Complete mesogastric excision for locally advanced gastric cancer: short-term outcomes of a randomized clinical trial.

Implementation of complete mesogastric excision in gastric cancer surgery, named D2 lymphadenectomy plus complete mesogastric excision (D2+CME), has recently been proposed as an optimal procedure. However, the safety and efficacy of D2+CME remain uncertain. In this randomized controlled trial, patients receiving D2+CME exhibit less intraoperative blood loss, more lymph node harvesting, and earlier postoperative flatus than patients receiving conventional D2 radical surgery. Univariate Cox regression analysis reveals that the risk ratio for postoperative flatus in D2+CME group is 1.247 (p = 0.044). Overall postoperative complications are comparable between the two groups, but complications are significantly less severe in the D2+CME group than the D2 group (Clavien-Dindo classification grade ≥ IIIa: 4 D2+CME patients [11.8%] versus 9 D2 patients [33.3%]; p = 0.041). In conclusion, our work shows that D2+CME is associated with better short-term outcomes and surgical safety than conventional D2 dissection for patients with advanced gastric cancer.

UK national cohort of anal cancer treated with intensity-modulated radiotherapy: One-year oncological and patient-reported outcomes.

BACKGROUND: Concurrent chemoradiotherapy is the standard treatment for anal cancer. Following national UK implementation of intensity-modulated radiotherapy (IMRT), this prospective, national cohort evaluates the one-year oncological outcomes and patient-reported toxicity outcomes (PRO) after treatment. MATERIALS AND METHODS: A national cohort of UK cancer centers implementing IMRT was carried out between February to July 2015. Cancer centers provided data on oncological outcomes, including survival, and disease and colostomy status at one-year. EORTC-QLQ core (C30) and colorectal (CR29) questionnaires were completed at baseline and one-year followup. The PRO scores at baseline and one year were compared. RESULTS: 40 UK Cancer Centers returned data with a total of 187 patients included in the analysis. 92% received mitomycin with 5-fluorouracil or capecitabine. One-year overall survival was 94%; 84% were disease-free and 86% colostomy-free at one-year followup. At one year, PRO results found significant improvements in buttock pain, blood and mucus in stools, pain, constipation, appetite loss, and health anxiety compared to baseline. No significant deteriorations were reported in diarrhea, bowel frequency, and flatulence. Urinary symptom scores were low at one year. Moderate impotence symptoms at baseline remained at one year, and a moderate deterioration in dyspareunia reported. CONCLUSIONS: With national anal cancer IMRT implementation, at this early pre-defined time point, one-year oncological outcomes were reassuring and resulted in good disease-related symptom control. one-year symptomatic complications following CRT for anal cancer using IMRT techniques appear to be relatively mild. These PRO results provide a basis to benchmark future studies.

Susceptibility to diarrhea is related to hemodynamic markers of sympathetic activation in the general population.

Objectives: Functional gastrointestinal (GI) symptoms, such as IBS (irritable bowel syndrome), have been suggested to be associated with autonomic neuropathy. We therefore examined associations between hemodynamic indices of autonomic control, functional GI symptoms and stress in a population-based cohort.Methods and materials: The study included 2094 participants of the Malmö Offspring Study (mean age 40.6 ± 13.8 years, 53.9% women). 509 (24.3%) reported having GI symptoms the last 2 weeks, without having organic GI disease, and 347 subjects (16.6%) reported IBS. Office and ambulatory 24-h systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were measured. Associations between hemodynamic parameters and abdominal pain, diarrhea, constipation, bloating and flatulence, vomiting and nausea and psychological well-being according to the visual analog scale for IBS (VAS-IBS), and stress, were performed by Spearman's correlation test and linear regression models.Results: Subjects who reported GI symptoms had lower office supine and standing DBP and lower 24 h SBP and DBP compared with those without GI symptoms. Regarding specific symptoms, diarrhea was correlated with 24-h measurements of SBP (rs = 0.197), DBP (rs = 0.173) and heart rate (rs = 0.134). Subjects with the most severe diarrhea had higher 24-h SBP (125.2 vs. 119.0 mmHg; p = .038), DBP (74.0 vs. 69.0 mmHg; p = .033) and heart rate (74.5 vs 71.1 beats/minute; p = .048), after adjustments for confounders, compared to the other. There were no associations between other GI symptoms, IBS, stress and hemodynamic alterations.Conclusion: Functional diarrhea was associated with hemodynamic indices of sympathetic activation, supporting a possible role of the autonomic nervous system in diarrhea.

Abdominal distension after eating lettuce: The role of intestinal gas evaluated in vitro and by abdominal CT imaging.

BACKGROUND: Some patients complain that eating lettuce, gives them gas and abdominal distention. Our aim was to determine to what extent the patients' assertion is sustained by evidence. METHODS: An in vitro study measured the amount of gas produced during the process of fermentation by a preparation of human colonic microbiota (n = 3) of predigested lettuce, as compared to beans, a high gas-releasing substrate, to meat, a low gas-releasing substrate, and to a nutrient-free negative control. A clinical study in patients complaining of abdominal distention after eating lettuce (n = 12) measured the amount of intestinal gas and the morphometric configuration of the abdominal cavity in abdominal CT scans during an episode of lettuce-induced distension as compared to basal conditions. KEY RESULTS: Gas production by microbiota fermentation of lettuce in vitro was similar to that of meat (P = .44), lower than that of beans (by 78 ± 15%; P < .001) and higher than with the nutrient-free control (by 25 ± 19%; P = .05). Patients complaining of abdominal distension after eating lettuce exhibited an increase in girth (35 ± 3 mm larger than basal; P < .001) without significant increase in colonic gas content (39 ± 4 mL increase; P = .071); abdominal distension was related to a descent of the diaphragm (by 7 ± 3 mm; P = .027) with redistribution of normal abdominal contents. CONCLUSION AND INFERENCES: Lettuce is a low gas-releasing substrate for microbiota fermentation and lettuce-induced abdominal distension is produced by an uncoordinated activity of the abdominal walls. Correction of the somatic response might be more effective than the current dietary restriction strategy.

Effects of the DASH Diet and Sodium Intake on Bloating: Results From the DASH-Sodium Trial.

INTRODUCTION: Bloating is one of the most common gastrointestinal complaints. Evidence has linked fiber and sodium to bloating; however, randomized trials examining these diet components are lacking. Here, we used a randomized trial to examine the effects of the high-fiber DASH diet and dietary sodium intake on abdominal bloating. We hypothesized that both the high-fiber DASH diet and higher sodium intake would increase bloating. METHODS: The DASH-Sodium trial (1998-1999) randomized healthy adults to a high-fiber (32 g/d) DASH or low-fiber (11 g/d) Western diet (control). On their assigned diet, participants ate 3 sodium levels (50, 100, and 150 mmol/d at 2100 kcal) in 30-day periods in random order, with 5-day breaks between each period. The participants reported the presence of bloating at baseline and after each feeding period. Statistical analyses included log-binomial models to evaluate the risk of bloating. RESULTS: Of 412 participants (mean age 48 years; 57% women; 57% black), 36.7% reported bloating at baseline. Regardless of the diet, high sodium intake increased the risk of bloating (risk ratio = 1.27; 95% confidence interval: 1.06-1.52; P = 0.01). The high-fiber DASH diet also increased the risk of bloating over all sodium levels (risk ratio = 1.41; 95% confidence interval: 1.22-1.64; P < 0.001). The effect of high-fiber DASH on bloating was greater in men than in women (P for interaction = 0.001). DISCUSSION: Higher dietary sodium increased bloating, as did the high-fiber DASH diet. Although healthful high-fiber diets may increase bloating, these effects may be partially mitigated by decreasing dietary sodium intake. Future research is needed to explore mechanisms by which sodium intake and diet can influence bloating.

Normative Data for the Low Anterior Resection Syndrome Score (LARS Score).

OBJECTIVE: To provide normative data for the Low Anterior Resection Syndrome (LARS) score. BACKGROUND: The LARS score is a validated and frequently used tool measuring bowel dysfunction after sphincter sparing surgery for rectal cancer. The interpretation of LARS score results has previously been limited by the lack of normative data. METHODS: An age and sex-stratified random sample of 3440 citizens from the general population was drawn from the Danish civil registration system (age range 20-89 years, 50% females). A brief questionnaire including the LARS score and health-related items were distributed electronically or by post. RESULTS: A total of 1875 (54.5%) responded, 54.0% were females. In the age group 50 to 79 years, relevant for most rectal cancer studies, the response rate was 70.5% (n = 807). In this specific age group, 18.8% of the females and 9.6% of the males had a LARS score ≥30, corresponding to the LARS score category "major LARS" (P = 0.001), and the median (interquartile range) LARS score was 16 (7-26) and 11 (4-22), respectively (P < 0.001). Responders with physical disease had a statistically significant higher risk of a LARS score ≥30, compared with responders without any physical disease (odds ratio 2.2, 95% confidence interval 1.6-2.9, P < 0.001). CONCLUSIONS: A LARS score ≥30 (major LARS) is common in the general population, especially in the age group 50 to 79 years. Normative data for the LARS score are now available and can be taken into account when interpreting LARS score results in scientific studies of bowel function after rectal cancer treatment.

Lactose Breath Test in Children: Relationship Between Symptoms During the Test and Test Results.

BACKGROUND: Lactose malabsorption affects 70% of the world population. The hydrogen breath test (HBT) is used clinically to test for this condition. The aim of our study was to describe the relationship between symptoms experienced before and during the HBT and test results. METHODS: We included children who underwent the HBT in the pediatric gastroenterology unit at Dana-Dwek Children's Hospital during a 6-month period. Previous symptoms and those experienced before and after the HBT were assessed using a questionnaire and a validated pain scale. RESULTS: Ninety-five children were included in the study, and 66.3% had a positive HBT. Diarrhea and flatulence during the test were significantly more frequent in the group with a positive HBT compared to those with a negative test (31.7% vs. 9.4%, P = 0.016 and 69.8% vs. 40.6%, P = 0.006, respectively). The frequency of abdominal pain and bloating was similar. CONCLUSIONS: Diarrhea and flatulence during the HBT are the most specific symptoms of lactose intolerance. Abdominal pain should not be automatically attributed to lactose intolerance even in the presence of lactose malabsorption. Coupling the HBT with a real-time questionnaire facilitates interpretation of results and subsequent recommendations.

Flatulencia: una enfermedad inocua, ¿un tratamiento inocuo? / Flatulence: an innocuous condition, an innocuous treatment?

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Gas and Bloating-Controlling Emissions: A Case-Based Review for the Primary Care Provider.

The evaluation of the patient with gas and bloating can be complex and the treatment extremely challenging. In this article, a simplified approach to the history and relevant physical examination is presented and applied in a case-oriented manner, suitable for application in the primary care setting.

Evaluation of the gastrointestinal tolerability of corn starch fiber, a novel dietary fiber, in two independent randomized, double-blind, crossover studies in healthy men and women.

Two independent clinical studies were conducted to compare the gastrointestinal (GI) tolerability of corn starch fiber, a novel dietary fiber, at up to 50 g/day (single-dose study) or 90 g/day (multiple-serving study) with a negative control (no fiber) and a positive control (50 or 90 g polydextrose, for single- and multiple-serving studies, respectively) in generally healthy study volunteers. Flatulence and borborygmus were the primary symptoms reported at the higher doses of corn starch fiber and for the positive control interventions. Bowel movements were increased over 48 h with corn starch fiber at 90 g. Thresholds for mild GI effects were established at 30 g as a single dose and 60 g as multiple servings spread over the day. Other than moderate abdominal pain and mild increased appetite in one subject at 90-g corn starch fiber, no test article-related adverse events were reported.

Effect of vitamin D on gastrointestinal symptoms and health-related quality of life in irritable bowel syndrome patients: a randomized double-blind clinical trial.

BACKGROUND: Low-grade mucosal inflammation and immune activation are involved in the pathogenesis of irritable bowel syndrome (IBS). Furthermore, IBS symptoms are associated with a significantly higher prevalence of psychological distress, which in itself results into an impaired quality of life (QoL). Vitamin D could ameliorate the symptoms of patients suffering from IBS through its beneficial effects on psychological factors and inflammation. METHODS: A total of 90 IBS patients participated in this double-blind, randomized, placebo-controlled study. Participants were randomly selected to receive either 50 000 IU vitamin D3 or a placebo fortnightly for a period of 6 months. Patients reported their IBS symptoms at the baseline and monthly during intervention periods. The IBS severity score system (IBSSS) and IBS-specific QoL questionnaires were used at the baseline and postintervention. KEY RESULTS: Over the 6-month intervention period, a significantly greater improvement in IBS symptoms such as abdominal pain and distention, flatulence, rumbling, and overall gastrointestinal (GI) symptoms (except dissatisfaction with bowel habits) was observed in the patients receiving vitamin D as compared to the placebo group. The IBSSS and the IBS-QoL scores in the vitamin D group significantly improved compared to the placebo group postintervention (mean IBSSS score change: -53.82 ± 23.3 vs -16.85 ± 25.01, p < 0.001, respectively; mean IBS-QoL score change: 14.26 ± 3 vs 11 ± 2.34, p < 0.001, respectively). CONCLUSIONS & INFERENCES: Vitamin D seems to be an effective and safe option to improve QoL and symptoms of IBS. ClinicalTrials.gov (NCT02579902).

Bloating: Avicenna's Perspective and Modern Medicine.

Bloating and abdominal distention are common complaints present in quite a number of organic and functional diseases. An important subject in traditional Persian medicine is digestive disorders, particularly bloating and its etiology. This is a literature review study conducted on The Canon in Medicine written by Avicenna and using the keywords: bloating, gas. In this article, causes for bloating, according to Avicenna, include diet causes, inappropriate lifestyle, gastrointestinal, and miscellaneous reasons. These were compared with causes suggested in modern medicine. Avicenna classifies causes based on the place of origin into upper part of the abdomen (stomach) and intestinal part of the abdomen. Also, 38 medicinal plants used as remedies were listed. Modern scientific data support all bloating causes that have been mentioned in the canon. Obviously, some causes such as uterine disorders and posterior nasal discharge need to be studied further.

Anal gas evacuation and colonic microbiota in patients with flatulence: effect of diet.

OBJECTIVE: To characterise the influence of diet on abdominal symptoms, anal gas evacuation, intestinal gas distribution and colonic microbiota in patients complaining of flatulence. DESIGN: Patients complaining of flatulence (n=30) and healthy subjects (n=20) were instructed to follow their usual diet for 3 days (basal phase) and to consume a high-flatulogenic diet for another 3 days (challenge phase). RESULTS: During basal phase, patients recorded more abdominal symptoms than healthy subjects in daily questionnaires (5.8±0.3 vs 0.4±0.2 mean discomfort/pain score, respectively; p=<0.0001) and more gas evacuations by an event marker (21.9±2.8 vs 7.4±1.0 daytime evacuations, respectively; p=0.0001), without differences in the volume of gas evacuated after a standard meal (262±22 and 265±25 mL, respectively). On flatulogenic diet, both groups recorded more abdominal symptoms (7.9±0.3 and 2.8±0.4 discomfort/pain, respectively), number of gas evacuations (44.4±5.3 and 21.7±2.9 daytime evacuations, respectively) and had more gas production (656±52 and 673±78 mL, respectively; p<0.05 vs basal diet for all). When challenged with flatulogenic diet, patients' microbiota developed instability in composition, exhibiting variations in the main phyla and reduction of microbial diversity, whereas healthy subjects' microbiota were stable. Taxa from Bacteroides fragilis or Bilophila wadsworthia correlated with number of gas evacuations or volume of gas evacuated, respectively. CONCLUSIONS: Patients complaining of flatulence have a poor tolerance of intestinal gas, which is associated with instability of the microbial ecosystem.

Endoscopic evaluation of laparoscopic nissen fundoplication: 89 % success rate 10 years after surgery.

BACKGROUND: The surgical outcome of fundoplication can be evaluated by means of esophagogastroduodenoscopy (EGDS). The literature reveals only one prior long-term follow-up series with endoscopic evaluation of the fundoplication wraps after laparoscopic Nissen fundoplication (LNF). The results achieved at a university clinic showed LNF to be more durable than open fundoplication (ONF). Previously, in our community-based hospital, the results of ONF were somewhat poorer than those achieved at a university clinic. The objective of the present study was to describe the long-term results of LNF in our hospital as regards surgical and symptomatic outcomes. METHODS: In 1997-1999, 107 LNFs were performed in our hospital. A questionnaire with symptom evaluation was mailed to all patients. The patients who agreed to participate were interviewed and underwent EGDS. RESULTS: Of the 107 patients, 64 (59.8 %) participated in the study (40 men, mean age 61.9 years, range 28-85 years). The mean follow-up time was 9.8 years. Seven endoscopic examinations (10.9 %) showed a defective fundic wrap; three of the patients had undergone reoperation. Fifty-eight (90.6 %) patients had no or minimal heartburn and 61 (95.3 %) had no or minimal regurgitation. Twenty-three (35.9 %) patients had moderate or severe dysphagia, and 43 (67.2 %) patients had moderate or severe flatulence. Fifty-seven (89.1 %) patients would have opted for surgery again. CONCLUSIONS: This study contributes to the previous notion that LNF is associated with fewer surgical failures than ONF. Our results indicate that LNF can well be performed in a community-based hospital with acceptable long-term results.

Evaluation of gastrointestinal symptoms in different patient groups using the visual analogue scale for irritable bowel syndrome (VAS-IBS).

BACKGROUND: Irritable bowel syndrome (IBS) and gastrointestinal (GI) dysmotility disorders have a similar clinical picture, although dysmotility disorders require the attention of a specialist. Patients with primary Sjögren's syndrome (pSS) have also been described to suffer from IBS-like symptoms. No objective marker is available to distinguish between the patients. A visual analogue scale has been developed for IBS patients (VAS-IBS) to measure treatment response of GI symptoms and well-being in patients with IBS. The aim of the present study was to examine if VAS-IBS could be used to compare the degree of GI complaints in different patient populations, to get an objective marker to differentiate between the patients. METHODS: The VAS-IBS consists of 7 VAS scales, namely, abdominal pain, diarrhoea, constipation, bloating and flatulence, vomiting and nausea, psychological well-being and the intestinal symptoms' influence on daily life. Consecutive female patients suffering from IBS, dysmotility disorders and pSS were asked to complete the VAS-IBS questionnaire when visiting the out-patient clinics. In addition, a control population consisting of healthy female volunteers was included. RESULTS: Healthy volunteers had almost no GI symptoms, whereas all 3 patient groups expressed symptoms. There was no statistical significant difference between IBS and dysmotility in any of the scales besides vomiting and nausea (p = 0.044). Except for constipation, patients with pSS had less severe symptoms than the others. CONCLUSION: The VAS-IBS questionnaire could be used to assess the level of GI symptoms. However, VAS scores do not help the clinicians to differentiate between IBS and other dysmotility disturbances.

Gastrointestinal complaints in runners are not due to small intestinal bacterial overgrowth.

BACKGROUND: Gastrointestinal complaints are common among long distance runners. We hypothesised that small intestinal bacterial overgrowth (SIBO) is present in long distance runners frequently afflicted with gastrointestinal complaints. FINDINGS: Seven long distance runners (5 female, mean age 29.1 years) with gastrointestinal complaints during and immediately after exercise without known gastrointestinal diseases performed Glucose hydrogen breath tests for detection of SIBO one week after a lactose hydrogen breath test checking for lactose intolerance. The most frequent symptoms were diarrhea (5/7, 71%) and flatulence (6/7, 86%). The study was conducted at a laboratory.In none of the subjects a pathological hydrogen production was observed after the intake of glucose. Only in one athlete a pathological hydrogen production was measured after the intake of lactose suggesting lactose intolerance. CONCLUSIONS: Gastrointestinal disorders in the examined long distance runners were not associated with small intestinal bacterial overgrowth.

[Forty-four years of advances in pathogenesis, diagnosis and treatment of flatulence syndrome]. / 44 años de avances en etiopatogenia, diagnóstico y tratamiento del síndrome flatulencia.

In the present paper, the author reminds investigations performed, since forty-four years ago, to clarify the etiopathogenesis and to improve the diagnosis and treatment of the flatulence syndrome.