Analysis of risk factors and prevention strategies for functional delayed gastric emptying in 1243 patients with distal gastric cancer
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Abstract Background Analysis of the risk factors associated with functional delayed gastric emptying after distal gastric cancer surgery to provide a basis for further reduction of the incidence of this complication. Methods Total of 1382 patients with distal gastric cancer from January 2016 to October 2018 were enrolled. Correlation analysis was performed in 53 patients with FDGE by logistic regression. Subgroup risk analysis was performed in 114 patients with preoperative pyloric obstruction. A Pearson Chi-square analysis was used to compare categorical variables between normal distribution groups. Meanwhile, a t test was used to compare continuous variables between groups. Odds ratio (OR) was used for comparison of the two groups, and it was summarized with its 95% confidence interval (CI) and p value using logistic regression. Result In multivariable analysis, age (OR 1.081, 95% CI, 1.047–1.117), BMI (OR 1.233, 95% CI, 1.116–1.363), preoperative pyloric obstruction (OR 3.831, 95% CI, 1.829–8.023), smaller volume of residual stomach (OR 1.838, 95% CI, 1.325–6.080), and anastomosis in greater curvature perpendicular (OR 3.385, 95% CI, 1.632–7.019) and in greater curvature parallel (OR 2.375, 95% CI, 0.963–5.861) were independent risk factors of FDGE. In the preoperative pyloric obstruction group, higher BMI (OR 1.309, 95% CI, 1.086–1.579) and preoperative obstruction time (OR 1.054, 95% CI, 1.003–1.108) were independent risk factors of FDGE and preoperative gastrointestinal decompression (OR 0.231, 95% CI, 0.068–0.785) was independent protective factor of FDGE. Conclusion Adequate gastrointestinal decompression should be performed before the operation to reduce the incidence of postoperative gastroparesis in patients with preoperative pyloric obstruction. We also could improve the surgical methods to reduce the occurrence of FDGE, such as controlling the size of the residual stomach, ensuring blood supply. Especially selecting an appropriate stapler and anastomosis during the anastomosis process, the occurrence of FDGE can be reduced.Keywords:
Subgroup analysis
Surgical oncology
SUMMARY Simple meals are required for routine scintigraphic gastric emptying studies. We evaluated the reproducibility of a caloric liquid meal (520 kcal) compared to that of a solid meal (638 kcal) in 8 and 11 healthy volunteers, respectively. Gastric emptying rates and half-times were similar in two tests using the same meal, while the methods used to express lag times were not highly reproducible. The emptying rates and half-times of the liquid meal were delayed after the intake of bellafoline. In conclusion, this study demonstrates that: (a) gastric emptying rates and half-times are reproducible parameters for the expression of scintigraphic gastric emptying studies; (b) mathematical methods to express lag times are not highly reproducible; (c) a 500 kcal liquid meal is sensitive to the effects of bellafoline, a drug able to delay gastric emptying. Further clinical evaluation is required to test its applicability in routine studies.
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Introduction: Rapid gastric emptying has been described not only in patients with nausea and vomiting and gastroparesis but also in obesity and dyspepsia. We investigated the use of three measures of rapid gastric emptying in a large group of patients with gastroparesis as compared to normal controls. Patients: From a pool of 214 consecutive patients with the symptoms of gastroparesis we reviewed the results of standardized solid gastric emptying tests and compared the results to a group of normal controls as previously described (AJG 95: 1456‐14622000). Patients were 39 males, 175 females mean age 42 years, with diagnosis of 42 Diabetes Mellitus, 26 Post Surgical and 146 Idiopathic diseases. Methods: Gastric emptying was compared by three models: Area under the emptying curve (AUC, rapid < 0.257), total gastric emptying (TGE: the sum of 1, 2 and 4 hours; rapid < 47), and percentage remaining at 1 hour (<37%) for rapid and/or at 4 hours (>10%) for delayed emptying, using data and techniques previously described (AGJ2004; 99: S45 and NGM 2005; 17: 470). Results: Measurable gastric emptying could be determined for 4 hours emptying in 146 patients; 87 patients had complete 1, 2 and 4 hours emptying. 44 patients had delayed emptying by 4 hour% >10%, seven patients (8%) had rapid gastric emptying by AUC and eight pts (9%) had rapid emptying by the TGE values; and 16 (18%) pts had rapid emptying by the 1 hour value alone. Conclusion: Rapid gastric emptying of a solid meal is not uncommon in patients with the symptoms of gastroparesis. The AUC and TGE models identified approximately the same number of patients with rapid emptying, while the 1‐hour model identified approximately twice as many patients. Using the three techniques described to determine rapid gastric emptying awaits prospective use in other patients, including dyspepsia and obesity. Standardized measure for rapid gastric emptying may be useful in evaluating therapeutic outcomes for these disorders.
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Gastric emptying studies in mice have been limited by the inability to follow gastric emptying changes in the same animal since the most commonly used techniques require killing of the animals and postmortem recovery of the meal1,2. This approach prevents longitudinal studies to determine changes in gastric emptying with age and progression of disease. The commonly used [13C]-octanoic acid breath test for humans3 has been modified for use in mice4-6 and rats7 and we previously showed that this test is reliable and responsive to changes in gastric emptying in response to drugs and during diabetic disease progression8. In this video presentation the principle and practical implementation of this modified test is explained. As in the previous study, NOD LtJ mice are used, a model of type 1 diabetes9. A proportion of these mice develop the symptoms of gastroparesis, a complication of diabetes characterized by delayed gastric emptying without mechanical obstruction of the stomach10. This paper demonstrates how to train the mice for testing, how to prepare the test meal and obtain 4 hr gastric emptying data and how to analyze the obtained data. The carbon isotope analyzer used in the present study is suitable for the automatic sampling of the air samples from up to 12 mice at the same time. This technique allows the longitudinal follow-up of gastric emptying from larger groups of mice with diabetes or other long-standing diseases.
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Purpose: Standard teaching is that only solid gastric emptying scintigraphy is needed to diagnose gastroparesis because liquid emptying is less sensitive and often normal until the disorder is advanced. However, we have seen numerous patients with prolonged liquid but normal solid emptying. The purpose of this investigation was to determine if liquid gastric emptying has added diagnostic value when obtained in addition to solid emptying for detection of gastroparesis. Methods: Sixty consecutive patients (age 18–65, 39 male, 21 female) referred for suspected gastroparesis had sequential clear liquid and solid gastric emptying scintigraphic studies the same morning. Three were diabetics, 8 had GER, none had prior gastric surgery. They were on medications as prescribed by the referring physician, although none were known to affect emptying. The patients initially ingested 300 ml water with 0.2 mCi In-111 DTPA and 1 minute gamma camera images were acquired for 30 minutes. They then ingested a standardized egg substitute meal (Tougas et al.) labeled with Tc-99m sulfur colloid, 2 mCi, and images were acquired at 0, 1, 2, 3, and 4 hours. A half-time of emptying was quantified for the liquid studies (Chaudhuri et al) and the percent emptying at each time interval for the solid studies (Tougas et al.). The results of the two studies were analyzed. Results: Both solid and liquid emptying studies were normal in 50% of patients. Both studies were delayed in 10%. The solid study showed delayed emptying in 23% of patients. The liquid study was delayed in 33%. Solid emptying was delayed and liquid was normal in 13%. Solid emptying was normal but liquid emptying was abnormal in 27%. Of those patients with normal solid emptying, 31% had delayed liquid emptying. The addition of patients with delayed liquid emptying to those with delayed solid increased the rate of gastroparesis detection from 23% to 40%. Conclusion: The addition of liquid to solid gastric emptying scintigraphy increased the detection rate of gastroparesis compared to the solid emptying study alone. Both studies should be performed routinely to maximize sensitivity for detection of gastroparesis.
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1. Gastric emptying studies in small laboratory animals are hampered by the deficiency of a technique that is non-invasive and repeatable. The aim of the present study was to adapt the non-invasive [13C]-octanoic acid breath test, which has been validated in humans, to assess both liquid and solid gastric emptying in the mouse. 2. Gastric emptying rates were investigated for a liquid meal (Intralipid; Kabi Pharmacia AB, Stockholm, Sweden; n = 7) and two solid meals (egg yolk and mouse chow; n = 7) incorporating [13C]-octanoic acid. All meals were analysed for natural enrichment of [13C]. Mathematical analysis of the 13CO2 excretion rate allowed the determination of gastric emptying parameters. 3. Gastric emptying of Intralipid was more rapid than egg yolk (P < 0.0001). Gastric emptying of mouse chow could not be assessed due to intragastric separation of [13C]-octanoic acid and natural [13C] enrichment of the pellet. 4. The [13C]-octanoic acid breath test can reproducibly assess both liquid and solid gastric emptying non-invasively in the mouse. This method can now be used to assess gastric emptying in drug studies and disease studies for which there are established mouse models.
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Patients are often evaluated for gastric motility disorders, such as gastroparesis by measuring gastric emptying. For nearly 30 years, scintigraphy has been considered the main test for measuring gastric emptying and documenting delayed gastric emptying. There are a variety of ways to measure gastric emptying with scintigraphy with marked variations in the type of meal and duration of imaging. Clinically, it is best to measure the emptying of solids because liquid emptying can often be normal when solid emptying is markedly delayed. Recently, it has become apparent that prolonging the GES for 4 h may improve the diagnostic utility of the test. However, institutions perform the test in different ways with regards to meal content, imaging intervals, and length of test. These differences in performance of gastric emptying scintigraphy at different institutions have made this test less helpful in clinical settings. Scintigraphy is also limited by several drawbacks, including radiation exposure, expensive equipment, and the limited availability of facilities. Thus, there has been great interest in developing alternatives for effective measurement of gastric emptying in a standardized fashion. One such alternative is nonradioactive isotope breath testing.
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Gastric emptying of the solid and liquid components of an ordinary meal was evaluated by a dual isotopic technique in 36 patients referred to our hospital for early postprandial symptoms induced by various esophageal and/or gastric operations. Patients were classified as typical (n = 11), equivocal (n = 9) or improbable (n = 16) dumpers, in accordance with their presenting symptoms, as assessed before gastric emptying measurement. Patients with typical dumping symptoms displayed, as expected, significant acceleration of gastric emptying of liquids (t1/2: 18 +/- 6 min. vs. 48 +/- 7 min. in healthy controls; p less than 0.02), and also exhibited a dramatic enhancement of gastric emptying of solids (t1/2: 11 +/- 1 min. vs. 126 +/- 12 min. in healthy controls; p less than 0.001) and a complete loss of solid-liquid discrimination (7 +/- 6 min. vs. 78 +/- 7 min. in healthy controls; p less than 0.01). Mean gastric emptying rates for equivocal and improbable dumpers were not significantly different from those of healthy controls, but individual results were very heterogeneous; they included stasis, acceleration, or both disorders, and were not predictable by analysis of symptoms alone. Thus gastric emptying of solids as well as liquids is accelerated in symptomatic dumping patients, and objective evaluation of the emptying of both solid and liquid gastric emptying is essential in atypical dumpers, in order to characterize their disorders and prescribe the most rational treatment.
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