Long-term urodynamic findings following colo-, gastro- and ileocystoplasty.

PURPOSE: To evaluate the urodynamic changes in patients who have undergone colocystoplasty (CCP), gastrocystoplasty (GCP) and ileocystoplasty (ICP) in a retrospective study. Changes in urinary continence, incidence of pathologic contractions before and after augmentation, alterations of urodynamic parameters were also examined. METHODS: Eighty-four patients were included in the study who underwent bladder augmentation between 1987 and 2017. Group I: 35 patients with CCP. Group II: 18 patients with GCP. Group III: 31 patients with ICP. Cystometry was performed at 3, 6, and every 12 months, then biannually after augmentation. Pre- and postoperative urodynamic changes were analysed statistically. RESULTS: In Group I, two patients and in Group III, one patient remained incontinent after CCP and ICP. Bladder capacity increased significantly, maximal intra-vesical pressure decreased and compliance improved in all groups (p < 0.001). Postoperative studies showed pathologic contractions in the augmented bladder in half of the patients with GCP, in 43% of patients after CCP and 26% of patients with ICP. CONCLUSION: From the urodynamic point of view, ileum is the most adequate option in the long term. Contractions after augmentation might be caused by the remaining peristalsis of the detubularised segment. Further investigations are needed to evaluate pathologic contractions that remained after detubularisation.

The Evaluation of Gastric Emptying Using the 13 C-Acetate Breath Test in Neurologically Impaired Patients - A Focus on the Stomach Function and Morphology.

PURPOSE: We explored factors affecting gastric emptying in neurologically impaired (NI) patients using the 13C-acetate breath test. METHODS: Twenty-four NI patients were classified by the presence of gastroesophageal reflux disease (GERD), which was treated by fundoplication plus gastrostomy, or the absence of GERD, which was treated by gastrostomy alone, along with gastric malposition involving cascade stomach and organoaxial gastric volvulus (OGV). Gastric emptying parameters (GEPs), which were the emptying half time (T 1/2 , minute), the lag phase time (T lag , minute), and the gastric emptying coefficient (GEC), were measured before and after surgery. We evaluated the relationship between GEPs and GERD, gastric malposition, and surgical intervention. All data were expressed as the median (interquartile range). RESULTS: The T1/2 and GEC of patients with OGV were significantly worse than in those without OGV before surgery (T1/2 with OGV: 241.3 [154.9, 314.3] vs. T1/2 without OGV: 113.7 [105.2, 151.4], p = 0.01, GEC with OGV: 3.19 [2.46, 3.28] vs. GEC without OGV: 3.65 [3.24, 3.90], p = 0.02). GERD and cascade stomach were not associ ated with GEPs. The GEPs of all NI patients showed no significant difference between before and after surgery. The surgical change in T1/2 (ΔT 1/2 ) in the patients with OGV was significantly lower than in those without OGV (ΔT1/2 with OGV: -47.1 [-142.7, -22.1] vs. ΔT1/2 without OGV: -3.78 [-26.6, 12.0], p = 0.03). CONCLUSION: Stomach malposition, such as OGV, seems to affect gastric emptying and may be improved by surgi cal intervention.

Prevalence of gastric hypomotility after additional cryoballoon ablation of the left atrial roof.

INTRODUCTION: Gastric hypomotility (GH) is a major complication of atrial fibrillation (AF) ablation. We aimed to clarify whether additional cryoballoon ablation (CBA) of the left atrial (LA) roof is associated with GH. METHODS AND RESULTS: This study included 54 patients with non-paroxysmal AF who underwent CBA for pulmonary vein isolation and of the LA roof line. GH was defined according to the results of esophagogastroscopy performed 2 days after ablation. GH was observed in 10 patients. There were significant differences in LA diameter (LAD), right inferior pulmonary vein (RIPV) diameter, and the height of the LA roof from the point where the LA posterior wall and esophagus make contact between patients with (GH+) and without GH (GH-) (LAD: 41.0 [36.3-41.8] mm vs. 46.5 [42.8-50.0] mm, p < .01; RIPV diameter: 19.7 [19.0-20.5] mm vs. 23.2 [21.2-24.9] mm, p < .01; height of LA roof: 5.7 [5.1-6.1] mm vs. 8.8 [7.1-11.2] mm for, p < .01, respectively). Multivariate analysis revealed that LA roof height was a predictor of GH. Moreover, Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) scores increased significantly 1 week after ablation (from 1.0 [0.0-2.8] to 5.0 [3.0-11.0], p = .03) in patients with GH. CONCLUSION: The height of the LA roof may be a predictor of GH after CBA of the LA roof line. Additionally, GH-related symptoms may still appear 1 week after ablation.

Inter-specialty collaboration in the formalization of a new foregut subspecialty.

Historical context and converging market conditions present a unique opportunity to study the factors contributing to the formalization of foregut, or upper gastrointestinal, surgery as a new subspecialty in United States healthcare. The aim of this study was to examine the justifications of those pursuing the formalization of a foregut subspecialty and to extract lessons for healthcare leaders on the evolving relationships between competing providers. This was a qualitative, cross-sectional study consisting of interviews, secondary survey data, and observation of society meetings between October 2018 and June 2019. Thirty interviews with healthcare professionals were conducted, transcribed, and analyzed for themes using qualitative coding software. Themes were correlated with observational field notes and archival data and compared against established social theories on professions and medical specialization. Analysis revealed that traditionally competing surgeons and gastroenterologists articulate a professional need to qualify foregut surgical expertise based on superior knowledge and outcomes, to define the allocation of certain tasks and procedures, and to foster collaboration across specialties. Converging market conditions precipitate individual and organizational decisions to pursue formal specialization. Participants in the formalization of this subspecialty should consider the history of professional competition and turf wars to achieve meaningful collaboration. Advocacy for multi-specialty societies and organizational movements could be a model for reduced conflict in other specialties as well.

Influence of gastric morphology on gastroesophageal reflux in adults: An observational study.

ABSTRACT: The study's aim was to determine if there was an association between gastric morphology and gastroesophageal reflux (GER). Few published studies have investigated the relationship between gastric morphology and the risk of GER.A total of 777 patients were randomly selected from 3000 to 3300 patients who presented at a medical center in Taipei for annual health checkups from early 2008 through to late 2010 and underwent a series of radiographs of the upper gastrointestinal tract (UGI). GER was recorded during the real-time fluoroscopic study. Thirty-nine participants had a follow-up endoscopy, and another 164 participants were followed up by a second UGI series 12 +/ -1.5 months later, from late 2008 through to early 2022. All participants completed a lifestyle and symptom questionnaire. The variables included current smoking and alcohol consumption. Participants who had heartburn and dysphagia were included in the study. Additionally, all participants underwent a limited physical examination which recorded age, sex, body mass index, and total cholesterol and triglyceride levels.All participants were classified into types 1 to 6 based on the gastric morphology determined from the first UGI. Cascade stomach is recognized by characteristic findings on UGI. Gastric types 2 and 3 tend to appear as cascade stomachs and were significantly associated with GER (P < .05) compared with the other groups. Morphologic type 5 appeared as an elongated sac extending downward into the pelvic cavity and was less likely to develop GER (P < .001). The results of follow-up studies by UGI and endoscopy were similar to those of the first UGI. Gastric morphologic type 2 was significantly associated, and type 5 was usually not associated, with GER and erosive esophagitis (P < .05) compared with the other groups, by both UGI and endoscopy.Gastric morphologic types 2 and 3, with cascade stomach, might provide a relatively easy method for the development of the GER phenomenon. Gastric morphologic type 5 appeared as an elongated sac that might reduce the incidence of the GER phenomenon. The study suggested that gastric morphologic type could influence the occurrence of GER.

Comparison of intragastric pressure between endotracheal tube and supraglottic airway devices in laparoscopic hepatectomy: A randomized, controlled, non-inferiority study.

BACKGROUND: Supraglottic airway (SGA) devices do not definitively protect the airway from regurgitation of gastric contents. Increased gastric pressure and long operation time are associated with development of complications such as aspiration pneumonia. The aim of this study was to compare intragastric pressure between second-generation SGA and endotracheal tube (ETT) devices during long-duration laparoscopic hepatectomy. METHODS: A total of 66 patients was randomly assigned to 2 groups; 33 patients each in the ETT and SGA groups. Intragastric pressure was continuously measured via a gastric drainage tube with a three-way stopcock connected to the pressure monitoring device. Normal saline was added to the end of the gastric drainage tube at each operation time point. RESULTS: Intragastric pressure during pneumoperitoneum was no different between the 2 groups (P = .146) or over time (P = .094). The mean (standard deviation [SD]) pH of the SGA tip measured after operation was 6.7 (0.4), and a pH <4 was not observed. Relative risk of postoperative complications was significantly higher in the ETT group relative to the SGA group (sore throat, 5.5; cough,13.0). CONCLUSIONS: Use of SGA devices does not further increase intragastric pressure, even during prolonged upper abdominal laparoscopic surgery. Also, the frequency of postoperative sore throat and cough was significantly lower when the second-generation SGA device was used.

Differential gastric emptiness according to preoperative stomach position in neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy.

PURPOSE: We sometimes experienced prolonged delayed gastric emptying (DGE) in neurologically impaired patients undergoing laparoscopic fundoplication and gastrostomy. We explored the difference in the DGE rate according to the preoperative stomach position. METHODS: Thirty-two neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy between 2015 and 2019 were classified into two groups based on stomach position: non-elevated stomach position (NESP) and elevated stomach position (ESP). Patients' characteristics, operative result and postoperative gastric emptying were reviewed. RESULTS: The 11 ESP patients were significantly older than the 21 NESP patients (p < 0.05). The ESP patients had a significantly heavier body weight (BW) than the NESP patients (p < 0.05). The time taken (days) to reduce gastric drainage (days, below BW × 10 ml) in the NESP (4.3 ± 3.6) was significantly longer than that of ESP (1.3 ± 1.6) (p < 0.05). The time taken (days) to achieve full enteral nutrition in the NESP (14.1 ± 8.9) was significantly longer than that of the ESP patients (8.8 ± 3.1) (p < 0.05). CONCLUSION: Elevated stomach position (ESP) patients archived full enteral nutrition earlier than NESP patients after laparoscopic fundoplication and gastrostomy. Stomach position correction might, therefore, be involved in the incidence of DGE.

Gastric Electrical Pacing Reduces Apoptosis of Interstitial Cells of Cajal via Antioxidative Stress Effect Attributing to Phenotypic Polarization of M2 Macrophages in Diabetic Rats.

BACKGROUND: Gastric electrical pacing (GEP) could restore interstitial cells of Cajal in diabetic rats. M2 macrophages contribute to the repair of interstitial cells of Cajal injury though secreting heme oxygenase-1 (HO-1). The aim of the study is to investigate the effects and mechanisms of gastric electrical pacing on M2 macrophages in diabetic models. METHODS: Sixty male Sprague-Dawley rats were randomized into control, diabetic (DM), diabetic with the sham GEP (DM+SGEP), diabetic with GEP1 (5.5 cpm, 100 ms, 4 mA) (DM+GEP1), diabetic with GEP2 (5.5 cpm, 300 ms, 4 mA) (DM+GEP2), and diabetic with GEP3 (5.5 cpm, 550 ms, 4 mA) (DM+GEP3) groups. The apoptosis of interstitial cells of Cajal and the expression of macrophages were detected by immunofluorescence technique. The expression levels of the Nrf2/HO-1 and NF-κB pathway were evaluated using western blot analysis or immunohistochemical method. Malonaldehyde, superoxide dismutase, and reactive oxygen species were tested to reflect the level of oxidative stress. RESULTS: Apoptosis of interstitial cells of Cajal was increased in the DM group but significantly decreased in the DM+GEP groups. The total number of macrophages was almost the same in each group. In the DM group, M1 macrophages were increased and M2 macrophages were decreased. However, M2 macrophages were dramatically increased and M1 macrophages were reduced in the DM+GEP groups. Gastric electrical pacing improved the Nrf2/HO-1 pathway and downregulated the phosphorylation of NF-κB. In the DM group, the levels of malonaldehyde and reactive oxygen species were elevated and superoxide dismutase was lowered, while gastric electrical pacing reduced the levels of malonaldehyde and reactive oxygen species and improved superoxide dismutase. CONCLUSION: Gastric electrical pacing reduces apoptosis of interstitial cells of Cajal though promoting M2 macrophages polarization to play an antioxidative stress effect in diabetic rats, which associates with the activated Nrf2/HO-1 pathway and the phosphorylation of NF-κB pathway.

Gastric Ultrasound Assessing Gastric Emptying of Preoperative Carbohydrate Drinks: A Randomized Controlled Noninferiority Study.

BACKGROUND: Tools for the evaluation of gastric emptying have evolved over time. The purpose of this study was to show that the risk of pulmonary aspiration is not increased with carbohydrate drink, by demonstrating that the gastric antral cross-sectional area (CSA) of the NO-NPO group is either equivalent to or less than that of the NPO (nil per os) group. METHODS: Sixty-four patients scheduled for elective laparoscopic benign gynecologic surgery were enrolled and randomly assigned to the NPO group (n = 32) or the NO-NPO group (n = 32). After having a regular meal until midnight before surgery, the NPO group fasted until surgery, while the NO-NPO group ingested 400 mL of a carbohydrate drink at midnight and freely up to 2 hours before anesthesia. The primary outcome was the gastric antral CSA by gastric ultrasound in right lateral decubitus position (RLDP). Noninferiority was defined as a mean difference of CSA <2.8 cm2. Secondary outcomes included CSA in supine position, gastric volume (GV), GV per weight (GV/kg), GV/kg >1.5 mL/kg, and Perlas grade. RESULTS: CSA in RLDP was not different between the NPO group (6.25 ± 3.79 cm2) and the NO-NPO group (6.21 ± 2.48 cm2; P = .959). The mean difference of CSA in RLDP (NO-NPO group - NPO group) was 0.04 (95% confidence interval [CI], -1.56 to 1.64), which was within the noninferiority margin of 2.8 cm2. CSA was not different between the 2 groups (4.17 ± 2.34 cm2 in NPO group versus 4.28 ± 1.23 cm2 in NO-NPO group; P = .828). GV in NPO group (70 ± 56 mL) was not different from NO-NPO group (66 ± 36 mL; mean difference, 3.66; 95% CI, -20 to 27; P = .756). GV/kg in the NPO group (1.25 ± 1.00 mL/kg) was not different from the NO-NPO group (1.17 ± 0.67 mL/kg; P = .694). The incidence of GV/kg > 1.5 mL/kg was not different between NPO (31.3%) and NO-NPO group (21.9%; P = .768). The median (interquartile range) of the Perlas grade was 1 (0-1) in NPO group and 0.5 (0-1) in NO-NPO group (P = .871). CONCLUSIONS: Preoperative carbohydrates ingested up to 2 hours before anesthesia do not delay gastric emptying compared to midnight fasting, as evaluated with gastric ultrasound.

Gastric ablation as a novel technique for modulating electrical conduction in the in vivo stomach.

Gastric motility is coordinated by underlying bioelectrical "slow wave" activity. Slow wave dysrhythmias are associated with motility disorders, including gastroparesis, offering an underexplored potential therapeutic target. Although ablation is widely used to treat cardiac arrhythmias, this approach has not yet been trialed for gastric electrical abnormalities. We hypothesized that ablation can create localized conduction blocks and modulate slow wave activation. Radiofrequency ablation was performed on the porcine serosa in vivo, encompassing a range of parameters (55-85°C, adjacent points forming a line, 5-10 s/point). High-resolution electrical mapping (16 × 16 electrodes; 6 × 6 cm) was applied to define baseline and acute postablation activation patterns. Tissue damage was evaluated by hematoxylin and eosin and c-Kit stains. Results demonstrated that RF ablation successfully induced complete conduction block and a full thickness lesion in the muscle layer at energy doses of 65-75°C for 5-10 s/point. Gastric ablation may hold therapeutic potential for gastric electrical abnormalities in the future.NEW & NOTEWORTHY This study presents gastric ablation as a new method for modulating slow wave activation and propagation in vivo, by creating localized electrical conduction blocks in the stomach, validated by high-resolution electrical mapping and histological tissue analysis. The results define the effective energy dose range for creating conduction blocks, while maintaining the mucosal and submucosal integrity, and demonstrate the electrophysiological effects of ablation. In future, gastric ablation can now be translated toward disrupting dysrhythmic slow wave activation.

Clinical features and gastric myoelectrical activity in patients with idiopathic and post-surgical rapid gastric emptying who present with unexplained chronic nausea.

BACKGROUND: The cause of chronic nausea can be difficult to diagnose. Idiopathic rapid gastric emptying (iRGE) can cause nausea, but limited literature exists on clinical and pathophysiological features. In contrast, dumping syndrome or post-surgical rapid gastric emptying (psRGE) is well-known and may present with early phase vasomotor symptoms, diarrhea, and late phase reactive hypoglycemia. Our aim is to compare clinical and gastric motility characteristics in patients with iRGE and psRGE and unexplained chronic nausea. METHODS: A retrospective study was conducted on patients with unexplained chronic nausea and RGE (<30% retention of a standard isotope-labeled solid meal at 1-h). Gastric myoelectrical activity (GMA) was recorded during water load satiety tests (WLST) using validated electrogastrogram (EGG) recording methods. KEY RESULTS: Thirty iRGE and sixteen psRGE patients with unexplained chronic nausea were identified; average 1-hour meal retention was 18.6% and 16.2%, respectively. Nausea, bloating, early satiety, and bowel function were similar in the two groups; fewer iRGE patients had abdominal pain and none had vasomotor symptoms. Normal 3 cpm GMA was recorded in 44% of iRGE vs 29% of psRGE, tachygastria in 13% vs 43%, bradygastria in 25% vs 14%, and mixed in 19% vs 14% (p values >0.05). Abnormal WLST volume (<300 ml) was found in 69% of iRGE and 43% of psRGE (p = 0.36). CONCLUSIONS & INFERENCES: (a) iRGE and psRGE patients may present with unexplained chronic nausea rather than classic vasomotor symptoms and diarrhea. (b) iRGE and psRGE patients had similar gastric dysrhythmias and accommodation dysfunction, which may contribute to RGE.

Neural correlates of future weight loss reveal a possible role for brain-gastric interactions.

Lifestyle dietary interventions are an essential practice in treating obesity, hence neural factors that may assist in predicting individual treatment success are of great significance. Here, in a prospective, open-label, three arms study, we examined the correlation between brain resting-state functional connectivity measured at baseline and weight loss following 6 months of lifestyle intervention in 92 overweight participants. We report a robust subnetwork composed mainly of sensory and motor cortical regions, whose edges correlated with future weight loss. This effect was found regardless of intervention group. Importantly, this main finding was further corroborated using a stringent connectivity-based prediction model assessed with cross-validation thus attesting to its robustness. The engagement of senso-motor regions in this subnetwork is consistent with the over-sensitivity to food cues theory of weight regulation. Finally, we tested an additional hypothesis regarding the role of brain-gastric interaction in this subnetwork, considering recent findings of a cortical network synchronized with gastric activity. Accordingly, we found a significant spatial overlap with the subnetwork reported in the present study. Moreover, power in the gastric basal electric frequency within our reported subnetwork negatively correlated with future weight loss. This finding was specific to the weight loss related subnetwork and to the gastric basal frequency. These findings should be further corroborated by combining direct recordings of gastric activity in future studies. Taken together, these intriguing results may have important implications for our understanding of the etiology of obesity and the mechanism of response to dietary intervention.

Duodenal acidification induces gastric relaxation and alters epithelial barrier function by a mast cell independent mechanism.

Duodenal hyperpermeability and low-grade inflammation in functional dyspepsia is potentially related to duodenal acid exposure. We aimed to evaluate in healthy volunteers the involvement of mast cell activation on the duodenogastric reflex and epithelial integrity during duodenal acidification. This study consisted of 2 parts: (1) Duodenal infusion of acid or saline during thirty minutes in a randomized, double-blind cross-over manner with measurement of intragastric pressure (IGP) using high resolution manometry and collection of duodenal biopsies to measure epithelial barrier function and the expression of cell-to-cell adhesion proteins. Mast cells and eosinophils were counted and activation and degranulation status were assessed. (2) Oral treatment with placebo or mast cell stabilizer disodiumcromoglycate (DSCG) prior to duodenal perfusion with acid, followed by the procedures described above. Compared with saline, acidification resulted in lower IGP (P < 0.01), increased duodenal permeability (P < 0.01) and lower protein expression of claudin-3 (P < 0.001). Protein expression of tryptase (P < 0.001) was increased after acid perfusion. Nevertheless, an ultrastructural examination did not reveal degranulation of mast cells. DSCG did not modify the drop in IGP and barrier dysfunction induced by acid. Duodenal acidification activates an inhibitory duodenogastric motor reflex and, impairs epithelial integrity in healthy volunteers. However, these acid mediated effects occur independently from mast cell activation.

Comparison of gastric insufflation using LMA-supreme and I-gel versus tracheal intubation in laparoscopic gynecological surgery by ultrasound: a randomized observational trial.

BACKGROUND: The application of bedside ultrasound to evaluate gastric content and volume can assist in determining aspiration risk. Applying positive pressure ventilation via supraglottic airway devices (SAD) can result in a degree of gastric insufflation. This study assessed and compared the antral cross-sectional area (CSA) in patients undergoing laparoscopic gynecological surgery when managed with different SAD. METHODS: One hundred American Society of Anesthesiologists I or II female patients were assessed for inclusion in this study and divided into three groups of different ventilation devices. Patients were randomly allocated into three groups to receive LMA-Supreme (Group S), I-gel (Group I) or tracheal tube (Group T). The primary outcome was the antral cross-sectional area and secondary outcomes included haemodynamic parameters and postoperative morbidity such as sore throat, hoarseness, dry throat, nausea and vomiting. RESULTS: The antral CSA was not significantly different among three groups before induction (P = 0.451), after induction (P = 0.456) and at the end of surgery (P = 0.195). The haemodynamic variables were significantly higher in the tracheal tube group than in the LMA-Supreme and I-gel groups after insertion (P < 0.0001) and after removal (P < 0.01). Sore throat was detected in none in the I-gel group compare to two patients (6.7%) in the LMA-Supreme group and fifteen patients (50%) in the tracheal tube group. Hoareness was detected in one (3.3%) in the I-gel group compare to two patients (6.7%) in the LMA-Supreme group and eleven patients (36.7%) in the tracheal tube group. CONCLUSIONS: The SADs do not cause obvious gastric insufflation. Thus, LMA-Supreme and I-gel can be widely used as alternative to endotracheal intubation for the short laparoscopic gynecological surgery. TRIAL REGISTRATION: This trial was registered at the Chinese Clinical Trial Registry (ChiCTR1800018212, data of registration, September 2018).

Gastroparesis: New insights into an old disease.

Gastroparesis (Gp) is a chronic disease characterized by a delayed gastric emptying in the absence of mechanical obstruction. Although this condition has been reported in the literature since the mid-1900s, only recently has there been renewed clinical and scientific interest in this disease, which has a potentially great impact on the quality of life. The aim of this review is to explore the pathophysiological, diagnostic and therapeutical aspects of Gp according to the most recent evidence. A comprehensive online search for Gp was carried out using MEDLINE and EMBASE. Gp is the result of neuromuscular abnormalities of the gastric motor function. There is evidence that patients with idiopathic and diabetic Gp may display a reduction in nitrergic inhibitory neurons and in interstitial cells of Cajal and/or telocytes. As regards diagnostic approach, 99-Technetium scintigraphy is currently considered to be the gold standard for Gp. Its limits are a lack of standardization and a mild risk of radiation exposure. The C13 breath testing is a valid and safe alternative method. 13C acid octanoic and the 13C Spirulina platensis recently approved by the Food and Drug Administration are the most commonly used diagnostic kits. The wireless motility capsule is a promising technique, but its use is limited by costs and scarce availability in many countries. Finally, therapeutic strategies are related to the clinical severity of Gp. In mild and moderate Gp, dietary modification and prokinetic agents are generally sufficient. Metoclopramide is the only drug approved by the Food and Drug Administration for Gp. However, other older and new prokinetics and antiemetics can be considered. As a second-line therapy, tricyclic antidepressants and cannabinoids have been proposed. In severe cases the normal nutritional approach can be compromised and artificial nutrition may be needed. In drug-unresponsive Gp patients some alternative strategies (endoscopic, electric stimulation or surgery) are available.

Administração de nutrição enteral em posição prona, volume de resíduo gástrico e outros desfechos clínicos em pacientes críticos: uma revisão sistemática / Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

RESUMO Esta revisão sistemática de estudos longitudinais objetivou avaliar o efeito da administração da dieta enteral em pacientes críticos adultos e pediátricos em posição prona no volume residual gástrico e em outros desfechos clínicos. A busca da literatura foi conduzida nas bases de dados PubMed®, Scopus e Embase, a partir de termos relacionados à população e à intervenção. Dois revisores independentes analisaram os títulos e resumos, e a coleta dos dados foi realizada a partir de uma ficha padronizada. Discrepâncias foram resolvidas por um terceiro revisor. A qualidade metodológica dos estudos foi avaliada considerando o potencial para erros sistemáticos e os dados analisados qualitativamente. Quatro estudos com pacientes adultos e um com pacientes pré-termos foram incluídos. O volume residual gástrico foi avaliado como principal desfecho: três não diferiram no volume residual gástrico entre as posições prona e supina (p > 0,05), enquanto um estudo demonstrou maior volume residual gástrico durante a administração da dieta em posição prona (27,6mL versus 10,6mL; p < 0,05), e outro apresentou maior volume residual gástrico na posição supina (redução do volume residual gástrico de 23,3% na posição supina versus 43,9% na posição prona; p < 0,01). Dois estudos avaliaram a frequência de vômitos, sendo maior na posição prona em um estudo (30 versus 26 episódios; p < 0,001) e sem diferença significativa em outro (p > 0,05). Incidência de pneumonia aspirativa e de óbito foram avaliadas por um estudo, não sendo observada diferença entre os grupos (p > 0,05). A literatura acerca da administração de dieta enteral em pacientes críticos em posição prona é escassa e de qualidade limitada, e os resultados sobre volume residual gástrico são contraditórios. Estudos observacionais com tamanho amostral apropriado deveriam ser conduzidos para fundamentar conclusões sobre o tema.

ABSTRACT This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.

Sleeve gastrectomy for treatment of delayed gastric emptying-indications, technique, and results.

INTRODUCTION: Delayed gastric emptying (DGE) can be caused by gastric motility disorders such as gastroparesis with idiopathic background, diabetic neuropathy, or postsurgical nerve damage. Currently, a variety of endoscopic and surgical treatment options are available. We noted clinical improvement of gastric emptying with reduction of the gastric fundus following both fundoplication and fundectomy. As a consequence, we explored the effect of sleeve gastrectomy on gastric emptying. The focus of this paper is to investigate the role of laparoscopic sleeve gastrectomy (LSG) in the treatment of gastroparesis. METHODS: Patients with symptoms suggestive of gastroparesis received diagnostic work-up (gastric emptying scintigraphy and/or Radiographic Barium-Sandwich Emptying studies). Patients with fundic emptying problems and moderate gastric dilation were selected for a LSG. All perioperative parameters were documented regarding patients characteristics, complications, and outcomes expressed as symptoms and quality of life (GIQLI gastrointestinal quality of life index). Assessment of DGE: Barium Emptying Radigraphy Index (BERI) 0-5. RESULTS: From 122 patients with gastroparesis, 19 patients were selected for LSG (mean age 54 years (23-68); 10 males/9 females. Morbidity 2/19; no mortality; follow-up mean 24 months (12-60); preop/postop: BERI: 2, 31/1, 27 (p < 0.01); we noted significant improvement of the quality of life (preoperative GIQLI 78 (44-89)) to postoperative values of 114 (range 87-120) (p < 0.0001). Preoperative median BMI of these 19 patients was 24 [1-10], which was not significantly changed in the 15 patients at > 1 year follow-up with 23 [1-8]. Postoperative recurrence of DGE occurred in 3 patients who were reoperated after >1 year follow-up. CONCLUSION: LSG is a potential surgical treatment option for selected patients with gastroparesis and fundic emptying problems.

Disturbed Gastrointestinal Contractility in a Polycystic Ovary Syndrome Rat Model.

BACKGROUND: Polycystic ovary syndrome (PCOS), a common hormonal disorder in women, affects 4-18% of women of reproductive age worldwide. A higher prevalence of irritable bowel syndrome was found in women with PCOS. However, the effects and mechanism of PCOS on stomach and colon contractility remain unclear. AIMS: This study aims to evaluate the correlation between PCOS and gastrointestinal disorder. METHODS: Four-week-old female rats were subcutaneously implanted with pellets containing 7.5 mg of dihydrotestosterone for 13 weeks to create PCOS rat models. After vaginal smears, the estrus cycle stage was evaluated. Oral glucose tolerance test was performed after 90 days of treatment. All animals were killed at 17 weeks. The rats were fasted overnight and then anesthetized before decapitation, and the stomach fundus and colon were surgically removed and cultured in oxygenated Krebs solution. Acetylcholine and carbachol were used to evaluate the cholinergic system on contractility. RESULTS: The basal and stomach fundus responded with a reduced frequency and contractility in response to acetylcholine in the PCOS group. Moreover, no difference was found in the spontaneous stomach contractility induced by carbachol in both groups. Lower maximal colon muscle contractility was also found in response to acetylcholine stimulation in PCOS rats. Furthermore, lower maximal muscle contractility was found in response to extracellular calcium levels. MLC20 phosphorylation was also reduced in the gastrointestinal tissue in PCOS rats. CONCLUSIONS: PCOS induces gastroparesis and reduces gastrointestinal muscle contractility. This effect is, at least partly, through reducing the responsiveness of acetylcholine and MLC20 phosphorylation.

Detection of gastric inflation using transesophageal echocardiography after different level of pressure-controlled mask ventilation: a prospective randomized trial.

This study aimed to assess the technique of using transesophageal echocardiography (TEE) to detect gastric inflation and to determine the optimal level of inspiratory pressure during face mask ventilation (FMV). In this prospective and randomized trial, seventy-five adults scheduled for cardiac surgery were enrolled to one of the three groups (P12, P15, P20) defined by the applied inspiratory pressure during FMV. After induction, mask ventilation was performed with the corresponding level of pressure-control ventilation for 2 min in each patient. Respiratory and hemodynamic parameters were recorded every 15 s. Arterial blood gases were tested before induction and at the time of intubation. Gastric cross-section area was detected using transesophageal echocardiography after intubation. The gastric cross-section areas were 3.1 ± 0.81, 3.8 ± 1.37 and 4.8 ± 2.29 cm2 respectively. It statistically increased in group P20 compared with group P12 and P15. PaCO2 before intubation statistically increased compared with the baseline in groups P12 and P15, while decreased in group P20. The mean values of PaCO2 equaled to 44.4 mmHg (40-51.5), 42.9 mmHg (34-50.5) and 36.9 mmHg (30.9-46) respectively in three groups. Peak airway pressure of 12-20 cmH2O could provide acceptable sufficient ventilation during mask ventilation, but 20 cmH2O result in higher incidence of gastric inflation. TEE is useful to detect the gastric inflation related to the entry of air into the stomach during pressure-controlled face mask ventilation.Trial Registration Number ChiCTR-IOR-14005325.

The Unconventional Role for Gastric Volume in the Response to Bariatric Surgery for Both Weight Loss and Glucose Lowering.

OBJECTIVE: To study the relationship between the amount of surgery-induced gastric volume reduction and long-term weight loss and glucose tolerance. BACKGROUND DATA: Vertical sleeve gastrectomy (VSG) has recently surpassed gastric bypass to become the most popular surgical intervention to induce sustained weight loss. Besides inducing significant weight loss, VSG also improves glucose tolerance. Although no clear correlation has been observed between the size of the residual stomach and sustained weight loss, this begs the question whether less aggressive gastric volume reduction may provide sufficient efficacy when weight loss is not the major goal of the surgical intervention. METHODS: A series of strategies to reduce gastric volume were developed and tested in Long Evans male rats, namely: VSG, Fundal (F)-Resection, Gastric Sleeve Plication (GSP), Fundal-Plication, and Fundal-Constrained. RESULTS: All surgical interventions resulted in a reduction of gastric volume relative to sham, but none of the interventions were as effective as the VSG. Gastric volume was linearly correlated to increased gastric emptying rate as well as increased GLP-1 response. Overall, cumulative food intake was the strongest correlate to weight loss and was logarithmically related to gastric volume. Regression modeling revealed a nonlinear inverse relation between body weight reduction and gastric volume, confirming that VSG is the only effective long-term weight loss strategy among the experimental operations tested. CONCLUSIONS: The data suggest a minimum threshold volume of the residual stomach that is necessary to induce sustained weight loss. Although all gastric volume interventions increased the GLP-1 response, none of the interventions, except VSG, significantly improved glucose tolerance. In conclusion, if weight loss is the primary goal of surgical intervention, significant volume reduction is required, and this most likely requires excising gastric tissue.