An analysis of surgical anatomy of the gastric fundus in bariatric surgery: why the gastric pouch expands? A point of technique.

In bariatric surgery, it is essential to completely release the Fundus in order to create a narrow gastric pouch. The upper part of the fundus is located above the omental bursa and is therefore retro-peritoneal. In order to release this completely, not only does the arterial supply to the fundus need to be divided to visualise the left diaphragmatic pillar, but the right attachment beginning at the left diaphragmatic pillar and running towards the fundus needs to be divided. This minimal dissection is compensated by further dissection at the level of the left diaphragmatic pillar and traction on the stomach from right to left during the final division stapling division process. The surgeon still has the impression of having released the posterior aspect of the Fundus, exposing the pillar of the diaphragm, although in fact part of the Fundus still remains adherent to the diaphragm and is therefore not released.

Self-administered symphysis-fundus measurements analyzed with a novel statistical method for detection of intrauterine growth restriction: a clinical evaluation.

OBJECTIVE: To assess the ability of self-administered symphysis-fundus measurements used with the Shiryaev-Roberts statistical method (SR method) to identify growth-restricted (IUGR) fetuses and compare it with the traditional SF method (symphysis-fundus measurements used with a population-based reference curve). DESIGN: Longitudinal study. SETTING: Pregnant women attending primary antenatal care centres. POPULATION: From a population of 1 888 women with singleton ultrasound-dated pregnancies, we analyzed data from 1 122 women. METHODS: Weekly self-administered SF measurements from gestational week 25 until delivery were analyzed according to the SR method. Neonatal morbidity and small for gestational age (SGA) were used as proxies for IUGR. Small for gestational age was defined as a birthweight less than two standard deviations (SD) and <10th percentile. We assessed the sensitivity of the SR and the SF methods to detect neonatal morbidity and SGA. MAIN OUTCOME MEASURES: Birth-related mortality, respiratory distress, hypoglycemia, Apgar score ≤6 at five minutes, pH ≤7.00 in the umbilical artery, neonatal care, preterm delivery, operative delivery for fetal distress and SGA. Results. For the SR method, the sensitivity for neonatal morbidity was between 6.0 and 36.4%, for SGA <2SD 36.8%, and for SGA <10th percentile 20.9%. The SF method had a sensitivity between 6.0 and 13.8% for neonatal morbidity, 52.3% for SGA <2SD and 28.6% for SGA <10th percentile. CONCLUSIONS: The SR and the SF methods had low sensitivities for neonatal morbidity.

Laparoscopic sleeve gastrectomy--radiological assessment of fundus size and sleeve voiding.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is now considered an effective bariatric procedure (American Society for Metabolic and Bariatric Surgery statement). We attempted to assess the size of the gastric fundus remaining after LSG and gastric voiding rate (fast/slow) by radiological upper gastrointestinal series (UGS) with a water-soluble contrast medium (CM). The findings were compared with weight loss data. METHODS: Seventy-four obese patients underwent LSG. Radiological UGS were used to measure the remaining fundus size in 28 of 74 patients 24-72 h after the procedure, with the aid of Matlab software and a library image processing toolbox (MathWorks®). Sleeve voiding was measured in 57 of 74 patients, based on the patients' radiological reports. RESULTS: The mean volume of the remaining fundus was 17.56 ml (range 1.00-77.03 ml). The mean percent excess BMI loss (%EBL) was 39.5%, 53.7%, and 60.8%, respectively, 3, 6, and 12 months after LSG. Sleeve voiding was fast in 49 of 57 patients (85.96%) and slow in eight (14.03%). CONCLUSIONS: No correlation was found between the estimated volume of the remaining gastric fundus and weight loss (%EBL) after LSG. Patients showing a rapid gastroduodenal transit of the CM achieved a better weight loss than patients with a slow voiding rate.

Gastric fundus tension before and after division of the short gastric vessels in a cadaveric model of fundoplication.

Short gastric vessels (SGV) division is a controversial topic in antireflux surgery. Some surgeons do not divide the SGV routinely to perform a fundoplication; however, excessive tension of the gastric fundus (GF) forces this procedure necessary in some cases. This study aims to evaluate in a cadaveric model of Nissen fundoplication: (i) the correlation of GF tension with anatomic parameters; and (ii) the effect of SGV division on GF tension. In total, 23 fresh cadavers (18 men, mean age 62 years) were studied. The abdominal esophagus was dissected, and the GF transposed to a limit of 3 cm to the right border of the esophagus. A dynamometer was attached to the GF and the tension recorded. Cadavers were grouped according to the presence or absence of tension. SGV were divided and GF tension measured again. The presence or absence of initial GF tension was correlated to: (i) number of SGV; (ii) length of the GF; (iii) distance between His angle and the first SGV; and (iv) size of the spleen. The mean GF pressure was 0.5 N +/- 1.0 (0-2.5) before SGV division and 0.1 N +/- 0.3 (0-1.5) after SGV division (P= 0.002). Initial tension was absent in 12 (52.2%) cases. GF tension did not correlate with any of the anatomic parameters. Our results show that: (i) GF tension does not correlate with anatomic parameters; and (ii) SGV division affects GF tension significantly.

Self-administered measurement of symphysis-fundus heights.

BACKGROUND: Antenatal identification of infants small for gestational age (SGA) improves their perinatal outcome. Repeated measurement of symphysis-fundus (SF) heights performed by midwives is the most widespread screening method for detection of SGA. However, the inefficiency of this method necessitates improved practices. Earlier start and more frequent SF measurements, which could be accomplished by self-administered measurements, might improve the ability to detect deviant growth. The present study was set up to evaluate whether pregnant women can reliably perform SF measurements by themselves. METHOD: Forty healthy women with singleton and ultrasound-dated pregnancies from 2 antenatal clinics in Uppsala, Sweden, were asked to perform 4 consecutive SF measurements once every week, from 20 to 25 weeks of gestation until delivery. The self-administered SF measurements were recorded and systematically compared with midwives' SF measurements. RESULTS: Thirty-three pregnant women performed self-administered SF measurements over a 14-week period (range: 1-21). The SF curves constructed from self-administered SF measurements had the same shape as previously constructed population-based reference curves. The variance for self-administered SF measurements was higher than that of the midwives. CONCLUSIONS: Pregnant women are capable of measuring SF heights by themselves, but with higher individual variance than midwives. Repeated measurements at each occasion can compensate for the higher variance. The main advantage of self-administered SF measurements is the opportunity to follow fetal growth earlier and more frequently.

A high-protein dietary treatment to intestinally hypotrophic rats induces ghrelin mRNA content and serum peptide level changes.

BACKGROUND & AIMS: Ghrelin is a peptide mainly secreted in stomach with a potent growth hormone releasing activity both in vitro and in vivo. The trophic mucosal effect of an enriched protein diet may be related with ghrelin and growth hormone plasma levels since peptides from the somatotrophic axis are well-known trophic factors. The possible relationship between nutritionally regulated active ghrelin plasma levels and the intestinal trophic effects of a high-protein diet was probed in rats with intestinal hypotrophy induced by an elemental diet. METHODS: Normal and elemental-diet-induced intestinally hypotrophic rats were treated with either a normoproteic or a high-protein diet for 1 week. It was determined ghrelin and IGF-1 plasma levels, fundic and duodenal ghrelin concentrations, ghrelin mRNA content and intestinal morphometric, proliferative and apoptotic parameters were determined. Growth hormone plasma levels were measured indirectly through IGF-1 plasma levels. RESULTS: Ghrelin plasma levels increased in elemental diet-induced intestinally hypotrophic rats fed either diet. Duodenum mRNA content, but not fundus, increased under the same conditions where plasma was studied. Dietary treatment did not modify the IGF-1 plasma levels. However, animals previously fed an elemental diet to induce intestinal hypotrophy had significantly lower levels of IGF-1. CONCLUSIONS: The trophic effects on the intestine of an enriched protein diet are associated with increased ghrelin serum peptide level and mRNA content, and this increase might be related to the IGF-1 plasma levels in elemental diet-induced intestinally hypotrophic rats.

The micropouch gastric bypass: technical considerations in primary and revisionary operations.

BACKGROUND: Roux-en-Y gastric bypass is an effective procedure for the long-term control of morbid obesity. An eventual revisionary operation, however, is necessary for some patients (0.8-29%). Redo procedures are required for pouch enlargement, staple-line dehiscence, or marginal ulceration. In 1994, the micropouch gastric bypass (MBG) was developed to eliminate the need for a repeat operation. Its design was based on two anatomical principles: 1) The fundus is elastic, aperistaltic, and may significantly dilate over time; 2) The proximal magenstrasse contains a high concentration of parietal cells, which potentiates the risk for marginal ulceration or gastroesophageal reflux after vertical pouch restriction. Construction of a micropouch limited to the gastric cardia avoids using the fundus and proximal lesser curvature, but requires a greater mobilization of the stomach and its peritoneal attachments. METHODS: Between February 1994 and February 2000, 1,120 patients underwent the MGB as a primary or revisionary operation. The fundus was mobilized completely, including transection of the left phreno-esophageal and gastrophrenic ligaments. The transected pouch was limited to the gastric cardia with 1 cm of fundus incorporated into the gastrojejunostomy stoma (GJS). RESULTS: There were 10 anastomotic leaks at the GJS (0.9%). All leaks sealed following surgical drainage or parenteral nutrition. One patient required re-operation (0.09%) for a dilated pouch and marginal ulceration. An additional patient (0.09%) developed a gastrogastric fistula secondary to a pharmacobezoar and stomal stenosis. CONCLUSION: With an appreciation for the finer anatomy of the proximal stomach and intra-abdominal esophagus, the micropouch can be constructed safely in both primary and redo procedures. The MGB, now in its seventh year, is durable and has, with rare exception, eliminated pouch enlargement, staple-line separation, reflux esophagitis, and marginal ulceration.

Variation in fundic dimensions with respect to short gastric vessel division in laparoscopic fundoplication.

BACKGROUND: This study analyzes the geometry involved in laparoscopic fundoplication with respect to short gastric vessel division for the creation of a tension-free Nissen fundoplication. METHODS: For fundoplication, the gastric fundus must be long enough to traverse the fixed distance between the right edge of the plication and the highest lateral fixation of the fundus (distance alpha) and to encircle the esophagus (esophageal circumference). We compared these two dimensions to the length of fundus available for fundoplication both before and, when needed, after division of the short gastric vessels. RESULTS: For tension-free Nissen fundoplication, the available fundic length must exceed the sum of the esophageal circumference and the distance alpha. In some patients, exceeding this sum requires division of the short gastric vessels, thereby increasing fundic length. Short gastric vessel division is not necessary in all patients due to significant individual variations in fundic length. CONCLUSION: There are significant individual variations in fundic length available for fundoplication. The length of the fundus can be increased by dividing short gastric vessels, but it is not always necessary. It is, however, important to take this parameter into consideration when performing the operation in order to avoid postoperative dysphagia.

Disruption of experimental fundic folds is prevented by interserosal scarring.

BACKGROUND: The main cause of recurrent reflux symptoms after Nissen fundoplication is disruption of the fundic wrap. Reoperation has shown a lack of scar tissue between the serosal surfaces of the fundic folds in these cases. METHODS: Attempts were made to induce serosal scarring during fundoplication performed in rabbits. In group 1 the serosal folds were attached to the upper fundus with three non-absorbable seromuscular sutures. In group 2 Teflon pledgets were placed between these sutures. Fibrin glue was injected between the folds in group 3 and polyglycolic acid mesh was inserted in group 4. RESULTS: When the rabbits were killed 6 months later, the serosa had unfolded and no macroscopic or microscopic scar tissue was found between the serosal surfaces, except in five of the six rabbits in group 3, in which fibronectin, laminin and collagen types I and III were present in interserosal scar tissue. CONCLUSION: Application of fibrin glue between the serosal surfaces of the fundic folds may prevent disruption of Nissen fundoplication.

A gastrofundoplicatura laparoscópica: a importância da liberaçäo do fundo gástrico / The laparoscopic gastric fundoplication: the importance of liberation of the gastric fundus

Os autores, através de medidas objetivas do fundo gástrico realizadas em 23 cadáveres, procuram demonstrar a diferença de comprimento entre as paredes anterior e posterior. As medidas obtidas mostram que o fundo gástrico, quando liberado de aderências da parede posterior, adquire dimensoes maiores que a parede anterior. Estes dados poderiam servir de substrato para futuro estudo que avaliasse a realizaçao da fundoplicatura parcial ou total sem necessidade de ligadura dos vasos breves.

Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter.

BACKGROUND: The structural equivalent to the manometric high pressure zone separating the stomach from the esophagus is still a matter of dispute. We compared the three-dimensional (3D) manometric pressure image with muscular thickness and architecture at the human gastroesophageal junction. METHODS: Three-dimensional manometric images were obtained in 25 volunteers by using a stepwise pullback technique of a catheter with eight radially oriented pressure transducers. Muscle thickness was measured in four radial directions at 10 levels between the midesophagus and stomach in 37 specimens obtained from organ donors. Muscular architecture was assessed in specimens from 10 organ donors and 12 human cadavers and was related to muscle thickness. RESULTS: Manometric 3D images of the lower esophageal high pressure zone showed a marked radial and longitudinal asymmetry. Radial pressures peaked at the respiratory inversion point and were highest toward the left posterior direction. Anatomic evaluation showed an asymmetric thickening of the muscular layer at the gastroesophageal junction that mirrored the manometric image. Muscle thickness was highest toward the greater curvature side corresponding to the gastric "sling" fibers and toward the lesser curvature corresponding to the semicircular "clasp" fibers. CONCLUSIONS: The human lower esophageal sphincter is not a muscular ring. Rather, the perfect match between the manometric pressures and the arrangement of muscular structures at the gastroesophageal junction indicates that the gastric sling fibers and the semicircular clasps are the anatomic correlate of the manometric lower esophageal sphincter in human beings.

Alternating laminated array of two types of mucin in the human gastric surface mucous layer.

Attempts have been made to develop a procedure for preserving and analysing the surface mucous layer of the human stomach in paraffin sections. Histologically normal gastric mucosae were obtained from 20 surgically removed stomachs. Of the different fixatives tested, Carnoy's solution gave rise to the most satisfactory results. In Haematoxylin-Eosin stained sections, the surface mucous layer appeared as a thick eosinophilic layer coating the gastric mucosal surface and measured 55.4 +/- 2.5 microns in the fundus and 21.8 +/- 1.0 microns in the pylorus respectively. A dual staining method consisting of galactose oxidase-cold thionine Schiff and paradoxical concanavalin A staining was applied to the surface mucous layer in order to reveal the distribution pattern of mucins secreted by two types of mucous cell in the gastric mucosa: surface mucous cells and gland mucous cells. As a result of this staining, an alternating laminated layer was visualized which consisted of the particular two types of mucin. In five cases, the surface mucous layer was examined in unfixed frozen sections. This layer was only partially preserved but revealed the same laminated structure. These results indicated that gland mucous cell mucins contribute to form the surface mucous layer.

[Correlation between the anterior antral branches of the vagus nerve and the antral-fundic boundary in duodenal ulcer].

The distances from the pylorus to the most proximal branch (proximal branch) and the most distal branch (distal branch) of the anterior antral branches were measured in 37 duodenal ulcer patients. The resected specimens were examined histologically to determine the antral-fundic boundary (F-line) and the distance from the pylorus to F-line was calculated. The distances from the pylorus to proximal branch, distal branch and F-line were 7.8 +/- 1.6 cm, 5.1 +/- 1.2 cm, 6.7 +/- 1.4 cm (M +/- SD), respectively. The mucosal area of proximal branch was fundic in 77% and pyloric in 23%. The mucosal area of distal branch was fundic in 14% and pyloric in 86%. There were three types of distribution of anterior antral branches in relation to F-line. In fundic type both proximal and distal branches intersect fundic mucosa. In ordinary type proximal branch intersects fundic mucosa whereas distal branch intersects pyloric mucosa. In pyloric type both proximal and distal branches intersect pyloric mucosa. The numbers of each type were 5(14%), 22(63%) and 8(23%), respectively. In conclusion, selective proximal vagotomy is not indicated for cases of fundic type in which the entire anterior antral branches intersect fundic mucosa.

Regional differentiation in the stomach of the green anole.

The stomach of Anolis carolinensis (Reptilia: Iguanidae) has four histologically and histochemically distinct regions. The gastroesophageal junction has an acidic surface mucin and no glands. The cardia has an acidic surface mucin and mucous glands. This acidic mucin appears to contain neither sulfates nor sialic acid. The fundus has a neutral surface mucin and mucoserous glands. The pylorus has a neutral surface mucin and mucous glands.

Effects of ethanol on parietal cell membrane phospholipids and proton pump function.

The effects of ethanol on membrane phospholipids of isolated rabbit parietal cells (PC) and fundic glands (FG) were evaluated by using proton nuclear magnetic resonance spectroscopy (NMR). The most conspicuous resonance bands in PC and FG spectra at 3.2 and 0.9 ppm were due to the protons of +N(CH3)3 groups of phosphatidylcholine and, to a lesser degree, other phospholipid derivatives and terminal -CH3 groups for all phospholipids, respectively. Ethanol treatment (1 min) of PC and FG at 37 degrees C significantly increased the peak intensity of -CH3 groups in a dose-dependent manner, while no intensity change in PC and a lesser change in FG were observed for the +N(CH3)3 groups, suggesting a greater disorganizing effect of ethanol in the inner hydrophobic (-CH3) compared with the outer hydrophilic [+N(CH3)3] membrane moieties of phospholipids. Ethanol at concentrations greater than 5% (vol/vol) inhibited K+-stimulated paranitrophenyl phosphatase activity of intact PC, which correlated with inhibition of basal and histamine-stimulated aminopyrine uptake ratio by PC and FG. NMR is a sensitive, noninvasive probe to show ethanol-induced changes in intact PC lipid membrane organization without altering ultrastructural morphology.

Observations on the anatomy of the stomach and duodenum of the bowhead whale, Balaena mysticetus.

Gastric and cranial duodenal structure of the bowhead whale (Balaena mysticetus) was examined grossly and microscopically. The stomach was arranged in a series of four compartments. The first chamber, or forestomach, was a large nonglandular sac lined by a keratinized stratified squamous epithelium. It was followed by the fundic chamber, a large, somewhat globular and entirely glandular compartment. At the entrance of the fundic chamber, a narrow cardiac gland region could be defined. The remaining mucosa of the chamber contained the proper gastric glands. A narrow, tubular connecting channel, the third distinct gastric division, was lined by mucous glands and joined the fundic chamber with the final stomach compartment, or pyloric chamber. This fourth chamber was also tubular and lined by mucous glands but was of a diameter considerably larger than the connecting channel. The stomach terminated at the pyloric sphincter which consisted of a well-developed band of circular smooth-muscle bundles effecting a division between the pyloric chamber and small intestine. The small intestine began with the duodenal ampulla, a dilated sac considerably smaller than the fundic chamber of the stomach. The mucosa of this sac contained mucous glands throughout. The ampulla led without a separating sphincter into the duodenum proper which continued the intestine in a much more narrow tubular fashion. The mucosal lining of the duodenum was composed of villi and intestinal crypts. Although their occurrence varied among whales, enteroendocrine cells were identified within the mucous glands of the cardiac region, connecting channel, pyloric chamber, and cranial duodenum. The hepatopancreatic duct entered the wall of the duodenum shortly after the termination of the duodenal ampulla and continued intramurally along the intestine before finally joining the duodenal lumen.

Normal histology of the stomach.

The normal microscopic and gross morphologic features of the stomach are described. Emphasis is given to mucosal anatomy and the recognition of minor alterations seen in disease that may be identified on an endoscopic biopsy. Advice is given in the interpretation of biopsy artefact that may present diagnostic problems. The various types of gastric metaplasia are discussed both in relation to altered morphology and to changes in mucin histochemistry.

[Features of the fundal glands of the mammalian stomach and their relation to type of diet (morphometric analysis)]. / Osobennosti fundal'nykh zhelez zheludka mlekopitaiushchikh i ikh zavisimost' ot tipa pitaniia (morfometricheskii analiz).

According to a standartized technique, a morphometrical investigation of the stomach tunica mucosa (STM) has been performed in 11 practically healthy persons and 69 animals representing 4 orders and 9 femilies of Mammalia. In Mammalia, together with a principle similarity in the stomach microscopical structure, there is a great variety of main morphometrical parameters of the STM. The whole complex of these parameters is species-specific. It is determined by the systemic position of the given species and reflects the filogenetically-dependent nutritional specialization. The main mechanism and the filogenetically-dependent characteristic of adaptation to protein nutrition is an increase in the number of the main, but not the parietal glandulocytes. The dependence revealed gives a new interpretation to the problem concerning the relation between the structure and function of the STM in animals with different nutrition type; this dependence makes it possible to consider the problem of ulcerogenesis and its biological prerequisites in the man from new positions.

Anatomical aspects in ultrasonic endoscopy for the stomach.

Gastric wall structure cannot be visualized neither by conventional ultrasonography nor by endoscopy alone. Using a newly developed ultrasonic endoscope (Olympus GF- UM1 / EUM1 Prototype III) twenty-two patients were examined with the stomach filled with 300-500 cc of de- aired water. Ultrasonographic appearance of the normal gastric wall consists of four layers of different echogenicity. The first inner layer, echogenic, seems to correspond to the mucosa and the submucosa, the 2nd echopoor to the muscularis propria, the 3rd echogenic to the serosa and the 4th echopoor to the subserosal-fat. For a complete exploration of the gastric cavity, starting with the scope near the pylorus and withdrawing it until the fundic region, four positions have been standardized. In the first, the antral region is explored, in the 2nd the antrum and the gastric body, in the 3rd the body and antrum and in the 4th position body and fundic region are visualized. For a satisfactory examination a good filling of the stomach must be achieved; problems in interpretation may arise when the gastric wall is not well distended or when peristaltic waves are present. Promising findings have been obtained in 3 cases of cancer involvement of the stomach. No complications were encountered during this study.