Feasibility of International Proposed Standardized Enteral Connector for Semi-Solid Formula Feeding.

BACKGROUND/AIMS: The current study was undertaken to assess if the semi-solid formulas could be used with a new ENFit connector with similar force to current percutaneous endoscopic gastrostomy (PEG) tubes. METHODS: Experiment 1: We measured the applied pressure (force) needed to compress the syringe containing 7 viscous semi-solid formulas with a 20 Fr PEG tube and low-profile tube through the ENFit connector or the current connector. Experiment 2: This experiment was conducted to evaluate the compression force through 2 connectors in 3 infusion velocity, 7 PEG tube types with 2 semi-solid formulas. RESULTS: Experiment 1: The force needed to compress the syringe through the ENFit connector was higher in 3 semi-solid formulas with a 20 Fr low-profile tube; otherwise, there were no significant differences. Experiment 2: Each formula required a higher force in the ENFit connector in 6 settings out of 21. CONCLUSIONS: The ENFit connector will likely not show any remarkable change in the force to administer the semi-solid formula. However, a higher force was required under some conditions in the prototype ENFit connector. Further investigation of sensory test is needed to confirm the feasibility of the ENFit connector for using the semi-solid formulas.

Metastasis to the skin at the drain site after complete resection of the lower bile duct cancer: report of a case.

There are extremely few reports of metastases from a lower cholangiocarcinoma to the skin except for metastatic seeding in a percutaneous transhepatic biliary drainage catheter tract. This report presents a rare case of metastases to the skin after the removal of a drain following curative pancreaticoduodenectomy for lower bile duct cancer (LBDC). A 73-year-old female had undergone subtotal stomach-preserving pancreaticoduodenectomy. Skin metastasis was noted at the site where the drain from the lower border at pancreaticojejunostomy had been removed 22 weeks postoperatively, and it was en bloc resected with the abdominal wall without exposing the carcinoma. Multiple nodules were confirmed in the axilla and chest wall 40 weeks after the initial operation. Careful discussion is necessary to avoid this mode of metastasis. The surgical field should not be exposed to pancreatic juice, even with LBDC. Nevertheless, this case is rare. Therefore, the risks and benefits of using such drains must be considered.

Microdialysis detection of lactate in subcutaneous tissue as a reliable indicator of tissue metabolic disorders in an animal sepsis model.

PURPOSE: Tissue dysoxia is thought to be a fundamental cause of the organ failure that occurs as a result of shock. Plasma lactate has been frequently measured as an indicator of the state of systemic tissue metabolism. On the other hand, tissue lactate levels can directly indicate a disorder in the state of cytological tissue metabolism. The continuous monitoring of lactate levels in subcutaneous tissue will reflect the state of tissue dysoxia more precisely than levels of lactate in the plasma lactate. We have investigated the differences in the levels of plasma and tissue lactate using a microdialysis (MD) technique in an animal septic shock model. METHOD: Male 8-week-old Wistar/ST rats were used. We prepared an animal model by injection of lipopolysaccharide (LPS) into the abdominal cavity. LPS was given to 9 animals in the experimental group while physiological saline was given to 6 animals in the control group. A MD probe was used to quantify the lactate levels in the subcutaneous tissue. The mean arterial pressure, blood gas content and lactate levels were measured every 50 min up to 400 min after injection and compared between both groups. RESULT: The MAP of both groups showed similar changes after injection. Plasma lactate levels in the LPS group showed a significant increase after 100 min and reached a plateau from 150 min to 250 min. Subcutaneous lactate in the LPS group showed a significant increase after 150 min. Subcutaneous pyruvate in the LPS group showed a significant increase after 100 min. The lactate/pyruvate (L/P) ratio in the subcutaneous tissue showed a sustained increase from 300 min in the LPS group. CONCLUSION: Monitoring plasma lactate levels is useful for the early assessment of anaerobic metabolism before hypotension. Plasma lactate levels did not increase during some periods. This phenomenon was due to the balance between production and utilization. However, tissue lactate showed a chronological increase. These results suggest that the measurement of tissue lactate levels is reliable for assessing local energy metabolic disturbances. Under conditions of septic shock, an increase in lactate levels was found to be a sensitive marker of tissue metabolism disorder.

Laparoscopy-assisted total gastrectomy for advanced gastric cancer with carcinomatous ascites after S1 plus cisplatin chemotherapy: a case report.

A 29-year-old man with a type 4 tumor, in the lower third of the stomach, and carcinomatous ascites was diagnosed by aspiration cytology of the ascitic fluid. Curative resection was considered impossible, and S1 (120 mg/d) and cisplatin (90 mg/d) were given for 21 days in 1 course. The cancer lesion showed marked remission (partial response), and the ascites completely disappeared after the fourth course. Twenty-five days after completion of the S1 treatment, laparoscopy-assisted total gastrectomy was performed. Histopathological examination showed no remnant cancer cells in the resected specimen and no lymph node metastases. The tumor was replaced with fibrosis having a granulomatous change. The patient's postoperative course was uneventful. The patient was continued with S1 monotherapy after surgery, and no signs of recurrence or metastases have been seen on any examination 12 months after the surgery.

Effects of half-solid nutrients on gastroesophageal reflux in beagle dogs with or without cardioplasty and intrathoracic cardiopexy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has become an important modality to provide enteral access for long-term nutritional support. Nevertheless, aspiration of liquid nutrients due to vomiting and reflux esophagitis caused by gastroesophageal reflux (GER) is a significant problem associated with tube feeding by PEG. MATERIALS AND METHODS: First, gastrostomy as an access for enteral nutrition and esophagostomy for gastroesophageal pH and Bilitec monitoring were performed in eight beagle dogs, in which the influence of viscosity of an enteral formula on the degree of GER was investigated using a commercially available liquid meal and a nearly isocaloric half-solid diet that was prepared by adding a solution mixed with dextrin, pectin, and calcium lactate. Second, similar studies were accomplished in seven beagle dogs that underwent cardioplasty and intrathoracic cardiopexy (a model of GER disease [GERD]). RESULTS: There was no difference in the degree of GER evaluated by Bilitec monitoring between liquid and half-solid nutrients in eight normal dogs, whereas solidifying nutrients significantly reduced the frequency of reflux during the feeding periods (P=0.0180) and post-feeding periods (P=0.0277) in a model of GERD. CONCLUSION: The use of half-solid nutrients for enteral feeding reduced the frequency of reflux in a dog model of GERD.

Effects of Gelatinization of Enteral Nutrients on Human Gastric Emptying.

BACKGROUND: Gastrointestinal side effects, particularly diarrhea, are still the main reasons for discontinuation of enteral nutrition. Gelatinization of liquid meal for the prevention of diarrhea has been reported as effective. The purpose of this study was to investigate the effects of gelatinization of liquid meal on gastric emptying. METHODS: Ten healthy volunteers were studied two times, with 2-week interval between tests. The total calorific value was set at 225 kcal, and 3 test meals were prepared: liquid meal and 2 types of gelatinized meals. These 2 types of gelatinized meals are different viscosity. 13C-sodium acetate (100 mg) was thoroughly mixed, and exhaled air was sampled. The results of gastric emptying were expressed as the time of peak excretion (Tmax), and absorption was expressed as the area under the 13CO2 curve up to Tmax (AUC-Tmax). At the same time, blood samples were collected to measure levels of blood glucose, insulin and gastrin. RESULTS: The mean value of Tmax were 52.0, 77.3 and 85.6 min. Compared to liquid meal, gastric emptying for gelatinized meals was significantly delayed. The mean value of AUC-Tmax were 22.7, 28.7 and 33.7%dose, respectively, and no significant differences in absorption were seen. No significant differences existed in blood glucose, gastrin and insulin. CONCLUSIONS: Gelatinization of liquid meal delays gastric emptying. Gelatinized liquid meal may be useful for the management of diarrhea accompanied with enteral nutrition without influencing gastrointestinal hormone and blood glucose.

Misinsertion of an esophageal bougie between the mucosa and muscular layer of the lower esophagus during operation in a case of achalasia.

Laparoscopic fundoplication is the current standard operation for gastroesophageal reflux disease and achalasia. An esophageal bougie is often placed for constructing a wrap or performing myotomy easily during the operation. The surgical complications reportedly include hemorrhage, esophageal perforation, gastric perforation, and vagus nerve damage. However, to the best of our knowledge, there is no report of any case of esophageal bougie misinsertion into the lower esophageal mucosa. The patient was a woman in her 50s who underwent laparoscopic Heller-Dor operation for achalasia in April 2007. During myotomy, we encountered difficulty in inserting a 56Fr-bougie and eventually realized that we had misinserted the Endolumina through the pyriform sinus into the esophageal mucosa. As the pyriform sinus injury was limited to the mucosa and there was no evidence of mediastinal perforation as assessed by intraoperative endoscopic examination, we continued the laparoscopic operation. On postoperative day 1, the patient complained of mild chest pain and pharyngeal pain, but there were only few signs of inflammation. Chest computed tomography revealed findings suggestive of a hematoma extending from the neck to the lower chest, most prominently in the right esophageal wall, however, the patient was followed up conservatively as there was no clear indication of perforation. Subsequently, both the chest pain and pharyngeal pain subsided. On postoperative day 5, the patient was allowed oral water intake, as a gastrografin swallow study did not indicate any problems. On postoperative day 6, the patient was allowed semiliquid foods orally. She was discharged from the hospital on day 11, without any particular problems. Currently, 10 months postsurgery, she is doing well, without any recurrence of symptoms such as dysphagia.

Primary gastric plasmacytoma refractory to Helicobacter pylori eradication therapy.

A 49-year-old woman underwent upper gastrointestinal endoscopic examination for epigastric discomfort, revealing giant folds on the greater curvature of the stomach. Histological examinations of biopsy specimens taken from the giant folds showed signs of chronic inflammation, and Helicobacter pylori was also identified. She underwent first-step H. pylori eradication. On follow-up endoscopy, H. pylori was not identified. However, endoscopic findings were unchanged and repeated biopsies showed dense infiltration of atypical plasma cells. No proliferation of centrocyte-like cells was seen. Immunohistochemically, plasma cells were positive for lambda-chain. Primary gastric plasmacytoma was diagnosed. Total gastrectomy was carried out with splenectomy and regional lymph node dissection. The patient remains disease free as of 6 years postoperatively.

Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia.

BACKGROUND: Laparoscopic Heller myotomy and Dor fundoplication are now widely performed for achalasia. In patients who have had dilatation in the past, inflammation between the esophageal mucosal and muscular layers may make it difficult to perform myotomy. PURPOSE: We investigated the effects of preoperative dilatation on the surgical outcomes. METHOD: : One hundred and twelve patients were divided into 2 groups: 37 patients with a past history of preoperative dilatation and 75 patients who had no history of preoperative dilatation. The operating time, intraoperative blood loss, days required to resume postoperative oral intake, postoperative hospital stay, improvement in dysphagia, and incidence of postoperative esophagitis were compared. RESULTS: The operating time, intraoperative blood loss, postoperative hospital stay, and improvement of dysphagia were no significant differences between these groups. Furthermore, there were no significant differences in the incidence of postoperative esophagitis. CONCLUSIONS: The therapeutic outcome of laparoscopic Heller myotomy and Dor fundoplication is not affected by preoperative pneumatic dilatation.

Effect of Dai-kenchu-to on gastrointestinal motility and gastric emptying.

BACKGROUND/AIMS: The gastrointestinal symptoms accompanying dysfunction of the remnant stomach were seen after pylorus-preserving operation. Against such complications, Dai-kenchu-to (DKT) is used, but scientific evidences for efficacy are poor. The effect of DKT on gastrointestinal motility and gastric emptying after pylorus-preserving operation was investigated. METHODS: Using beagle dogs, the experimental models mimicking the state after pylorus-preserving pancreaticoduodenectomy were prepared. We sutured strain gauge transducers to the stomach, duodenum and jejunum and inserted indwelling tubes into the stomach. About 4 weeks after operation, DKT 0.1g/kg was administered during the fasting or fed state. At the same time, the gastric emptying was evaluated by the acetoaminophene method. RESULTS: In the fasting state, administration of DKT enhanced the gastrointestinal motility and accelerated gastric emptying. In the postprandial state, no apparent effect on motility was seen. CONCLUSION: DKT enhances the gastrointestinal motility after pylorus-preserving pancreaticoduodenectomy in the fasting state. The effect of DKT may not be related to the continuity of the intramural nerve.

Early postoperative enteral nutrition is useful for recovering gastrointestinal motility and maintaining the nutritional status.

PURPOSE: The efficacy of enteral nutrition in postoperative nutritional management is known, but the effects on gastrointestinal motility and nutrition have not yet been elucidated. The purpose of this study was to compare the effects of enteral and parenteral nutrition soon after open abdominal surgery on gastrointestinal motility and nutritional status. METHODS: A partial resection of rectum models was prepared to compare two types of nutrient administration: enteral nutrition and total parenteral nutrition. The differences between the effects of nutrition types in terms of gastrointestinal motility and nutritional status were investigated. RESULTS: Enteral nutrition contributed to recovery of gastrointestinal motility and maintenance of nutritional status. CONCLUSION: Enteral nutrition should therefore be initiated soon after surgery if the gastrointestinal tract is available.

Utility of microdialysis to detect the lactate/pyruvate ratio in subcutaneous tissue for the reliable monitoring of hemorrhagic shock.

The present experiments were carried out to investigate the usefulness of measuring peripheral tissue metabolism for the clinical assessment of shock. Male Wistar/ST rats (8 weeks-old) were used. All rats were placed in a supine position while anesthetized. A tube for measuring arterial pressure and collecting blood samples was cannulated into the femoral artery. For microdialysis, the introducer was inserted into the subcutaneous tissue in the abdominal wall. Blood was exsanguinated to maintain the mean arterial pressure at 40 +/- 5 mmHg. Mean arterial pressure, arterial blood gas and serum lactate levels were measured. Microdialysis was performed to quantify the levels of lactate and pyruvate in the subcutaneous tissue. Six rats died due to hemorrhagic shock by 350 min (Group D) while six rats had survived for the 350 min period after exsanguination (Group A). These data was obtained at intervals of 50 min after exsanguination up to a period of 250 min and compared between Groups A and D. In Group A, serum lactate levels did not increase throughout the entire period of observation. Serum lactate levels in Group D transiently increased, but did not show a dramatic increase during the blood pressure maintenance period. In particular, serum lactate levels increased again after a period of more than 150 min following exsanguination. Lactate levels in the subcutaneous tissue gradually increased and were significantly higher in Group D than that in Group A after 150 min. The L/P ratio in Group A remained fairly constant during the period of observation. In contrast, the L/P ratio in Group D increased gradually, and was significantly higher than that in Group A after 100 min. It was concluded that the continuous increase in the L/P ratio in the subcutaneous tissue in Group D was indicative of tissue circulatory failure and of an abnormality in tissue oxygen metabolism prior to the detection of the collapse of compensatory mechanisms appearing in the vital signs. These findings suggest that measuring the L/P ratio is useful for the clinical assessment and monitoring of shock.

Total Enteral Nutrition Facilitates Wound Healing Through Preventing Intestinal Atrophy, Keeping Protein Anabolism and Suppressing Inflammation.

BACKGROUND: In clinical settings, early total enteral nutrition (TEN) is known to reduce the postoperative complication and infection rate as well as duration of postoperative stay compared with total parenteral nutrition (TPN) in a variety of critical conditions. We aimed to compare effects TEN and TPN on wound healing and explore its possible mechanisms using rat model. METHODS: Seven days after operation for inserting enteral tube into gastric space for TEN, Sprague-Dawley rats were made burn (15 mm) in the back. Rats were administrated with either TEN (N = 17) or TPN (N = 15) and evaluated condition of wound healing as well as serum/urine immunological and biochemical parameters at 28 days. RESULTS: Burned area was significantly reduced in TEN than in TPN group. Although body weight, serum levels of total protein, albumin and transferrin were the same levels between the two groups, urine nitrogen and intestinal atrophy were significant in TPN group. Conversely, weight of small bowel showed positive linear relationship with levels of parameters calculated as follows: [medication nitrogen quantity - (urine nitrogen + feces nitrogen)]/[medication nitrogen - feces nitrogen quantity]. Weights of spleen and tumor necrotizing factor-a levels in serum were higher in TPN than in TEN. CONCLUSIONS: These results suggest that TEN may facilitate wound healing compared with TPN through preventing intestinal atrophy, keeping protein anabolism and suppressing inflammation.

Effect of gelatinization on gastric emptying and absorption.

BACKGROUND/AIMS: For gastrointestinal functional analysis such as gastric emptying tests, either a liquid or solid meal is used as a test meal. Only a few studies have compared meal characteristics, such as liquid and solid. No previous study has compared test meals that had the same composition but different properties. The aim of this study was to compare the gastric emptying and absorption obtained by 13C-breath test after ingestion of liquid or gelatinized liquid nutrients. METHODOLOGY: Ten healthy volunteers were studied four times, with 2-week intervals. For the test meal, 200 mL of liquid meals (200 kcal) and gelatinized liquid meals were used. Gelatinized liquid nutrients were prepared by mixing 6 g, 12 g and 18 g of Natural psyllium husk with 200 mL of liquid meals. Breath samples were collected for four hours. Gastric emptying were expressed as the time of peak excretion, absorption were expressed as the area under the 13CO2 curve up to the time of peak excretion. RESULTS: Gastric emptying times were 54.5, 54.5, 81.7 and 93.3 min. Absorption was 20.8, 20.9, 27.8 and 29.8% dose. CONCLUSIONS: Gelatinization influences gastric emptying, but does not influence absorption. Gelatinized liquid meals may be useful for a substitute for solid meals on gastrointestinal functional analysis.

Epidural analgesia and gastrointestinal motility after open abdominal surgery--a review.

After major abdominal surgery, postoperative ileus is inevitable, and it has always been a challenge for the surgical team to shorten the duration of this period. Based on many clinical and basic reports that affirm the effect on the recovery of gastrointestinal motility, epidural analgesia has been used widely to promote recovery from postoperative ileus. Different techniques have been used to measure gastrointestinal motility in laboratory and clinical investigations. Many of the techniques used in clinical investigations of gastrointestinal motility are controversial because they are subjective. In the laboratory strain gauge force transducer (SGT) can provide objective data on gastrointestinal motility. Nevertheless the significance of SGT in the clinical setting is yet to be confirmed. Therefore in this review we examine both clinical and laboratory outcomes of epidural analgesia on gastrointestinal motility to present the possibility for the development of gastrointestinal motility research with SGTs. We suggest that further investigation using SGTs may lead to the development of objective methods that allow objective assessment of post-surgical gastrointestinal function.

Delayed traumatic diaphragmatic hernia after open splenectomy: report of a case.

A 50-year-old man experienced sudden chest pain radiating into his left shoulder about 16 months after undergoing an open splenectomy for malignant splenic lymphoma. As the patient did not respond to conservative therapy, he was transferred to our hospital. Computed tomography of the chest showed that the upper stomach had herniated into the thoracic cavity. Emergency surgery revealed that the hernial sac was partially torn and open to the thoracic cavity. We sutured the hernial orifice closed and performed Dor fundoplication. Although sporadic reports on this type of hernia following laparoscopic surgery have been reported, delayed diaphragmatic hernia following open splenectomy is rare.

Achalasia complicated by multiple intramucosal carcinomas: report of a case.

A 56-year-old woman underwent a laparoscopic Heller-Dor operation for esophageal achalasia in June 2002. As dysphagia became exacerbated and the oral intake became extremely poor, an esophagectomy was thus considered to be indicated. In September 2005, a transhiatal esophagectomy was performed, and the esophagus was reconstructed using a gastric tube through the posterior mediastinum. The patient developed pneumonia postoperatively, but responded to conservative therapy and was discharged in good health 30 days after surgery. A histopathological analysis demonstrated degeneration and a loss of gangliocytes throughout the esophagus as well as the presence of seven intramucosal cancers. The main cause of dysphagia was due to a marked flexion of the upper esophagus. Even though we identified a precancerous state, we believe that surgery was an appropriate option in this case.

Gastric ulcer after laparoscopic fundoplication for gastroesophageal reflux disease: significance of the eradication of Helicobacter pylori.

The occurrence of gastric ulcers after laparoscopic fundoplication for gastroesophageal reflux disease is not uncommon. Between December 1994 and December 2004, we performed laparoscopic fundoplication in 180 patients, of whom 4 (2.2%) men developed a gastric ulcer during follow-up. The ulcers occurred predominantly in the upper part of the lesser curvature of the stomach, which is definitely different from the usual location of gastric peptic ulcers. All cases we experienced had Helicobacter pylori infection and eradication was attempted in all of them. Although eradication was not possible in 1 patient because of adverse effects to the drugs, successful eradication was obtained in the remaining 3 patients. After successful eradication, these 3 patients were placed under observation without medication and the ulcer has not recurred. The eradication of H. pylori may be an effective therapeutic means to prevent gastric ulcers recurrence after fundoplication.

Epidural administration of morphine facilitates time of appearance of first gastric interdigestive migrating complex in dogs with paralytic ileus after open abdominal surgery.

Morphine is known to delay gastric emptying and intestinal transit, although epidural morphine is believed to decrease postoperative complications. However, these findings are still controversial and based only on clinical observations. We investigated the effects of epidural morphine administration on gut motility by measuring interdigestive migrating complex after open surgery in dogs. Twenty-eight beagles were divided into four groups (n = 7 each) to receive epidural saline (control group), epidural morphine, epidural ropivacaine, or low-dose continuous intravenous morphine. Strain gauge force transducers were sutured under open operation to the serosal surface of the stomach, duodenum, jejunum, and ileum to monitor gut motility. Time of appearance of first interdigestive migrating complex from the stomach propagated to the distal intestine was significantly shorter in the group that received epidural morphine compared with the other three groups. These results suggest that epidural administration of morphine may facilitate recovery from paralytic ileus after open abdominal surgery, perhaps through its effects on the central nervous system.

Effect of Dai-kenchu-to on gastrointestinal motility based on differences in the site and timing of administration.

The purpose of this study was to investigate the effects of the herbal medicine dai-kenchu-to on gastrointestinal motility based on differences in the administration site and timing. We sutured strain-gauge transducers to the stomach (three), duodenum (one), jejunum (one), ileum (one), and colon (two) and inserted indwelling tubes into the stomach, jejunum, and proximal colon of beagles. Dai-kenchu-to was administered to each site during the fasting or fed state. During the fasting state, the prokinetic effects of dai-kenchu-to were evident at all administration sites. The effects were attenuated during the fed state. With intracolonic administration, a contraction similar to the giant migrating contraction-like contraction was induced during the fasting and the fed state, and defecation occurred. Despite the differences in administration site and timing, no contraction complex appeared orad to the administration sites. These results indicate that the prokinetic effects of dai-kenchu-to differ with the site or timing of administration.