux esophagitis is a significant problem in patients after an esophagectomy with gastric tube reconstruction. The pathogenesis of reflux esophagitis is not fully understood. The aim of the present study was to evaluate whether gastropyloric motility influences the pathogenesis of reflux esophagitis after an esophagectomy.

METHODS

Thirty esophagectomized patients were assessed by endoscopy and manometry. The patients were classified into 3 groups according to the postoperative period as follows: Group 1 (less than 12 months), group 2 (12 to 24 months), and group 3 (more than 24 months). Gastropyloric motor activity was quantified by calculating the motility index, which is equivalent to the area under the contractile waves.

RESULTS

Reflux esophagitis was observed in 80% of group 1, 80% of group 2, and 30% of group 3. The severity of reflux esophagitis decreased with time. Contractions of the gastric body were not observed in any of the patients. The antral motility index in group 3 was significantly greater than that in groups 1 and 2. The pyloric motility index progressively increased. The severity of reflux esophagitis is significantly associated with gastropyloric motor activity.

CONCLUSIONS

The severity of reflux esophagitis decreases with time, coupled with recovery of antropyloric motor activity. Gastropyloric motor activity plays an important role in the genesis of reflux esophagitis after an esophagectomy.

Effect of rikkunshito, a Japanese herbal medicine, on gastrointestinal symptoms and ghrelin levels in gastric cancer patients after gastrectomy

BACKGROUND

Gastric cancer patients who undergo gastrectomy suffer from a post-gastrectomy syndrome that includes weight loss, dumping syndrome, reflux esophagitis, alkaline gastritis, and finally malnutrition. It is important to ameliorate the post-gastrectomy symptoms to restore postoperative quality of life (QoL). The aim of this study was to investigate the effect of rikkunshito, a Japanese herbal medicine, on postoperative symptoms and ghrelin levels in gastric cancer patients after gastrectomy.

METHODS

Twenty-five patients who had undergone gastrectomy received 2.5 g of rikkunshito before every meal for 4 weeks, and a drug withdrawal period was established for the next 4 weeks. Changes in gastrointestinal hormones, including ghrelin, and appetite visual analog scale scores were measured, and QoL was estimated by using the European Organization for Research and Treatment of Cancer core questionnaire QLQ-C30. The Dysfunction After Upper Gastrointestinal Surgery for Cancer (DAUGS) scoring system was used to evaluate gastrointestinal symptoms after gastrectomy.

RESULTS

Sixteen men and nine women (mean age 61.9 years) were enrolled in the study. All patients had either stage I (n = 24) or II (n = 1) disease and had undergone either distal gastrectomy (n = 17) or total gastrectomy (n = 8) by a laparoscopy-assisted approach. The mean ratio of the acyl-/total ghrelin concentration increased significantly after rikkunshito administration (Pre: 7.8 ± 2.1, 4 weeks: 10.5 ± 1.7 %, p = 0.0026). The total DAUGS score, as well as the scores reflecting limited activity due to decreased food consumption, reflux symptoms, dumping symptoms, and nausea and vomiting significantly improved after rikkunshito administration.

CONCLUSIONS

The present study demonstrated a significant attenuation of gastrointestinal symptoms after gastrectomy by treatment with rikkunshito. Rikkunshito is potentially useful to minimize gastrointestinal symptoms after gastrectomy.

Physiological evaluation of residual stomach motility after local resection in conscious dogs

PURPOSE

To investigate the phenomenon of remnant gastric motility and emptying after local resection.

METHODS

Fifteen dogs were divided into three groups: a control (CONT) group, a group that underwent local resection of the greater (GREAT) curvature, and a group that underwent resection of the lesser (LESS) curvature. We conducted a strain gauge force transducer study, a [(13)C]octanoic acid breath test ((13)C-OBT), and a mosapride citrate effect test. Based on these results, we worked out the receptive relaxation (RR), motility index (MI), and postprandial period (PP) in the postprandial state, and the frequency, duration, and MI of phase III in the fasted state. The half emptying time (T (1/2)) of (13)C-OBT was also calculated. The MI was compared according to the mosapride effect test results.

RESULTS

Postprandial RR, antro-pyloro-duodenal coordination, and fasting contractions were maintained in all three groups. Receptive relaxation was significantly shorter in the LESS group than in the other groups. Motility index was significantly lower in both treatment groups than in the CONT group. The PP was significantly longer in the GREAT group than in the other two groups. The (13)CO(2) excretion curves did not differ significantly among the groups. The duration of phase III was remarkably less in the treatment groups than in the CONT group, and MI was significantly lower in the LESS group than in the other groups in the fasted state. The MI increased remarkably after mosapride administration in the CONT group, showing no differences in other objective groups.

CONCLUSION

Gastric function was maintained after gastric local resection, although its motility decreased.

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.

Effect of rikkunshito, a chinese herbal medicine, on stasis in patients after pylorus-preserving gastrectomy

BACKGROUND

Distal gastrectomy (DG) and pylorus-preserving gastrectomy (PPG) have been employed for gastric cancer, with PPG having been reported to be superior to DG in regard to postoperative quality of life. Some patients with these operations still suffer from gastric stasis, however. In this study, we aimed to examine the clinical effects of rikkunshito on patients who were to undergo PPG.

METHODS

A total of 11 patients who were scheduled to undergo PPG for early gastric cancer at the Osaka University Hospital were enrolled. The patients were randomly assigned to the crossover study with and without rikkunshito 7.5 g/day. Questionnaires and emptying tests using (111)In-labeled liquid scintigraphy and (99m)Tc-labeled solid scintigraphy were performed at the end of each treatment period.

RESULTS

Stasis-related symptoms were significantly reduced during rikkunshito treatment (p = 0.043). The emptying test showed that rikkunshito improved emptying of solid meals (p = 0.0003) from the remnant stomach but did not accelerate gastric empting of liquid meals.

CONCLUSIONS

Rikkunshito improved gastric emptying and ameliorated postoperative symptoms of patients who had undergone a PPG.

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial

BACKGROUND

Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections.

MATERIALS AND METHODS

Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea.

RESULTS

One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups.

CONCLUSION

Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.

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.

Duodenal interdigestive migrating motor complex in patients 5 years or more after pylorus-preserving gastrectomy for early gastric cancer

BACKGROUND

We investigated the relationship between interdigestive migrating motor complex, phase III (IMMC-pIII) and postoperative quality of life (QOL) in pylorus-preserving gastrectomy (PPG) patients.

MATERIALS AND METHODS

A total of 40 patients (26 men and 14 women; average age 59.4 years) 5 to 7.5 years after PPG for early gastric cancer (Billroth I) (average 6 years and 3 months) were divided into two groups according to the occurrence of IMMC-pIII from the duodenum, and their postoperative quality of life (QOL) was compared.

RESULTS

As for appetite, "No change compared with before operation" was significantly more frequent in the IMMC-pIII positive group compared with the negative group (P=0.0002). Food consumption per meal compared with normal; "80% or more" was significantly more frequent in the IMMC-pIII positive group than the negative group (P=0.0002). Body weight loss during 5 years after surgery; "6 kg or more" was significantly more frequent in the IMMC-pIII negative group than the positive group (P=0.0002). Early dumping symptoms did not occur in any patients of either group. Reflux esophagitis and nausea; no patients in the IMMC-pIII positive group experienced these symptoms, which was significantly different from the negative group (P=0.0018). Abdominal pain occurred but was significantly less frequent in the IMMC-pIII positive group than in the negative group (P=0.0023). Epigastric fullness occurred but was less frequent in the IMMC-pIII positive group compared with the negative group (P<0.0001). Gastric stasis of the remnant stomach was significantly more frequent in the IMMC-pIII negative group than in the positive group (P<0.0001). Gholelithiasis was significantly more frequent in the IMMC-pIII negative group than in the positive group (P=0.0119).

CONCLUSIONS

These results showed more satisfactory QOL in the IMMC-PIII positive group than in the negative group.

Hydro-MRI of the small bowel: effect of contrast volume, timing of contrast administration, and data acquisition on bowel distention

OBJECTIVE

The purpose of this study was to assess oral contrast agents, volumes of the agents, and time points of data acquisition in regard to small-bowel distention and patient acceptance.

SUBJECTS AND METHODS

Six healthy volunteers underwent imaging on 16 different days. Four volumes (450, 900, 1,350, and 1,800 mL) of each of the four contrast compounds (0.2% locust bean gum plus 2.5% mannitol, VoLumen containing 2.0% sorbitol, VoLumen containing 1.4% sorbitol, and tap water) were used. Two-dimensional true fast imaging with steady-state free precession data sets were acquired at 5-minute intervals after contrast ingestion. Distention values for small-bowel segments (duodenum, proximal and distal jejunum, ileum) and occurrence of side effects were documented.

RESULTS

Analysis of bowel distention revealed significantly greater distention for all carbohydrate sugar alcohol-containing solutions compared with water but no significant difference among the three contrast agents. Sufficient duodenal distention was achieved with 900 mL of any of the contrast agents, but imaging had to be performed soon after ingestion. For MRI of the distal jejunum and ileum, a volume of 1,350 mL is preferable, and the time point of data acquisition plays a minor role. Ingestion of 1,800 mL of the carbohydrate sugar alcohol solutions led to a significantly higher rate of side effects such as abdominal cramps than did ingestion of smaller volumes.

CONCLUSION

The data indicate that sufficient contrast consumption and optimal timing of data acquisition are essential to distention of the small bowel. Oral contrast agent protocols should be adapted to the bowel region in question.

Oral contrast agents for small bowel distension in MRI: influence of the osmolarity for small bowel distention

To assess the effect of the osmolarity for small bowel distension in MRI, ten volunteers ingested at two separate occasions negative oral contrast agents with different quantity and osmolarity: (1) a water solution combined with 2.0% sorbitol and 0.2% locus bean gum (LBG) with a quantity of 1500 ml and an osmolarity of 148 mOsmol/l, (2) a water solution combined with 2.0% sorbitol and 2.0% barium sulphate with a quantity of 1000 ml and an osmolarity of 194 mOsmol/l. Small bowel distension was quantified on coronal 2D-TrueFISP images by measuring the small bowel diameters. There were no statistically significant differences in mean small bowel diameter between both contrast agents. The mean small bowel distension was 19.2 mm after ingestion of 1500 ml of sorbitol-LBG solution and 19.0 mm after ingestion of 1000-ml sorbitol-barium sulphate solution. Furthermore, all volunteers found the ingestion of 1000-ml solution more pleasant than the 1500-ml solution. The ingestion of 1000 ml of sorbitol-barium sulphate solution led to a sufficient small bowel distension compared to 1500 ml of sorbitol-LBG solution. The side effect rate of both solutions was low. Based on these data, we recommend a quantity of 1000 ml of sorbitol-barium sulphate solution as an alternative for 1500-ml sorbitol-LBG solution for optimal bowel distension.

Dose optimization of mannitol solution for small bowel distension in MRI

PURPOSE

To optimize the dose of a hydro solution containing 2.5% mannitol and 0.2% locust bean gum (LBG) for small bowel MRI in terms of bowel distension and patient acceptance.

MATERIALS AND METHODS

A total of 10 healthy volunteers ingested a hydro solution containing 2.5% mannitol and 0.2% LBG. Four different volumes (1500, 1200, 1000, and 800 ml) were assessed on four different examination days. Small bowel distension was quantified on coronal two-dimensional TrueFISP images by measuring the diameter of eight bowel loops throughout the jejunum and the ileum. In addition, volunteer acceptance was evaluated for every single examination by using a questionnaire.

RESULTS

Optimal distension was obtained with either, 1000, 1200, or 1500 ml, with no statistically significant differences in distension between these groups. Administration of 800 ml led to significantly less distension of the small bowel. Significantly less side effects were noted using either 800 or 1000 ml compared to using larger volumes.

CONCLUSION

We recommend a dose of 1000 ml mannitol/LBG solution as an oral contrast agent for optimal bowel distension and minimal side effects.

Small bowel hydro-MR imaging for optimized ileocecal distension in Crohn's disease: Should an additional rectal enema filling be performed?

PURPOSE

To assess the impact of an additional rectal enema filling in small bowel hydro-MRI in patients with Crohn's disease.

MATERIALS AND METHODS

A total of 40 patients with known Crohn's disease were analyzed retrospectively: 20 patients only ingested an oral contrast agent (group A), the other 20 subjects obtained an additional rectal water enema (group B). For small bowel distension, a solution containing 0.2% locust bean gum (LBG) and 2.5% mannitol was used. In all patients, a breathhold contrast-enhanced T1w three-dimensional volumetric interpolated breathhold examination (VIBE) sequence was acquired. Comparative analysis was based on image quality and bowel distension as well as signal-to-noise ratio (SNR) measurements. MR findings were compared with those of conventional colonoscopy, as available (N = 25).

RESULTS

The terminal ileum and rectum showed a significantly higher distension following the rectal administration of water. Furthermore, fewer artifacts were seen within group B. This resulted in a higher reader confidence for the diagnosis of bowel disease, not only in the colon, but also in the ileocecal region. Diagnostic accuracy in diagnosing inflammation of the terminal ileum was 100% in group B; in the nonenema group there were three false-negative diagnoses of terminal ileitis.

CONCLUSION

Our data show that the additional administration of a rectal enema is useful in small bowel MRI for the visualization of the terminal ileum. The additional time needed for the enema administration was minimal, and small and large bowel pathologies could be diagnosed with high accuracy. Thus, we suggest that a rectal enema in small bowel MR imaging be considered.

Oral contrast agents for small bowel MRI: comparison of different additives to optimize bowel distension

The purpose of this study was to compare two osmotic carbohydrate sugar alcohols (mannitol 2.5% and sorbitol 2.5%, 2.0%, and 1.5% watery solutions) in combination with 0.2% locust bean gum (LBG) for small bowel distension for MR imaging. Small bowel distension was quantified on coronal 2D TrueFISP images by measuring the diameters of 16 small bowel loops in each of 12 healthy subjects (age range 31-55 years). Additionally, the grade of small bowel distension was rated qualitatively. Patient acceptance concerning nausea, vomiting, flatulence, and diarrhea was noted for each solution, and all results were compared by a Wilcoxon test or t test, respectively. The ingestion of water combined with LBG and either 2.5% mannitol or 2.0% sorbitol showed the best distension of the small bowel. The lowest side effect rate was observed following ingestion of sorbitol in a concentration of 2.0 and 1.5%. Based on these data, we recommend a combination of LBG and 2% sorbitol use for optimal bowel distension and minimal side effects resulting in enhanced patient acceptance.