Changes in gut hormones, glycaemic response and symptoms after oesophagectomy

Weight loss, glycolipid profile changes in type 2 diabetes patients after esophagectomy: a propensity score matching analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a common co-morbidity in patients who receive esophagectomy and has unfavorable effects on glucose and lipid metabolism in patients. This study examines how weight and glycolipid metabolism change in patients with T2DM following esophagectomy.

METHODS

This retrospective, one-center, observational analysis with a propensity score matching analysis (PSM) included 114 patients who underwent esophageal surgery in the Department of Cardiothoracic Surgery, the 900th Hospital of Joint Logistic Support Force from 2017 to 2020, which were separated into T2DM group and Non-T2DM group. Weight, body mass index (BMI), fasting plasma glucose (FPG), triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were measured and analyzed before and after the operation.

RESULTS

Two groups showed similar reductions in weight and BMI after surgery. In the T2DM group, weight decreased from 63.10(10.31) before surgery to 55.10(11.60) kg at 6 months (P < 0.001) with BMI decreasing from 22.67 (2.90) to 19.77 (3.48); While in the Non-T2DM group, weight decreased from 61.42 (8.46) to 53.19 (9.26) kg at 6 months after surgery with BMI decline from 22.49 (2.77) before operation to 19.45 (3.08) at 6 months after surgery. Fasting plasma glucose levels showed a significant decrease (P = 0.035) in the T2DM group at a six-month point of 7.00 (2.21) mmol/L compared to preoperative levels of 7.67 (2.32) mmol/L. HDL levels increased significantly in the Non-T2DM group at six months postoperatively at 1.52 (0.05) with P < 0.001 compared to preoperative levels of 1.22(0.04) mmol/L. TG, LDL, and TC levels decreased significantly in both groups from the preoperative to the 6-month point.

CONCLUSIONS

Esophagectomy induces weight loss in T2DM and Non-T2DM groups, improves long-term glucose metabolism in the T2DM group, and enhances lipid metabolism in both groups. Further research is needed to understand their mechanisms.

Factors Affecting the Readmission of Patients with Pancreatic Cancer after Surgery

Objective

Pancreatic cancer is one of the deadliest solid malignancies. Its surgical resection is technically very challenging and has a high risk of complications even after discharge. This study analyzed the risk factors associated with unplanned readmission after pancreatic cancer surgery.

Methods

Pancreatic cancer patients who were readmitted within 30 days after surgery were classified as the observation group, while those not readmitted within 30 days postsurgery were classified as the control group. The serum levels of gastrointestinal hormones, stress hormones, and peripheral immune cells of the two groups were compared at different intervals.

Results

No significant differences in gender and age were observed between the two groups. At 7, 14, and 21 days postsurgery, the levels of gastrointestinal hormones motilin, gastrin, calcitonin gene-related peptide, and growth hormone-releasing peptide of the observation group were lower than the control group, while the levels of adrenocorticotropin, renin, angiotensin, and plasma aldosterone of the observation group were significantly higher than the control group. In addition, compared to the control group, lower levels of CD4+T cells, CD8+T cells, and NKT cells and higher levels of Treg, Breg, and MDSC cells were observed in the peripheral blood of the observation group.

Conclusion

The serum levels of gastrointestinal hormones, stress hormones, and peripheral immune cells could be associated with the risk of unplanned readmission within 30 days after pancreatic cancer surgery.

Body Mass Index-Adjusted Weight Loss Grading System and Cancer-Related Fatigue in Survivors 1 Year After Esophageal Cancer Surgery

BACKGROUND

The association between pre- and postoperative weight loss and cancer-related fatigue after esophageal cancer surgery is unclear. This nationwide, prospective, longitudinal cohort study aimed to assess the influence of weight loss on cancer-related fatigue among esophageal cancer survivors.

METHODS

Patients who underwent esophagectomy for cancer between 2013 and 2019 in Sweden were enrolled in this study. Exposure was measured by the body mass index-adjusted weight loss grading system (WLGS). Cancer-related fatigue was assessed using the fatigue scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the EORTC QLQ-Fatigue 12 (QLQ-FA12) questionnaire measuring overall fatigue and physical, emotional, and cognitive fatigue. Growth mixture models were used to identify unobserved trajectories of cancer-related fatigue. Multivariable linear and logistic regression models were fitted to assess the associations between WLGS and cancer-related fatigue, adjusting for potential confounders.

RESULTS

Three trajectories were identified-low, moderate, and severe persistent fatigue. Cancer-related fatigue remained stable in each trajectory between 1 and 3 years after esophagectomy. Among the 356 enrolled patients, 4.5-22.6% were categorized into the severe persistent fatigue trajectory in terms of QLQ-C30 (19.9%), FA12 overall (10.5%), physical (22.6%), emotional (15.9%), and cognitive fatigue (4.5%). No association between pre- or postoperative WLGS and cancer-related fatigue was found between 1 and 3 years after esophageal cancer surgery.

CONCLUSIONS

Weight loss did not seem to influence cancer-related fatigue after esophageal cancer surgery.

Gut hormones profile after an Ivor Lewis gastro-esophagectomy and its relationship to delayed gastric emptying

Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established.

The negative association between skeletal muscle and fat mass wasting caused by oesophagectomy in patients with oesophageal squamous cell carcinoma

OBJECTIVES

This prospective observational study aimed to investigate postoperative skeletal muscle and fat mass wasting and their clinical significance in oesophageal cancer patients undergoing minimally invasive McKeown oesophagectomy.

METHODS

Bioelectrical impedance analyses of body compositions were conducted before surgery and 1, 4 and 12 weeks after surgery. Curve-fitting analysis was used to describe the relationship between changes in the skeletal muscle mass index (ΔSMI) and fat mass index (ΔFMI). A logistic regression-based nomogram was established using the R tool.

RESULTS

Among the 78 patients, 74.4% were male, and the mean age was 64.8 [standard deviation (SD): 6.6] years. Decreased SMIs and FMIs were concentrated in the first 4 weeks after surgery, with proportions of -3.42% (SD: 4.58) and -17.7% (SD: 11.9), respectively. A negative relationship between ΔFMI and ΔSMI was detected by linear regression (coefficient -0.341, P < 0.001). Based on the median ΔSMI to ΔFMI ratio (35.5%), 2 postoperative weight loss types were defined: SMI-dominated (SMDT) and FMI-dominated (FMDT) types. SMDT patients reported increased feeding-related problems, poorer functional status and more unhealthy symptoms than FMDT patients within 12 weeks after surgery. SMDT patients also showed poorer 2-year overall survival (71.1% vs 87.3%, P = 0.021) and disease-free survival (60.5% vs 84.9%, P = 0.032) than FMDT patients. A nomogram based on baseline and perioperative parameters was established to quantify postoperative SMDT and FMDT tendencies with good accuracy (C-index: 0.897).

CONCLUSIONS

The negative relationship between ΔFMI and ΔSMI indicated differentiated metabolism post-oesophagectomy. SMDT was associated with adverse therapeutic outcomes and warranted aggressive interventions.

CLINICAL REGISTRATION NUMBER

The study protocol was registered at the Chinese Clinical Trial Registry with the registration number ChiCTR1800018511.

PREVENT: A Randomized, Placebo-controlled Crossover Trial of Avexitide for Treatment of Postbariatric Hypoglycemia

CONTEXT

Postbariatric hypoglycemia (PBH), characterized by enteroinsular axis overstimulation and hyperinsulinemic hypoglycemia, is a complication of bariatric surgery for which there is no approved therapy.

OBJECTIVE

To evaluate efficacy and safety of avexitide [exendin (9-39)], a glucagon-like peptide-1 antagonist, for treatment of PBH.

METHODS

A multicenter, Phase 2, randomized, placebo-controlled crossover study (PREVENT). Eighteen female patients with PBH were given placebo for 14 days followed by avexitide 30 mg twice daily and 60 mg once daily, each for 14 days in random order. The main outcome measures were glucose nadir and insulin peak during mixed-meal tolerance testing (MMTT) and hypoglycemic events captured by self-monitoring of blood glucose (SMBG), electronic diary, and blinded continuous glucose monitoring (CGM).

RESULTS

Compared with placebo, avexitide 30 mg twice daily and 60 mg once daily raised the glucose nadir by 21% (P = .001) and 26% (P = .0002) and lowered the insulin peak by 23% (P = .029) and 21% (P = .042), corresponding to 50% and 75% fewer participants requiring rescue during MMTT, respectively. Significant reductions in rates of Levels 1 to 3 hypoglycemia were observed, defined, respectively, as SMBG <70 mg/dL, SMBG <54 mg/dL, and a severe event characterized by altered mental and/or physical function requiring assistance. CGM demonstrated reductions in hypoglycemia without induction of clinically relevant hyperglycemia. Avexitide was well tolerated, with no increase in adverse events.

CONCLUSION

Avexitide administered for 28 days was well tolerated and resulted in robust and consistent improvements across multiple clinical and metabolic parameters, reinforcing the targeted therapeutic approach and demonstrating durability of effect. Avexitide may represent a first promising treatment for patients with severe PBH.

Exaggerated postprandial GLP-1 secretion following esophagectomy is not associated with gastric emptying and intestinal transit

Esophagectomy causes postprandial symptoms associated with an exaggerated postprandial gut hormone response. This study aimed to compare the gastrointestinal transit time of patients 1 year after esophagectomy with unoperated controls, including its relation to satiety gut hormone release. In this cross-sectional study, consecutive, disease-free patients after esophagectomy with pyloroplasty were compared with unoperated control subjects to assess gastric emptying (GE) and cecal arrival time (CAT). Serial plasma samples were collected before, and for 300 minutes after, a mixed-meal challenge. Body composition was assessed, and symptom scores were calculated. Eleven patients 1 year post-esophagectomy (age: 62.6 ± 9.8, male: 82%) did not show a significantly different GE pattern compared with 10 control subjects (P = 0.245). Rather, patients could be categorized bimodally as exhibiting either rapid or slow GE relative to controls. Those with rapid GE trended toward a higher postprandial symptom burden (P = 0.084) without higher postprandial glucagon-like peptide-1 (GLP-1) secretion (P = 0.931). CAT was significantly shorter after esophagectomy (P = 0.043) but was not significantly associated with GE, GLP-1 secretion, or symptom burden. Neither early nutrient delivery to the proximal small intestine nor to the colon explains the exaggerated postprandial GLP-1 response after esophagectomy. GE varies significantly in these patients despite consistent pyloric management.

Defining clinically important hypoglycemia in patients with postbariatric hypoglycemia

BACKGROUND

Postbariatric hypoglycemia (PBH) is a rare but growing complication of bariatric surgery. Many aspects have yet to be established, including the blood glucose threshold which represents clinically important hypoglycemia in affected patients.

OBJECTIVE

To confirm the glucose threshold below which neuroglycopenic (NG) symptoms arise in patients with PBH during provoked and real-world hypoglycemia as an indicator of clinically important hypoglycemia.

SETTING

Stanford University School of Medicine.

METHODS

Forty patients with PBH were enrolled. Thirty-two patients underwent hypoglycemia provocation in the clinical research unit (CRU) during which symptoms and blood glucose concentrations were assessed. A sensitivity analysis and stepwise linear regression were conducted evaluating relationships between symptoms and glucose levels. To validate CRU findings in the real-world setting, 8 sex-, age-, body mass index (BMI)-, and disease severity-matched patients underwent 20 days of at-home continuous glucose monitoring (CGM), self-monitoring of blood glucose (SMBG), and symptom assessment by electronic diary (eDiary).

RESULTS

In response to hypoglycemia provocation 19%, 59%, and 22% of patients developed a postprandial glucose nadir <70-54 mg/dL , <54-40 mg/dL, and <40 mg/dL, respectively. Number of NG symptoms was highest when glucose was in the <54-40 mg/dL range, although 23% of those with NG symptoms in this range, and 37% with NG symptoms below this range lacked autonomic symptoms, indicating substantial hypoglycemia unawareness. Sensitivity of symptoms to detect hypoglycemia was poor other than for drowsiness, while specificity was high for all NG symptoms. Confusion, sweating, drowsiness, and incoordination were significant independent predictors of hypoglycemia. Events captured during real-world monitoring mirrored CRU data, showing a spike in NG symptoms in the <54-40 mg/dL range. CGM captured up to 10-fold more events than were patient-perceived and captured by SMBG/eDiary.

CONCLUSION

Due to the peak in NG symptoms at glucose <54-40 mg/dL during provoked and real-world hypoglycemia, the low sensitivity/high specificity of NG symptoms to detect hypoglycemia, and high prevalence of hypoglycemia unawareness at glucose values <54 mg/dL, we propose that blood glucose <54 mg/dL should be taken to signify clinically important hypoglycemia in patients with established PBH.

Early experience with a nutrition and survivorship clinic in esophageal cancer

Improved cure rates in esophageal cancer care have increased focus on health-related quality of life (HRQL) in survivorship. To optimize recovery after esophagectomy, particularly nutritional well-being, a personalized multidisciplinary survivorship clinic was established at this center. Assessments at 6 and 12 months postoperatively include validated European Organization for the Research and Treatment of Cancer (EORTC) symptom and health-related quality of life (HRQL) questionnaires, functional status review, anthropometry, and biochemical screening for micronutrient deficiencies. 75 patients, at a mean age of 63 years, 84% male, 85% with adenocarcinoma, and 73% receiving multimodal therapy were included. Mean preoperative body mass index (BMI) was 27.5 (4.3) kg m -2. 6- and 12-month assessments were completed by 66 (88%) and 37 (93%) recurrence-free patients, respectively. Mean body weight loss at 6 months was 8.5 ± 6.6% and at 12 months 8.8 ± 7.3%. Of the 12-month cohort, micronutrient deficiency was present in 27 (79.4%) preoperatively and 29 (80.6%) after 1 year (P = 0.727), most commonly iron deficiency (preoperative: 16 [43.2%] and postoperative: 17 [45.9%] patients, P = 0.100). 26 (70.3%) of these patients also had clinically significant dumping syndrome persisting to 12 months after surgery. We describe a novel follow-up support structure for esophageal cancer patients in the first year of survivorship. This may serve as an exemplar model with parallel application across oncological care.

A Pilot Study of Gut-Brain Signaling After Octreotide Therapy for Unintentional Weight Loss After Esophagectomy

BACKGROUND

Recurrence-free patients after esophageal cancer surgery face long-term nutritional consequences, occurring in the context of an exaggerated postprandial gut hormone response. Acute gut hormone suppression influences brain reward signaling and eating behavior. This study aimed to suppress gut hormone secretion and characterize reward responses and eating behavior among postesophagectomy patients with unintentional weight loss.

METHODS

This pilot study prospectively studied postoperative patients with 10% or greater body weight loss (BWL) beyond 1 year who were candidates for clinical treatment with long-acting octreotide (LAR). Before and after 4 weeks of treatment, gut hormone secretion, food cue reactivity (functional magnetic resonance imaging), eating motivation (progressive ratio task), ad libitum food intake, body composition, and symptom burden were assessed.

RESULTS

Eight patients (7 male, age: mean ± SD 62.8 ± 9.4 years, postoperative BWL: 15.5 ± 5.8%) participated. Octreotide LAR did not significantly suppress total postprandial plasma glucagon-like peptide-1 response at 4 weeks (P = .08). Postprandial symptom burden improved after treatment (Sigstad score median [range]: 12 [2-28] vs 8 [3-18], P = .04) but weight remained stable (pre: 68.6 ± 12.8 kg vs post: 69.2 ± 13.4 kg, P = .13). There was no significant change in brain reward system responses, during evaluation of high-energy or low-energy food pictures, nor their appeal rating. Moreover, treatment did not alter motivation to eat (P = .41) nor ad libitum food intake(P = .46).

CONCLUSION

The protocol used made it feasible to characterize the gut-brain axis and eating behavior in this cohort. Inadequate suppression of gut hormone responses 4 weeks after octreotide LAR administration may explain the lack of gut-brain pathway alterations. A higher dose or shorter interdose interval may be required to optimize the intervention.

Attribution of Ghrelin to Cancer; Attempts to Unravel an Apparent Controversy

Ghrelin is an endogenous peptide hormone mainly produced in the stomach. It has been known to regulate energy homeostasis, stimulate secretion of growth hormone, and mediate many other physiologic effects. Various effects attributed to ghrelin contribute to many aspects of cancer development and progression. Accordingly, a large body of evidence has emerged about the association of ghrelin with several types of cancer in scales of cell-line, animal, and human studies. However, existing data are controversial. This controversy occurs in two main domains: one is the controversial results in local effects of ghrelin on different types of human cancer cell-lines; the second is the apparent disagreement in the results of in-vitro and clinical studies that investigated ghrelin association to one type of cancer. These inconsistencies have hampered the indications to consider ghrelin as a potential tumor biomarker or therapeutic agent in cancer patients. Previous studies have reviewed different parts of current literature about the ghrelin-cancer relationship. Although they have highlighted these controversial results in various ways, no specific recommendations have been given to address it. In this study, we comprehensively reviewed in-vitro, in-vivo, and clinical studies and attempted to use the following approaches to unravel the inconsistencies detected: (a) to distinguish local and systemic effects of ghrelin in interpreting its summary clinical role in each cancer; (b) scrutinizing factors that regulate local effects of ghrelin and could justify different effects of ghrelin on different cancer cell-lines. These approaches could have notable implications for future in-vitro and clinical studies.