Postoperative nausea and vomiting (PONV) is a common complication after surgery with general anesthesia and remains one of the leading reasons for overnight admission in day- surgery patients. PONV can lead to severe dehydration with the need for IV rehydration and increased mortality in certain patient populations. Prokinetic drugs have been used to resolve this problem with limited success, 9,10 whereas acupuncture of point Neiguan (PC-6) has proven highly effective in the prevention and treatment of PONV as a nonpharmacological alternative in the direct postoperative period. 11 In addition previous studies have found that acupuncture modulates important components involved in the pathogenesis of delayedgastricemptying, such as relaxation of the lower esophageal sphincter and gastric
Anorexia is commonly associated with gastrointestinal complaints such as bloating, nausea, epigastric discom- fort, belching and postprandial fullness 1. These symp- toms have a negative impact on refeeding 2,3. Delayedgastricemptying has been found in both anorexic and bulimia patients mostly for solids and semi-solids, but not for liquids 4. It has long been debated whether de- layed gastricemptying is influenced by the “fear to eat”— cited by Cannon in 1988 and by Inui in 1995 in their re- spective papers, or whether primary alterations in gastric motor function are the driving force 5-8. Gastric dilate- tion is common in binge-eating 9. In rare cases dilate- tion impairs circulation of the gastric wall and mucosa and may lead to gastric perforation.
A gastricemptying test for solids was performed using a previously validated 13 C octanoic acid breath test ( 13 C-OABT) [15-17]. After an overnight fast, each patient received a 250 Kcal meal consisting of 60 g of white bread, 5 g of margarine and 1 egg (the yolk of which was labeled with 100 mg of 13 C octanoic acid and sodium salt). The meal was ingested in 10 minutes and was fol- lowed immediately by 150 mL of water. Breath samples were obtained from the subjects exhaling into closed alu- minized plastic bags before the meal administration (baseline measurement) and then at 15-minute intervals for 4 hours. During the test, patients were advised to remain seated and refrain from physical activity. Both the equipment (IRIS II - 13 C-Breath Test System) and substrate ( 13 C octanoic acid) used were provided by Wagner Analysen Technik GmbH, Bremen, Germany. The t lag (minutes) was defined the time with maximum speed of gastricemptying after ingestion of the test meal, the t 1/2 (minutes) was defined the time when first half of the 13 C-labelled substrate dose of the test meal has been metabolized. Delayedgastricemptying were defined as a t 1/2 above 200 minutes, and t lag above 150 minutes, taking into account the manufacture’s reference (http://www.wagner-bremen.de), as well as data from previous studies .
Functional dyspepsia (FD) is characterised by similar symptoms as gastroparesis, and it may reflect either underlying delayed or accelerated gastricemptying, impaired gastric accommodation and/or gastro-duo- denal hypersensitivity to food or distension. 4 Data suggest that approximately 30% of patients with FD have delayedgastricemptying when tested, although this may not be the only mechanism at play nor necessarily responsible for symptom pathogenesis. 5 Two categories of functional dyspepsia are recognised: epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS) with the latter having a similar clinical phenotype to idiopathic gastroparesis. 6 In clinical practice, it is not uncommon to encounter patients with FD and symptoms suggestive of gastricemptying delay, many of them with overlap- ping oesophageal symptoms, such as acid regurgitation and dysphagia raising the possibility of an underlying oesophageal dysmotility. Indeed, GP has been noted to be present in 10% of patients with gastro-oesophageal reflux disease (GERD), contributing to symptom severity and treatment refractoriness. 7 It is unclear whether there is an association between GP and refractory GERD. 8
delayedgastricemptying (DGE) is even more common with up to 61% reported rates [5, 7]. The type of recon- struction technique after PD is considered to influence the frequency of DGE. While antecolic position of the gastro-/ duodenojejunal loop has been considered superior in terms of DGE [8, 9], recent studies demonstrated compar- able benefits of retrocolic reconstruction [7, 10, 11]. In terms of DGE frequency, this could also be shown for pylorus-preserving PD compared to classic PD with an- trectomy (Kausch-Whipple procedure) . However, in recent years, pylorus resection without antrectomy has been increasingly advocated [13–15]. Furthermore,
EN without and with pectin, respectively. Fluorescence intensity in the resected stomachs from mice receiving EN with pectin also persisted, indicating that pectin delayedgastricemptying throughout the experimental period. Adding pectin retards the gastricemptying of not only liquid, but also of solid food . In addition to liquid gelation, pectin might also induce delayedgastricemptying via other factors such as duodenal feedback regulation. Soluble and viscous fibers such as pectin slow digestion and nutrient absorption and prolong the pres- ence of nutrients in the critical region. Therefore, nutrients that lag in the duoderm continue to elicit factors involved in the feedback mechanism. If duodenal feedback is regu- lated due to initial volume-dependent outflow in pectin- free controls, a mechanism evoked by increased viscosity would predominate in controlling gastricemptying.
Our study has some weaknesses. As mentioned, scinti- graphy is considered gold standard for assessing gastricemptying, whereas we compared ROM with GEBT. However, GEBT has in several studies proved excellent diagnostic reliability in comparison to scintigraphy, both in healthy volunteers and in patients with diabetes. 13–16 The two tests were not performed simultaneously, but one day after another. Previous studies have shown that GEBTs are highly reproducible with a low intra-individual variation between tests (a coef ﬁ cient of variation ≤ 15%). 13 Furthermore, the total number of included patients in our study was relatively small, making us susceptible to spur- ious statistical outcomes. Test meals also differed slightly in composition of nutrients and total caloric content (400 kcal for ROM; 300 kcal for GEBT). Meals with higher caloric content are expected to empty more slowly from the stomach. 29 In contrast, we identi ﬁ ed a higher percen- tage with delayedgastricemptying with GEBT than ROM. If the caloric content of the meals were identical, one would expect ﬁ nding an even larger difference between the tests.
Treating patients with DGP remains a very challenging task. Early satiety, upper abdominal pain, nausea, and vomiting impact the patient’s quality of life and can result in significant medical problems, most notably malnutrition and poor glycemic control. Management of DGP consists of maintaining adequate glycemic control, hydration, and nutrition, and controlling symptoms of delayedgastricemptying. An accurate nutrition assessment is vital in the initial evaluation of a patient, as malnutrition contributes to significant morbidity and mortality in this patient population. Providing nutritional support, assuring excellent glucose control, and treating nutrient deficiencies can be extremely challenging in the patient with gastroparesis. Nutritional interventions can decrease symptoms, replenish nutrient stores, and improve an individual’s overall quality of life; however, very few interventions used to manage the symptoms of DGP have been thoroughly studied. Therefore, well-designed randomized controlled trials are needed to determine the optimal nutritional management of this condition.
Abstract: Diabeticgastroparesis (DMGP) is a condition of delayedgastricemptying after gastric outlet obstruction has been excluded. Symptoms of nausea, vomiting, early satiety, bloating, and abdominal pain are associated with DMGP. Uncontrolled symptoms can lead to overall poor quality of life and financial burdens on the healthcare system. A combination of antiemetics and prokinetics is used in symptom control; metoclopramide is the main prokinetic available for clinical use and is the only U.S. Food and Drug Administration-approved agent in the United States. However, a black box warning in 2009 reporting its association with tardive dyskinesia and recommending caution in chronically using this agent beyond 3 months has decreased its role in clinical practice. There is an unmet need for new prokinetics with good efficacy and safety profiles. Currently, there are several new drugs with different mechanisms of action in the pipeline that are under investigation and show promising preliminary results. Surgically combin- ing gastric electrical stimulation with pyloroplasty is considered “gold” standard. Advances in therapeutic endoscopic intervention with gastric per-oral endoscopic pyloromyotomy have also been shown to improve gastricemptying and gastroparesis (GP) symptoms. In this review, we will comment on the challenges encountered when managing patients with DMGP and provide an update on advances in drug development and endoscopic and surgical interventions. Keywords: bloating, fullness, nausea, vomiting, Enterra, diabetes
Abstract: Background: Pancreaticoduodenectomy (PD) is an aggressive surgery with considerable operative risks. Objective: The purpose of this study was to evaluate the safety of PD in patients of≥75 years of age and to show the influence of advanced age on the mortality and morbidity associated with PD. Methods: Between July 2009 and December 2013, 131 patients underwent PD at Hyogo College of Medicine. We analyzed the perioperative data and outcomes after PD in patients of≥75 years of age (elderly group) in comparison to those of patients of<75 years of age (younger group). Results: There were no differences between the elderly group (n=28) and younger group (n=103) in terms of gender, body mass index (BMI), biochemistry test results, operative time or intraoperative blood loss. There were significant differences in the incidence of preoperative complications in the elderly and younger groups. There were no differences in the rates of mortality (0% vs. 1%; p=0.601) or morbidity (64% vs. 49%; p=0.139). Morbidities included pancreatic fistula, delayedgastricemptying, intra-abdominal bleeding, intra-abdominal abscess, ascites and pneumonia. Conclusion: The preoperative complication rate in the elderly group was significantly higher than that in the younger group. However, PD can be performed safely in elderly patients and advanced age alone should not be a contraindication to PD.
Background: Partial pancreatico-duodenectomy (PD) is the standard treatment for tumors of the pancreatic head. Today, preservation of the pylorus has been widely accepted as the surgical standard in this procedure. A common postoperative complication is the occurrence of delayedgastricemptying (DGE), which causes impairment of oral intake andpatients ’ quality of life, prolongation of hospital stay and delay of further treatment (for example adjuvant chemotherapy). In a small number of two retrospective and one randomized studies, a modification by resection of the pylorus with preservation of the stomach has shown to reduce DGE incidence. The aim of the present study is to investigate the effect of pylorus resection on postoperative DGE in PD.
± 2.15 hours, the T50 was 6.05 ± 2.99 hours and the T75 was 8.32 ± 2.72 hours. If delayedgastricemptying is suspected, taking two or three sets of radiographs at regular intervals from 6-16 hours after feeding and comparing the results with the reference curve is probably the most appropriate method of assessing gastricemptying in a patient. Conversely, if excessively rapid gastricemptying is suspected, taking two or three sets of radiographs at regular intervals from 0-5 hours after feeding and comparing the results with the reference curve is most appropriate.
Unfortunately, upper gastrointestinal symptoms, especially nausea and vomit- ing, are too frequently attributed to gas- troparesis, which then becomes the focus of therapy. Gastroparesis is found in dia- betic as well as nondiabetic subjects and has many causes. Delayedgastric empty- ing, like slow transit in other gut organs, appears to be one of the gastrointestinal sequelae of diabetes, but because of its many other causes, the relationship of gastroparesis to markers of advancing diabetes (including neuropathy) is only modest in symptomatic patients. As many as 40% of nondiabetic patients with functional nausea and vomiting and no definable pathological explanation for symptoms also have delayedgastricemptying. Thus, gastroparesis should be considered a nonspecific finding in dia- betes and may be unrelated to the meta- bolic disorder.
Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically de- manding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require famil- iarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayedgastricemptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis.
This study is the third in the pediatric literature to compare the sensitivity of a 2 h and 4 h gastricemptying study in children and its ability to identify children with delayedemptying. We found that 15% of participants who had normal studies at 2 h had ab- normal studies at 4 h. This is less than the 23% re- ported by Chogle et al., but is very similar to the findings of Wong and colleagues where 13% of pa- tients with normal 2- h emptying were abnormal at 4 h [5, 6]. Our study adds independent confirmation that extending studies from 2 to 4 h increases the diagnostic yield and should be the standard in chil- dren and adolescents as it is in adults. In the current study, we did not find any differences in symptoms or symptom clusters between patients with delayedemptying at 4 h as compared to those with normal emptying. At 2 h, delayedemptying was actually asso- ciated with lower scores for the postprandial fullness/ early satiety cluster. This might suggest that meal re- lated symptoms are not generated by an early post- prandial delay in emptying of a meal in children and adolescents. Although some studies have reported symptoms (e.g. postprandial fullness, nausea, and vomiting) associations with delayedgastricemptying of solids, there have not been any consistently repro- ducible relationships between specific symptoms or symptom severity and delayedemptying in adults [10, 12–16]. There have been fewer studies in children
Open oesophagectomy may be associated with significant morbidity and mortality. With the increa- sing experiences in laparoscopic and thoracoscopic techniques, minimal invasive approaches to oesophagectomy are being explored to determine the feasibility, results, and potential advantages. Pyloroplasty is performed during oesophagectomy to avoid delayedgastricemptying and hence reduces the risk of aspiration pneumonia. By contrast, it has been argued that pyloroplasty is unnecessary as gastric outlet obstruction is a rare occurrence following oesophagectomy and that the procedure itself is associated with a number of complications.
Delayedgastricemptying is commonly encountered in the ICU and may be present in 50 to 60% of all ICU patients [11-13]. A recent retrospective analysis in ICUs from 21 countries demonstrated an enteral feed intoler- ance among 30.5% of patients after a median 3 days on enteral nutrition. Prokinetic drugs were administered in 37.9% of cases, primarily metoclopramide and erythro- mycin far less frequently . Furthermore, enteral feed intolerance was associated with worse nutrition adequacy versus the tolerant (56% vs. 64%, P < 0.0001), fewer ventilator-free days (2.5 vs. 11.2, P < 0.0001), increased ICU stay (14.4 vs. 11.3 days, P < 0.0001), and increased mortality (30.8% vs. 26.2, P = 0.04) . Studies such as the EDEN trial reporting on trophic feeding in contrast to full feeding have shown noninferior mortality in moder- ately obese and younger patients with acute respiratory failure, limiting the generalisability to other ICU patients . In patients on the full feeding regimen there was a nonsignificant trend towards better long-term physical function . Recent data suggest that providing at least 80% of prescribed amounts of protein and calories is asso- ciated with improved clinical outcomes and thus could be established as a quality indicator for ICU practice, particu- larly in high-risk patients .
Delayedgastricemptying is defined as the nasogastric tube placement for more than 10 days postoperatively or the output of gastric aspiration from gastrostomy tube more than 200 ml. Pancreatic leakage is defined as an external discharge greater than 50 ml obtained through drain or percutaneous aspiration, containing at least three times normal serum value of amylase, as described by Yeo et al. . Major leakage of pancreatic juice was defined as a leakage with peripancreatic abscess forma- tion. Biliary fistula was diagnosed by the distinctive color of discharge containing bilirubin. Postoperative mortality was defined as death occurring in the first 30 postopera- tive days or before discharge from the hospital.
Previous studies have shown that the oxytocin recep- tor antagonist atosiban prolonged gastricemptying in healthy subjects  and diabetic patients with gastropar- esis lacked an elevation of the oxytocin plasma concen- tration postprandially compared to patients without gastroparesis [3,4]. These findings gave rise to the hypothesis that oxytocin may have an essential role in GI motility, especially gastricemptying. However, we could not see any effect of oxytocin on the gastric emp- tying [5,8]. This may be explained by the dual effect oxytocin evokes on normal GI physiology. First, a direct effect of oxytocin on its receptors leads to stimulation of gastric muscle contraction . Secondly, as oxytocin stimulates to CCK release, an indirect action via CCK receptors are activated, leading to inhibition of gastricemptying [11,12]. As atosiban only blocks the oxytocin receptor, delayedgastricemptying was seen during the administration of this specific drug .