A multi-institutional prospective observational study to compare postoperative quality of life of patients who undergo total or proximal gastrectomy for early gastric cancer (CCOG1602).

BACKGROUND: Proximal gastrectomy (PG) has become an increasingly preferred procedure for treating early cancer in the upper third of the stomach. However, advantages of PG in postoperative quality of life (QOL) over total gastrectomy (TG) has not fully proven. METHODS: We conducted a multi-institutional prospective observational study (CCOG1602) of patients who undergo TG or PG for cStage I gastric cancer. We used the PGSAS-37 and EORTC-QLQ-C30 to evaluate the changes in body weight and QOL over a 3-year postoperative period. The primary endpoint was the weight loss rate 3 years after surgery. RESULTS: We enrolled 109 patients from 18 institutions and selected 65 and 19 patients for inclusion in the TG and PG groups, respectively. Mean postoperative weight loss rates were 16.0% and 11.7% for the TG and PG groups, respectively (p = 0.056, Cohen's d 0.656) during postoperative year 1% and 15.0% and 10.8% for TG and PG (p = 0.068, Cohen's d 0.543), respectively, during postoperative year 3, indicating that the PG group achieved a better trend with a moderate effect size. According to the PGSAS-37, the PG group experienced a better trend in the indigestion subscale (p < 0.001, Cohen's d -1.085) and total symptom score (p = 0.050, Cohen's d -0.59) during postoperative year 3 compared with the TG group. In contrast, the EORTC-QLQ-C30 detected no difference between the groups at any time point during 3-year postoperative period. CONCLUSIONS: This prospective study demonstrates that PG tended to be more favorable compared with TG with respect to postoperative weight loss and QOL, particularly regarding indigestion.

Patient-reported outcomes, weight loss, and remission of type 2 diabetes 3 years after gastric bypass and sleeve gastrectomy (Oseberg); a single-centre, randomised controlled trial.

BACKGROUND: Little is known about the comparative effects of various bariatric procedures on patient-reported outcomes. We aimed to compare 3-year effects of gastric bypass and sleeve gastrectomy on patient-reported outcome measures in patients with obesity and type 2 diabetes. METHODS: The Oseberg trial was a single-centre, parallel-group, randomised trial at Vestfold Hospital Trust, a public tertiary obesity centre in Tønsberg, Norway. Eligible patients were aged 18 years or older with previously verified BMI 35·0 kg/m2 or greater. Diabetes was diagnosed if glycated haemoglobin was at least 6·5% (48 mmol/mol) or by their use of anti-diabetic medications with glycated haemoglobin at least 6·1% (43 mmol/mol). Eligible patients were randomly assigned (1:1) to gastric bypass or sleeve gastrectomy. All patients received identical preoperative and postoperative treatment. Randomisation was done with a computerised random number generator and a block size of ten. Study personnel, patients, and the primary outcome assessor were blinded to allocations for 1 year. The prespecified secondary outcomes reported here were 3-year changes in several clinically important patient-reported outcomes, weight loss, and diabetes remission. Analyses were done in the intention to treat population. This trial is ongoing, closed to recruitment and is registered with ClinicalTrials.gov, NCT01778738. FINDINGS: Between Oct 15, 2012 and Sept 1, 2017, 319 consecutive patients with type 2 diabetes scheduled for bariatric surgery were assessed for eligibility. 101 patients were not eligible (29 did not have type 2 diabetes according to inclusion criteria and 72 other exclusion criteria) and 93 declined to participate. 109 patients were enrolled and randomly assigned to sleeve gastrectomy (n=55) or gastric bypass (n=54). 72 (66%) of 109 patients were female and 37 (34%) were male. 104 (95%) of patients were White. 16 patients were lost to follow up and 93 (85%) patients completed the 3-year follow-up. Three additional patients were contacted by phone for registration of comorbidities Compared with sleeve gastrectomy, gastric bypass was associated with a greater improvement in weight-related quality of life (between group difference 9·4, 95% CI 3·3 to 15·5), less reflux symptoms (0·54, 0·17 to -0·90), greater total bodyweight loss (8% difference, 25% vs 17%), and a higher probability of diabetes remission (67% vs 33%, risk ratio 2·00; 95% CI 1·27 to 3·14). Five patients reported postprandial hypoglycaemia in the third year after gastric bypass versus none after sleeve-gastrectomy (p=0·059). Symptoms of abdominal pain, indigestion, diarrhoea, dumping syndrome, depression, binge eating, and appetitive drive did not differ between groups. INTERPRETATION: At 3 years, gastric bypass was superior to sleeve gastrectomy in patients with type 2 diabetes and obesity regarding weight related quality of life, reflux symptoms, weight loss, and remission of diabetes, while symptoms of abdominal pain, indigestion, diarrhoea, dumping, depression and binge eating did not differ between groups. This new patient-reported knowledge can be used in the shared decision-making process to inform patients about similarities and differences between expected outcomes after the two surgical procedures. FUNDING: Morbid Obesity Centre, Vestfold Hospital Trust. TRANSLATION: For the Norwegian translation of the abstract see Supplementary Materials section.

Case Report: Severe back pain, epigastric distress and refractory nausea; an unusual presentation of mediastinal bronchogenic cyst.

Background: Bronchogenic cysts are congenital malformations from abnormal budding of embryonic foregut and tracheobronchial tree. We present a case of bronchogenic cyst with severe back pain, epigastric distress and refractory nausea and vomiting.   Case Presentation: A 44-year-old Hispanic female presented with a 3-week history of recurrent sharp interscapular pain radiating to epigastrium with refractory nausea and vomiting. She underwent cholecystectomy 2-years ago. Computed tomography (CT) abdomen at that time showed a subcarinal mass measuring 5.4 X 5.0 cm. Subsequent endoscopic ultrasound diagnosed it as a bronchogenic cyst. Endobronchial ultrasound (EBUS) guided aspiration resulted in incomplete drainage and she was discharged after partial improvement. Current physical examination showed tachycardia and tachypnea with labs showing leukocytosis, elevated inflammatory markers, and hypokalemic metabolic alkalosis. CT chest showed an increased size of the bronchogenic cyst (9.64 X 7.7 cm) suggestive of possible partial cyst rupture or infected cyst. X-ray esophagram ruled out esophageal compression or contrast extravasation. Patient's symptoms were refractory to conservative management. The patient ultimately underwent right thoracotomy with cyst excision that resulted in complete resolution of symptoms. Conclusion: Bronchogenic cysts are the most common primary cysts of mediastinum with the prevalence of 6%. The most common symptoms are chest pain, dyspnea, cough, and stridor. Diagnosis is made by chest X-Ray and CT chest. Magnetic resonance imaging chest and EBUS are more sensitive and specific. Symptomatic cysts should be resected unless surgical risks are high. Asymptomatic cysts in younger patients should be removed due to low surgical risk and potential late complications. Watchful waiting has been recommended for asymptomatic adults or high-risk patients. This case presents mediastinal bronchogenic cyst as a cause of back, nausea and refractory vomiting. Immediate surgical excision in such cases should be attempted, which will lead to resolution of symptoms and avoidance of complications.

Gastric lipoma: an unusual cause of dyspeptic symptoms.

Gastric lipomas are rare tumours accounting for 2-3% of all benign gastric tumours. These are usually submucosal in origin but in rare cases may be subserosal in origin. Although a majority of gastric lipomas are asymptomatic and usually detected incidentally, occasionally these can cause abdominal pain, dyspeptic disorders, obstruction, invagination and haemorrhages. In the literature, only 200 cases of gastric lipomas have been reported so far. We report a case of a 56-year-old female with a submucosal symptomatic gastric lipoma presenting with disabling dyspeptic symptoms.

Is laparoscopic cholecystectomy effective in relieving dyspepsia in patients of cholelithiasis? A prospective study.

Background: Laparoscopic cholecystectomy (LC) is routinely done for symptomatic gallstone disease; however, its role in relieving dyspeptic symptoms in cholelithiasis is controversial. Aim: The study was designed to assess the role of laparoscopic cholecystectomy in relieving dyspeptic symptoms in patients having cholelithiasis with only dyspeptic symptoms. Methods: Patients with cholelithiasis having only dyspeptic symptoms not attributable to other causes (like Helicobacter pylori) were subjected to laparoscopic cholecystectomy. Dyspepsia scores (Dyspepsia Severity Assessment Score-DSAS and Gastrointestinal Quality of Life Index- GIQLI) were measured before and after surgery and analyzed using Greenhouse-Geisser, McNemar's and ANOVA tests. Results: 27 patients (M:F=1:26, mean age=40.48±10.60 years) having dyspepsia with asymptomatic gallstones were included in the study. There was significant improvement in DSAS (20.11±4.36 vs 28.63±3.42; p<0.001) and GIQLI(106.11±5.77 vs 122.56±7.95; p<0.001) after 2 months of LC. All symptoms improved individually; relief in early satiety and vomiting was the maximum (outcome benefit ratios=0.954, p=0.007 and 0.937, p=0.005 respectively). Multiple gallstones caused more dyspepsia than single (p=0.005). There was no significant difference between H. pylori positive and negative groups in terms of improvement of DSAS and GIQLI scores after LC (p=0.897 and p=0.375 respectively; however dyspepsia was seen to improve significantly within both groups). Conclusion: Dyspepsia may be a symptom of gallstone disease, and these patients can benefit from LC especially when early satiety and vomiting are the main symptoms. A larger sample size may offer more insight.

Effect of laparoscopic cholecystectomy on gastric emptying and dyspepsia.

BACKGROUND: Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gallstone disease. Nonresolution of dyspepsia postoperatively is of major concern nowadays. The present study was conducted to study the effect of laparoscopic cholecystectomy on gastric emptying in symptomatic gallstone disease using (99m)Tc sulfur colloid scintigraphy. This pilot study sought to obtain preliminary data and to establish a base for further detailed study. METHODS: A total of 25 patients with a diagnosis of symptomatic gallstone disease scheduled for laparoscopic cholecystectomy were included in the study. All patients underwent gastric scintigraphic emptying study preoperatively and 2 weeks after laparoscopic cholecystectomy. Laparoscopic cholecystectomy was done as a day care procedure. RESULTS: Mean ± standard deviation preoperative gastric percentage clearance was 51.36 ± 12.67%. Preoperative gastric emptying half-time was 62.72 ± 21.59 min. Forty percent of patients experienced dyspeptic symptoms before surgery. Twenty-four percent of patients had dyspeptic symptoms during postoperative follow-up at 2 weeks. Postoperative percentage gastric clearance was 49.92 ± 13.17%. Postoperative gastric emptying half-time was 64.12 ± 19.13 min. Statistical analysis revealed no significant effect of laparoscopic cholecystectomy on gastric emptying parameters. CONCLUSIONS: Laparoscopic cholecystectomy does not alter gastric emptying or stomach percentage clearance in gallstone patients who have preoperative delayed gastric emptying on scintigraphy. Laparoscopic cholecystectomy has no effect on gastric emptying in symptomatic gallstone patients.

Rate and yield of repeat upper endoscopy in patients with dyspepsia.

AIM: To determine the rate and yield of repeat esophagogastroduodenoscopy (EGD) for dyspepsia in clinical practice, whether second opinions drive its use, and whether it is performed at the expense of colorectal cancer screening. METHODS: We performed a retrospective cohort study of all patients who underwent repeat EGD for dyspepsia from 1996 to 2006 at the University of California, San Francisco endoscopy service. RESULTS: Of 24,780 EGDs, 5460 (22%) were performed for dyspepsia in 4873 patients. Of these, 451 patients (9.3%) underwent repeat EGD for dyspepsia at a median 1.7 (interquartile range, 0.8-3.1) years after initial EGD. Significant findings possibly related to dyspepsia were more likely at initial (29%) vs repeat EGD (18%) [odds ratio (OR), 1.45; 95% confidence interval (CI): 1.20-1.75, P < 0.0001], and at repeat EGD if the initial EGD had reported such findings (26%) than if it had not (14%) (OR, 1.32; 95% CI: 1.08-1.62, P = 0.0015). The same endoscopist performed the repeat and initial EGD in 77% of cases. Of patients aged 50 years or older, 286/311 (92%) underwent lower endoscopy. CONCLUSION: Repeat EGD for dyspepsia occurred at a low but substantial rate, with lower yield than initial EGD. Optimizing endoscopy use remains a public health priority.

Gastric emptying before and after cholecystectomy in patients with cholecystolithiasis.

BACKGROUND/AIMS: The objective of the present study was to measure gastric emptying time of solids and semisolids in dyspeptic individuals with cholecystolithiasis before and 6 months after cholecystectomy in order to determine whether cholecystectomy interferes with gastric emptying. METHODOLOGY: A prospective, self-pairing study was conducted on 29 patients selected according to appropriate inclusion and exclusion criteria. Gastric emptying time of solids and semisolids was determined before and six months after laparoscopic cholecystectomy by the 13C-octanoic acid and 13C-acetate breath tests, respectively. The samples were analyzed by infrared spectrometry. The gastric retention time (lag phase) and gastric emptying half-time of solid and semisolid were determined and the results obtained before and after surgery were compared in the same patient. In addition, the effects of surgery on dyspeptic symptoms were assessed. RESULTS: No significant differences (p>0.05) in gastric retention time and gastric emptying half-time of solid and semisolid test meals were observed before and after cholecystectomy. Dyspeptic symptoms (pain, upper abdominal gases, early satiety, nausea and vomiting) improved after surgery. CONCLUSIONS: Laparoscopic cholecystectomy does not interfere with the gastric emptying time of solids or semisolids in dyspeptic individuals with cholecystolithiasis.

Isolated food intolerance after adjustable gastric banding: a major cause of long-term band removal.

BACKGROUND: Erosion, slippage, and esophageal dilatation have been acknowledged as typical long-term issues after lap banding. Yet it seems from our experience that isolated food intolerance has become a leading cause for band removal, although not reported as such in the literature. METHODS: There were 1,450 patients who have been operated on over 12 years (May 1995-May 2007). Food intolerance occurred in 41 cases (2.9%), representing 1/3 of the causes of band removal. The average time for diagnosis was 58 months (16-110). Seventeen cases occurred before 5 years of follow-up, and 25 after. RESULTS: The postoperative course has been uneventful in all cases of simple removal. No patient had re-banding after removal, one had vertical banded gastroplasty in another center, two a gastric bypass, one a BPD, and four had a sleeve gastrectomy at the same operative time as band removal. Food intolerance is rarely reported in the literature, or often attributed to "poor compliance" or "poor results" after lap banding. The background and symptoms of this entity should be separated from other issues, i.e., esophageal dilatation and band slippage. Gastric bypass is a valuable option after band removal, but like others, we prefer sleeve gastrectomy as a second step procedure, given the weight loss that has already been achieved in many cases. CONCLUSION: Food intolerance after lap-banding is likely to represent the most common cause for band removal in the long run, although we do not know its future rate. From the literature and our experience, there is no clear cause to this complication in the majority of the cases; neither the type of band nor the type of procedure are sufficient explanations.

Laparoscopic sleeve resection of a recurrent gastric cascade: a case report.

The cascade stomach consists of a biloculation of the gastric cavity into a ventral (corpus and antrum) and a dorsal (fundus) recess and is a rare cause of upper abdominal symptoms. The causes of gastric cascade described in the literature are manifold and are separated into congenital, functional, or organic disorders. Patients with a gastric cascade can have a range of upper abdominal symptoms, including nausea, vomiting, dyspepsia, eructation, heartburn, epigastric pain, and early satiety. This disorder is often difficult to diagnose or is not recognized and, therefore, its true incidence is currently not known. As a consequence, data on the treatment of the condition are limited. Suggested treatment options in the literature range from conservative measures, such as bending exercises or dietary adjustments, to operative corrections, such as gastropexy and laparoscopic gastro-gastric anastomosis. In this paper, we summarize the literature findings on gastric cascade and report on a new treatment option: the laparoscopic gastric sleeve resection.

[Guideline "Dyspepsia"]. / Richtlijn 'Maagklachten'.

For the management of patients with dyspepsia a multidisciplinary working party has made recommendations, i.e. about indications for prompt endoscopy, the management of dyspeptic complaints of recent onset, the application of diagnostic tests and treatment of recurrent dyspepsia and the indications for long term use of acid suppressants. Endoscopy is indicated in every patient with alarm symptoms, i.e. blood loss, dysphagia, weight loss or anemia in combination with dyspepsia. Age alone is not a decisive factor in this. Given the good prognosis of recent onset dyspepsia, the application of diagnostic tests is generally not required. Treatment should be restricted to antacids or H2 receptor antagonists. Only in case of persistent or recurring complaints, diagnostic tests or another treatment (Helitobacter pylori diagnostic tests, empirical treatment or endoscopy) should be considered. Testing for H. pylori is especially effective in patients at risk for peptic ulcer disease: those with recurrent complaints, and those with a history of peptic ulcer, without typical reflux symptoms or those with a history ofpeptic ulcer. Short term empirical treatment with a proton pump inhibitor is especially effective in patients with typical reflux symptoms. Endoscopy is the only way to rule out malignancy, and should be used to solve serious diagnostic uncertainty in patient or physician. The only indication for continuous proton pump inhibitor treatment is severe oesophagitis. All other patients with less severe reflux disease should preferably be treated on either on demand or intermittent basis. Long term proton pump inhibitor treatment is not indicated for patients with peptic ulcer disease or functional dyspepsia.

Peptic ulcer disease in dyspeptic patients with ischemic heart disease: search and treat?

OBJECTIVE: The aim of this study was to determine the prevalence and risk factors for peptic ulcer disease (PUD) in dyspeptic patients with ischemic heart disease (IHD), and to assess whether the healing of PUD before coronary artery bypass grafting (CABG) could reduce the need for urgent postoperative endoscopy. PATIENTS AND METHODS: A series of 894 patients referred to Dubrava University Hospital in Zagreb for elective CABG during the period from May 1998 until April 2001 was prospectively analysed. Dyspepsia was assessed by a questionnaire, PUD by upper gastrointestinal endoscopy, and H. pylori status by histology/Giemsa staining and the rapid urease test. The need for urgent postoperative endoscopy (hematemesis and/or melena, sudden onset of anemia or unexplained epigastric pain) was compared between the prospective study group of 894 patients and a series of 463 patients referred for CABG to Dubrava University Hospital during the period from January 1997 until April 1998. RESULTS: Gastroduodenal dyspepsia predominated in 184 (20.6 %) patients, 142 (77.2 %) of them with Helicobacter (H.) pylori infection and 69 (37.5 %) with verified PUD. Univariate analysis indicated the increased risk of multiple PUD to be related to a previous diagnosis of PUD (OR 3.61, 95 % CI 1.32 - 9.82), H. pylori infection (OR 18.86, 95 % CI 2.31 - 153.98), use of aspirin (OR 5.70; 95 % CI 1.80 - 18.03) and left coronary artery occlusions (3.10, 95 % CI 1.00 - 9.59). Multivariate analysis pointed to H. pylori infection (OR 16.30, 95 % CI 1.57 - 168.53) and left coronary artery occlusions (OR 4.84, 95 % CI 1.05 - 22.30) as independent risk factors for multiple PUD. The OR for urgent postoperative endoscopy due to a major gastrointestinal event was 9.9 (95 % CI 2.2 - 45.1) and the OR for active peptic ulcer with stigmata of recent bleeding was 6.9 (95 % CI 1.4 - 33.1) in the group of patients with IHD who were not submitted to evaluation for dyspepsia prior to elective heart surgery. CONCLUSIONS: In areas with a high prevalence of H. pylori infection, endoscopy and a "search and treat" strategy for IHD patients with dyspepsia before elective cardiac surgery should significantly reduce the need for urgent postoperative endoscopy due to major gastrointestinal events.

Helicobacter pylori test and eradicate versus prompt endoscopy for management of dyspeptic patients: 6.7 year follow up of a randomised trial.

BACKGROUND: Dyspepsia is a chronic disease with significant impact on the use of health care resources. A management strategy based on Helicobacter pylori testing has been recommended but the long term effect is unknown. AIM: To investigate the long term effect of a test and treat strategy compared with prompt endoscopy for management of dyspeptic patients in primary care. PATIENTS: A total of 500 patients presenting in primary care with dyspepsia were randomised to management by H pylori testing plus eradication therapy (n = 250) or by endoscopy (n = 250). Results of 12 month follow up have previously been presented. METHODS: Symptoms, quality of life, and patient satisfaction were recorded during a three month period, a median 6.7 years after randomisation (range 6.1-7.3 years). Number of endoscopies, antisecretory medication, H pylori treatments, and hospital visits were recorded from health care databases for the entire follow up period. RESULTS: Median age was 45 years; 28% were H pylori infected. Use of resources was registered in all 500 patients (3084 person years) of whom 312 completed diaries. We found no difference in symptoms between the two groups. Median proportion of days without symptoms was 0.52 (interquartile range 0.10-0.88) in the test and eradicate group versus 0.64 (0.14-0.90) in the prompt endoscopy group (p = 0.27) (mean difference 0.05 (95% confidence interval (CI) -0.03 to 0.14)). Compared with the prompt endoscopy group, the test and eradicate group underwent fewer endoscopies (mean difference 0.62 endoscopies/person (95% CI 0.38-0.86)) and used less antisecretory medication (mean difference 102 defined daily doses/person (95% CI -1 to 205)). CONCLUSION: On a long term basis, a H pylori test and eradicate strategy is as efficient as prompt endoscopy for management of dyspeptic patients in primary care and reduces the use of endoscopy and antisecretory medication.

Cost-effectiveness and long-term impact of Helicobacter pylori 'test and treat' service in reducing open access endoscopy referrals.

INTRODUCTION: We have shown that the introduction of a carbon urea breath test (13C-UBT) service for Helicobacter pylori screening and eradication is effective in reducing the rate of open access endoscopy referrals in patients aged < 40 years in the short term. This has been substantiated by several randomized controlled trials comparing a 'test and treat' strategy with early endoscopy in these patients. However, the long-term impact of such a strategy is not established. OBJECTIVE: To ascertain the influence of 13C-UBT services on open access endoscopy referral rates in dyspeptic patients under the age of 40 years over a period of 5 years. METHODS: Retrospective analysis of open access endoscopy referral rates between August 1990 and July 2000. Cost minimization analysis was performed with a Decision Analysis Model using Treeage Data 3.5. RESULTS: The total number of open access referrals for endoscopy during 1990-1995 was between 765 and 1325 per year. The proportion of endoscopies performed in patients < 40 years ranged between 33.4% and 34.6%. The total number of endoscopy referrals during 1995-2000 after the introduction of the 13C-UBT services was between 1178 and 1321 per year. However, there was a sustained reduction in the proportion of patients aged < 40 years, ranging between 23.2% and 26.2% (Chi2 = 153.9, degrees of freedom = 9, P < 0.0001) during this period. CONCLUSIONS: The H. pylori screening and treatment strategy using the 13C-UBT service results in a sustained reduction of the number of endoscopy referrals and is cost effective in dyspeptic patients under the age of 40 years, enabling better utilization of available resources.

Persistent dyspepsia after laparoscopic cholecystectomy. The influence of psychological factors.

BACKGROUND: Many patients with gallstone disease continue to report gastrointestinal symptoms after cholecystectomy, but the predictive value of preoperative factors is not well understood. We aimed to investigate whether psychological symptoms can be associated with poor outcome after cholecystectomy in patients with gallstones and dyspepsia. METHODS: A sample of 52 consecutive patients with uncomplicated gallstone disease and dyspepsia (conceived in a broader sense to include symptoms of the whole digestive tract) were assessed for psychological (revised 90-item Hopkins Symptom Checklist) and gastrointestinal symptoms (Gastrointestinal Symptom Rating Scale). One year after laparoscopic cholecystectomy, patients rated their gastrointestinal symptoms and were divided into improved and unimproved on the basis of the change in symptoms. RESULTS: Twenty-one (40.4%) patients did not improve after surgery. Improved and unimproved patients did not differ in terms of sex, age, education or illness duration. Unimproved patients showed significantly higher psychological and dyspeptic symptoms than improved patients before surgery. Logistic regression showed that psychological factors were significantly associated with unimprovement after surgery. CONCLUSIONS: Patients with gallstone disease and dyspeptic symptoms are unlikely to improve 1 year after surgery if they show psychological distress before surgery. Psychological symptoms were strongly associated with poor post-cholecystectomy outcome, thus highlighting the clinical relevance of joint assessment of psychological and gastrointestinal symptoms before surgery.

Gastric lipoma presenting with dyspepsia.

Gastric lipoma is one of the rare benign gastric tumors. Its preoperative diagnosis obviates the need of an extended gastrectomy. We report a case of gastric lipoma who presented with symptoms of dyspepsia and was treated by surgical gastrectomy and tumour enucleation.

Gastric accommodation and emptying in evaluation of patients with upper gastrointestinal symptoms.

BACKGROUND & AIMS: Endoscopy-negative dyspepsia is a common symptom that often is difficult to define in pathophysiologic terms. The aim of this study was to assess the frequency of disordered gastric accommodation and emptying in patients referred with unexplained upper gastrointestinal symptoms. METHODS: A computerized diagnostic index was used to identify all patients, 18-70 years old, who underwent single-photon emission computed tomography (SPECT) to assess gastric accommodation at Mayo Clinic Rochester over a 3-year period. Demographics, clinical features, and results of diagnostic testing, including scintigraphic gastric emptying, were extracted from the electronic record. RESULTS: A total of 214 patients were identified; the primary clinical diagnoses were functional dyspepsia, postfundoplication syndromes, rumination syndrome, and diabetic dyspepsia. Gastric accommodation was impaired in 43% of the whole group: 47% of functional dyspepsia, 44% of postfundoplication syndromes, and 33% of diabetic dyspepsia. Delayed gastric emptying was most prevalent in diabetic dyspepsia, and was accelerated in postfundoplication syndromes groups. Thirty-seven percent of patients had abnormal gastric emptying. The highest prevalence of delayed gastric emptying was in the diabetic dyspepsia and accelerated gastric emptying in postfundoplication syndromes groups. Twenty-five percent of patients with normal gastric emptying had impaired accommodation. Upper-gastrointestinal symptoms were not different in groups based on gastric accommodation or emptying results. CONCLUSIONS: Impaired gastric accommodation is common in patients with unexplained dyspepsia. Symptoms alone cannot predict physiologic disturbances. These noninvasive tests identify single or combined pathophysiologic disturbances and may help to identify subgroups of patients as candidates for more selective pharmacotherapy in the future.

Impact of delayed gastric emptying on the outcome of antireflux surgery.

OBJECTIVE: To study the effect of Nissen fundoplication on the pattern of gastric emptying and intragastric distribution of symptoms in patients with normal and delayed gastric emptying before surgery, especially in those with delayed emptying before surgery. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease is associated with delayed gastric emptying and dyspeptic symptoms in approximately 40% of the patients. After Nissen fundoplication, dyspeptic symptoms are also not uncommon. METHODS: Thirty-six patients (26 men, 10 women, mean age 43.1) were studied before and 3 months after Nissen fundoplication. Gastric emptying (dual-isotope, expressed in lag phase, emptying rate, T50, and intragastric distribution) was not included in the decision for surgery. Reflux-related and dyspeptic symptoms were scored before and at 3, 6, and 12 months after surgery. RESULTS: Twenty-six patients had normal and 10 had delayed gastric emptying before surgery. Nissen fundoplication on average enhanced gastric emptying for solids in both subgroups by a combination of a decrease in mean lag phase, emptying rate, and T50. The preoperative difference in intragastric distribution between patients with and without delayed gastric emptying was abolished by fundoplication. Patients with normal gastric emptying before surgery showed an increase in early postprandial satiety; in those with delayed emptying, this was not observed. A correlation was found between preoperative T50 for liquid gastric emptying and postoperative nausea at 3 months in patients with normal gastric emptying. In patients with delayed emptying, preoperative correlations between lag phase for liquids and nausea respectively early satiety were significant, as well as for T50 for liquids and vomiting. CONCLUSIONS: Nissen fundoplication equalizes the preoperative difference in intragastric distribution and accelerates gastric emptying without an effect on symptoms in patients with preexisting delayed gastric emptying, but with an increase in early satiety in patients with normal gastric emptying. Delayed gastric emptying is not a contraindication for antireflux surgery.