Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.

Impaired Gastrointestinal Function Affects Symptoms and Alimentary Status in Patients After Gastrectomy.

BACKGROUND: Postgastrectomy syndrome (PGS) remains a common complication after gastrectomy that affects patients' quality of life. Although impaired gastrointestinal (GI) function by gastrectomy procedures is thought to be the cause, the precise pathophysiology of PGS is yet to be clarified. AIM: The aim of this study was to investigate relationships between GI function and various symptoms or alimentary status in patients after gastrectomy. METHODS: Fifty-one patients who underwent total or distal gastrectomy at least 1 year previously were studied. All patients replied to a questionnaire that asked presence of symptoms (esophageal reflux, nausea, abdominal pain, early satiation, diarrhea, early dumping general, early dumping abdominal, and late dumping symptoms) and alimentary status (change in body weight, food intake per meal, frequency of meals per day). They also underwent assessment of GI function consisting of gastric emptying study by 13C-acetate breath test to examine reservoir capacity and gastric emptying, and water load drink test to evaluate tolerance to volume loading (TVL). The relationships between GI function and each symptom or alimentary status were examined. RESULTS: The patients with nausea and early dumping general symptoms had significantly smaller reservoir capacity*, the patients with diarrhea and early dumping general symptoms had significantly faster gastric emptying*, and the patients with early satiation and early dumping abdominal symptoms had significantly impaired TVL*. Significant correlations were identified between TVL and body weight changes* or food intake per meal* (* p < 0.05). CONCLUSION: Impaired postoperative GI function was closely related to symptoms or worse alimentary status.

[THE DIGESTIVE TRACT MOTILITY AND NUTRITIONAL SUPPORT WITH POSTGASTRORESECTIONAL SYNDROME].

The variety of clinical manifestations operated stomach fits in the sequence of pathological syndromes: dumping and hypoglycemic syndromes, postgastroresectional post gastrectomy anemia, afferent loop syndrome, postoperative dystrophy, reflux esophagitis, a syndrome of "small" stomach, and hypoglycemic syndrome. Aim--to elucidate the role of disorders of motor function of the gastrointestinal tract in postgastroresectional syndromes and their correction. The nutrient administration reduced a motor function level of the stomach, restore motor function of the duodenum and ascending colon intestine, normalize ino- and chronotropic relations in the smooth muscles of the sigmoid colon.

Assessment of motor function of the remnant stomach by ¹³C breath test with special reference to gastric local resection.

BACKGROUND: Indications for gastric local resection (LR) include gastrointestinal stromal tumors, neuroendocrine tumors, and early gastric cancer. LR is expected to preserve physiological function and ameliorate postgastrectomy syndrome. METHODS: Gastric emptying was assessed by the (13)C-acetate breath test in 20 healthy volunteers (HVs) and 60 gastrectomized patients [distal gastrectomy with Billroth I reconstruction (DGBI) in 26 patients, LR in 34 patients]. For the (13)C breath test, 100 mg of (13)C-acetate sodium salt was mixed in a test meal. Breath samples were collected before intake and during the next 3 h. We compared the gastric reservoir capacity using the gastric retention rate at 5 min (RR5) and gastric emptying by the half emptying time (T½). Patients completed a questionnaire survey about their symptoms, dietary intake, body weight, and restriction of activities of daily living [reflecting quality of life (QOL)]. RESULTS: The RR5 values for the HV, LR, and DGBI groups were 93.7, 90.0, and 45.3* %, respectively (*compared to HV and LR, p < 0.0001). The T½ values were 23.3, 20.2, and 5.9* min, respectively. Dietary intake and body weight change were significantly more reduced in the DGBI group than the LR group (p < 0.05). Subgroup analysis indicated that the reservoir capacity in those with LR at the lesser curvature was more disturbed than that in patients with LR at the greater curvature. The questionnaire showed no differences in those patients' QOL. CONCLUSIONS: Because the reservoir capacity, the gastric emptying and QOL were maintained, LR is an option for selected patients with early gastric cancer.

[State of duodenal patency in patients with postgastrectomy syndromes].

It was analyzed the examination and treatment results of 100 patients who underwent resection of stomach by Billroth-I in case of peptic ulcer. Chronic disorders of duodenal patency were diagnosed in 86% of patients. The main role of chronic disorders of duodenal patency in postgastrectomy syndromes development was proved. There were a combination of reflux gastritis with dumping syndrome in 66.3% of patients, a combination of reflux gastritis with recurrent ulcer in 8.1% of patients. Correction of chronic disorders of duodenal patency is necessary stage in conservative and surgical treatment of postgastrectomy syndromes.

Bariatric and metabolic surgery.

In the beginning of the 21st century obesity still represents health, social and economical threat for most of economically wealthy countries worldwide. Estimated direct costs for obesity and related comorbidities treatment exceed 5% of the total health care costs both in the US and in European Union. However, in addition there are obesity-related indirect costs linked to more frequent work sickness leave, higher unemployment rates and overall lower productivity of obese patients. Surgical treatment of obesity (bariatric surgery) is the most effective long-term treatment modality for those patients suffering from higher degrees of obesity. Bariatric surgery has not only positive effects on weight loss, but is also extremely effective in improving or resolving many of obesity-related comorbidities, which have evolved rapidly into the so-called metabolic surgery. T2DM may serve as excellent example of metabolic, obesity-related comorbidity which can be treated with bariatric-metabolic procedure even without direct relation to weight loss. In such cases bariatric surgery evolves into metabolic surgery. Thus metabolic operations (namely from the malabsorptive end) deeply influence hormonal secretion especially in the proximal part of small bowel, change parametres of entero-insular axis and have positive influence on insulin secretion, sensitivity and on the entire complex of glucose tolerance. Nowadays we can witness dramatic changes in perception of T2DM from bariatric surgeons, diabetologists, and many other medical specialists. T2DM has evolved from primarily medical disease into a condition where surgeons may play a more active role in the management of the diabetic patient. However, it has to be stressed that metabolic treatment of T2DM and other metabolic disorders need multidisciplinary approach and collaboration and that surgeon should play very important role as a multidisciplinary team member, however metabolic surgery should not yet be considered as stand-alone treatment modality.

[The role of chronically disordered duodenal patency in the development of post-gastroresection syndrome].

We assessed results of examination and treatment of 100 patients with ulcer disease who had undergone Bilroth-1 stomach resection. Chronic disorder of duodenal patency was revealed in 86% of the patients. This condition was shown to play the leading role in the development of post-gastric resection syndrome. Reflux-gastritis was associated with damping syndrome in 66.3% of the patients and with recurrent ulcer in 8.1%. It is concluded that conservative and surgical treatment of post-gastric resection syndrome should be aimed at correction of chronic disorders of duodenal patency.

[The substantiation of the method of gastrointestinal reconstruction after the gastric resection].

Functional results of 289 major gastric resections and gastrectomies were analyzed. New methods of the gastrointestinal reconstruction after these procedures. The comparative analysis of immediate and long-term results allowed to work out criteria of choice for the reconstructive procedure. Benefits of the suggested reconstructive techniques demonstrated with the use of modern diagnostic means.

Effects of emptying function of remaining stomach on QOL in postgastrectomy patients.

BACKGROUND: Attention has recently focused on decreased quality of life (QOL) that occurs in postgastrectomy patients. We verified how gastric emptying function affected QOL. METHODS: Subjects were 72 consecutive patients after gastrectomy for cancer, including 25 after distal gastrectomy (DG), 18 after proximal gastrectomy (PG), 16 after pylorus-preserving gastrectomy (PpG), and 13 after total gastrectomy (TG). Using the (13)C breath test method, (13)CO(2) levels in breath were measured over 2 h, and T (max) was determined. Questionnaires (Japanese versions of the Short-Form 36 [SF-36] and Gastrointestinal Symptom Rating Scale [GSRS]) were used to analyze QOL and correlations between questionnaire results and T (max). RESULTS: Mean T (max) (min) for each procedure was 15.4 for DG, 21.1 for PG, 41.3 for PpG, and 10.4 for TG. T (max) differed between procedures, but not between survey periods. SF-36 was not correlated with T (max), whereas GSRS showed a difference in diarrhea and total score between procedures, but not between survey periods. In addition, GSRS correlated with T (max) for abdominal pain, indigestion, and total score. The total scores showed a significant symptom aggregation in patients with T (max) less than 21 min. CONCLUSIONS: Gastrointestinal symptoms in postgastrectomy patients were associated with the function of the remaining stomach. The (13)C breath test is useful for objectively assessing such symptoms.

[Improving the quality of life after gastrectomy is the next issue after saving the lives of patients with gastric cancer].

Gastrectomy saves the lives of many patients with gastric cancer. However, this surgical treatment is associated with clinical problems called postgastrectomy syndrome (PGS) which affect the quality of life (QOL) of such patients. For surgeons, improving the QOL after gastrectomy is an important goal after performing curative surgery. In the clinical setting, various surgical procedures such as limited resection, function-preserving procedures, and reconstruction using gastric substitutes have been advocated to reduce the severity of PGS. However, the actual conditions and pathophysiology of PGS have not been fully investigated. Various clinical studies and basic research have partially clarified the features and pathophysiology of PGS, although the strategies developed to treat PGS have been limited. The development of standardized, reliable instruments for understanding PGS and performing large-scale collaborative studies are required to improve the diagnosis and treatment of PGS. In Japan, such a project called the PGSAS has recently been completed. The results are being analyzed and will be reported in the near future.

[Postgastrectomy syndromes in therapeutic practice ].

AIM: To specify policy of nutritive support late after radical gastric resection. MATERIAL AND METHODS: Patients with postgastroresectional dystrophy were examined using standard techniques and estimation of intestinal electric activity (registration of body surface biopotentials on Conan-M myngograph). RESULTS: Frequency-amplitude parameters of the intestine serve the basis for choice of mixtures for enteral correction. Nutritive support provided for on demand pharmaconutrients--microbiotic correctors. CONCLUSION: Myography gives additional information for decisions on the policy of nutritive support.

Correlation between the length of the pyloric cuff and postoperative evaluation after pylorus-preserving gastrectomy.

BACKGROUND: Recent years have seen the preserved pyloric cuff being lengthened in pylorus-preserving gastrectomy for early gastric cancer. We performed clinical assessment of the symptoms after pylorus-preserving gastrectomy in patients treated at the National Cancer Center Hospital in Japan during the past 9 years. METHODS: Four hundred and fifty-six patients who had undergone pylorus-preserving gastrectomy and been followed up for at least 3 years were studied. We classified the patients into two groups according to the length of the pyloric cuff (group A, within 3.0 cm; group B, more than 3.0 cm). Medical records were reviewed for further histological and follow-up data. A questionnaire regarding dumping syndrome and gastric stasis was also completed by the patients. RESULTS: Our results showed no statistically significant differences in symptoms, such as dumping syndrome or emptying disturbances, between the two groups. CONCLUSION: Our study revealed that the differences in several functions and symptom scales were not pronounced between the two groups. Regardless of the length of the pyloric cuff, pylorus-preserving gastrectomy can be utilized for the treatment of early gastric cancer even if the tumor is located proximal to the middle body.

Gastric emptying function in patients 5 years after pylorus-preserving distal gastrectomy with or without preserving pyloric and hepatic branches of the vagal nerve for early gastric cancer.

BACKGROUND: To clarify the significance of preserving pyloric and hepatic branches of the vagal nerve (PHV) after pylorus preserving distal gastrectomy (PPG) for early gastric cancer, the author investigated the postgastrectomy syndrome and gastric emptying function at 5 years in PPG patients with or without preserving the PHV. METHODS: A total of 18 subjects (mucosal cancers) who underwent PPG with D1 lymph node dissection and preserving the PHV; they comprised group A-12 men and 6 women aged 38-68 years (mean 58.9 years). They were interviewed to inquire about gastrointestinal symptom (appetite, weight loss, gastric fullness, reflux esophagitis, early dumping syndrome) and then were compared with 24 PPG patients (submucosal cancers) with D2 lymph node dissection without preserving the PHV (group B-16 men and 8 women aged 33 to 69 years, mean 60.1 years). Esophagogastric endoscopy, abdominal ultrasonography, and gastric emptying function tests (GET) were undertaken, the latter by both radioisotope (solid diet) and acetaminophen (liquid diet) methods. RESULTS: There were no differences in the postoperative gastrointestinal symptoms, endoscopic reflux esophagitis, or endoscopic mucosal edema and redness (gastropathy) between groups A and B. However, more cholecystolithiasis (gallbladder stones) was found in group A than in group B, with the difference being significant (P < 0.0391). The GET for solid diet and liquid diet were the almost same among groups A and B. CONCLUSIONS: There were no significant differences in the postoperative QOL and GET between PPG patients with preserving PHV and those without preserving PHV. Cholecystolithiasis was only found in patients without preserving PHV.

The influence of reconstruction methods on food retention phenomenon in the remnant stomach after a subtotal gastrectomy.

BACKGROUND AND OBJECTIVES: Food retention and bile reflux has been frequently observed in gastric cancer patients following a subtotal gastrectomy. The aim of this study was to determine whether reconstruction methods after the distal subtotal gastrectomy influenced the degree of food residue and bile reflux. METHODS: The prospectively collected data was reviewed retrospectively for 522 patients with early gastric cancer who had undertaken a follow-up endoscopic examination after a distal subtotal gastrectomy between 2003 and 2006. RESULTS: The incidence of food retention was 55.5%, 31.9%, and 20.9% at 3, 12, and 24 months after distal subtotal gastrectomy, respectively. The food residue score was higher in the Billroth I (stapling) group than the Billroth II (hand sewing) group at 3 months after surgery (P = 0.006). The incidence of bile reflux was higher in the Billroth II group than in the Billroth I group at 12 and 24 months after surgery (P < 0.001, P = 0.002, respectively). No significant association was found between the food retention and body weight changes. CONCLUSIONS: Food retention was detected in lots of patients after subtotal gastrectomy and the reconstructive methods after subtotal gastrectomy was not relevant to food retention.

Postgastrectomy Syndromes and Nutritional Considerations Following Gastric Surgery.

Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.

Long-term consequences of total gastrectomy: quality of life, nutritional status, bacterial overgrowth and adaptive changes in esophagojejunostomic mucosa.

OBJECTIVES: The aim of the study was to evaluate long-term quality of life and adaptive changes in the mucosa of the proximal section of the small intestine used for esophagojejunostomy reconstruction in stomach cancer patients after total gastrectomy. MATERIAL AND METHODS: Thirty-one patients who had undergone stomach cancer-related total gastrectomy were included in the study, which spanned a period of 48 to 127 months (79.6 months on the average) after the surgery. The analysis included: a) evaluation of selected biochemical parameters; b) microbiological evaluation of esophagojejunostomic area; c) evaluation of adaptive changes in esophagojejunostomic mucosa using light and electron microscopy; d) quality of life evaluation with a Troidl questionnaire. RESULTS: Quality of life was subjectively rated as good or very good by almost all subjects. The analyzed biochemical parameters were within the range of normal values in all the subjects with the exception of mild abnormalities in alkaline phosphatase and vitamin B12 levels in some patients. Microbiological examination of mucosal specimens from below the esophagojejunostomy revealed significant bacterial flora overgrowth in all the patients, with streptococci being the most abundant species. Light and electron microscopy examination of the epithelium confirmed it was normal and characteristic of a healthy small intestine. CONCLUSIONS: Long-term quality of life in patients after complete stomach resection is considered good or very good, irrespective of the reconstruction method used, and the esophagojejunostomic mucosa of the reconstructed area is normal and typical for a healthy small intestine.

Management of gastric emptying disorders following the Roux-en-Y procedure.

In 46 patients with gastric resection and Roux-en-Y gastrojejunostomy, gastric emptying was studied with the gamma camera. Seventeen patients were free of symptoms, 11 vomited occasionally (less than 5 times weekly), and 18 were severely incapacitated with daily vomiting, weight loss, and bezoar formation. Patients with occasional vomiting had early rapid emptying similar to that seen in the patients who were without symptoms and responded satisfactorily to nonsurgical therapy. The 18 patients with severe vomiting showed a marked delay in the emptying of the solid meal (p less than 0.01) but normal emptying of the liquid. There was no difference between those with and those without stomal ulceration or stomal stenosis. The stasis occurred in the stomach and not in the Roux limb. All 18 patients had a further extensive gastric resection, leaving a 50 to 75 ml upper gastric remnant drained by Roux-en-Y gastroenterostomy. Fifteen of these patients showed improvement and gained weight, and the gastric emptying of both the solid and liquid test meals is now faster than in any of the other groups (p less than 0.03). We conclude that extensive gastric resection is an effective means to reduce symptoms and improve gastric emptying in selected patients with severe gastric stasis of solid food after the Roux-en-Y procedure.

Gastric emptying and postprandial symptoms after Billroth II resection.

Gastric emptying was studied in 18 symptomatic and 16 asymptomatic patients after Billroth II (BII) resection (without vagotomy) and the possible relationships between emptying and postprandial symptoms in these patients were assessed. The BII patients were compared with 20 nonoperated patients who had duodenal ulcer disease and 16 healthy subjects. Gastric emptying of two test meals (a semisolid porridge meal and a solid pancake meal) was measured with a radionuclide technique. The major difference between the BII patients and control subjects and duodenal ulcer patients was an increased rate of emptying of the semisolid meal in the first 5 minutes after meal consumption. The percentage of the meal remaining in the stomach at 5 minutes after completion was significantly less in the symptomatic (45.3% +/- 4.3%) than in the asymptomatic BII patients (79.4% +/- 2.6%). A positive correlation was demonstrated between the initial emptying rate of semisolids and the intensity of postprandial nausea (p less than 0.01), vomiting (p less than 0.05), and vasomotor symptoms (p less than 0.001). The duration of the lag phase for solid and semisolid meals was shorter in BII patients than in healthy subjects but was as short in nonoperated duodenal ulcer patients. The duration of the lag phase for solid food in the BII patients correlated positively with the score for postprandial epigastric pain (p less than 0.001). The rate of emptying of the solid meal was lower in symptomatic BII patients (28.1% +/- 3.6% per hour) than in asymptomatic patients (47.8% +/- 7.2% per hour) and correlated with the severity of postprandial fullness and nausea. The emptying of the solid meal was inversely related to the initial emptying rate of the semisolid meal (p less than 0.05). Therefore, the results of this study support the assumption that many of the postprandial symptoms occurring after BII resection reflect alterations in gastric emptying. Some of the emptying abnormalities present after BII resection may be related to duodenal ulcer disease rather than to the surgical procedure.

Pyloric reflux gastritis: the offending agent.

Tubes of canine gastric corpus were constructed so that the mucosa was exposed chronically to jejunal contents, pancreatic juice, or bile. Biopsies of these mucosae obtained 4 to 24 months later were compared with each other and with the normal stomach for parietal cell numbers, mucus cell numbers, inflammation, glandular disorder, and surface-cell hyperplasia. All three preparations showed marked gastrititis, but whole jejunal contents caused more severe changes than did either pancreatic juice or bile, which were approximately equal.

Reverse phasic contractions are present in antiperistaltic jejunal limbs up to twenty-one years postoperatively.

One of the surgical procedures that has been performed to reduce symptoms of dumping is the antiperistaltic jejunal limb (APL). We hypothesized that the polarity of the Phase III activity fronts would be maintained after creation of an APL. To test that hypothesis, water perfused, low compliance intestinal manometry was performed upon four patients with APL, four patients with vagotomy, antrectomy and Roux-en-Y gastrojejunostomy (VARY) and four volunteers. The patients were studied for a minimum of four hours of fasting. Recordings were analyzed by visual inspection by two observers and results are expressed as mean plus or minus standard error of the mean. Statistical analysis was performed with Student's t test. Phase III activity fronts occurred more frequently (1.4 +/- 0.3 per hour) in the patients with a VARY reconstruction than in the volunteers (0.5 +/- 0.5 minute). The duration of Phase II activity was significantly less in the patients with the VARY reconstruction (19.1 +/- 5.1 minutes) than in the volunteers (49.5 +/- 5.2 minutes). Patients with reversed activity fronts showed statistically significant propagation velocity (3.0 +/- 0.6 versus 9.6 +/- 2.0 centimeters per minute) (p < 0.005), but longer Phase III activity fronts (8.0 +/- 0.8 versus 4.9 +/- 0.3 minutes) (p < 0.001) than in the volunteers. Although there were a number of abnormalities identified in the patients with VARY reconstruction, there were no reverse Phase III activity fronts seen in the four patients with APL reconstruction. The polarity of the small intestine is maintained up to 21 years after construction of an antiperistaltic jejunal segment.