Pancreatic carcinoma is associated with delayed gastric emptying

Perioperative outcomes after open biliary bypass for malignant biliary obstruction (MBO) in resource-limited setups; a multicenter prospective cohort study, 2023

INTRODUCTION

Obstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass.

METHODS

From June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications.

RESULTS

The hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]).

CONCLUSION

Patients who had long operation times, preoperative cholangitis, and elevated total bilirubin levels are at increased risk for poor perioperative outcomes. Clinicians may use these results to optimize these patients to decrease their elevated risk of serious morbidity and mortality.

GI Symptoms in Pancreatic Cancer

This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.

Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies

Background

Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions.

Methods

Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented.

Results

The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented.

Conclusion

Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.

Gastric Electrical Stimulation Is an Effective Treatment Modality for Refractory Gastroparesis in a Postsurgical Patient with Pancreatic Cancer

Gastroparesis-related hospital visits contribute significantly to healthcare costs. Gastroparesis can lead to chronic symptoms, such as nausea, vomiting, bloating, early satiety, and abdominal pain. It can result in a significant impairment of quality of life. Diabetes and postsurgery are common causes for gastroparesis, but most cases of gastroparesis are idiopathic in presumed etiology. Malignancy-related gastroparesis has also recently been described in the literature, and pancreatic cancer is a malignancy commonly associated with gastroparesis. Whipple surgery for pancreatic cancer is often complicated by gastroparesis during its postoperative course. We report a case where gastric electrical stimulation was an effective treatment option in the treatment of refractory malignancy-related gastroparesis.

Clinical Factors as a Component of the Personalized Treatment Approach to Advanced Pancreatic Cancer: a Systematic Literature Review

INTRODUCTION

Pancreatic cancer is often diagnosed at late stages, where disease is either locally advanced unresectable or metastatic. Despite advances, long-term survival is relatively non-existent.

DISCUSSION

This review article discusses clinical factors commonly encountered in practice that should be incorporated into the decision-making process to optimize patient outcomes, including performance status, nutrition and cachexia, pain, psychological distress, medical comorbidities, advanced age, and treatment selection.

CONCLUSION

Identification and optimization of these clinical factors could make a meaningful impact on the patient's quality of life.

Roux-en-Y duodenojejunostomy improves gastric emptying in experimental obstruction of the distal duodenum

Introduction

We undertook a comparative survey of gastric emptying (GE) kinetics after two variants of bypass surgery for upper bowel obstruction.

Material & methods

In 10 dogs with experimental upper bowel obstruction, five were randomized to obtain gastrojejunal anastomosis (GA), and the other five received Roux-en-Y duodenojejunal anastomosis (DA). Duplicate scintigraphic measurements of GE of a solid meal were accomplished in every animal before surgery and during the early (2–3 weeks), medium (3 months), and late (6 months) post-operative period. The GE curves were fitted with a power-exponential function to derive the GE half time T½, and the curve shape parameter S.

Results

Early after surgery T½ slightly decreased by -18±21 min in the DA group and lengthened by 91±37 min in the GA group (p = 0.042). In both groups an increase in the S parameter was found then. In either group T½ gradually declined towards the basal value during the medium and late post-operative period. On the other hand, net differences relative to the basal situation in the S values appeared to be positive in the GA group (0.32±0.11 at 3 months; 0.64±0.19 at six months), and negative in the DA group (-0.30±0.09 at 3 months; -0.01±0.20 at six months). Hence a statistically significant contrast was found between those differences: p = 0.0022 at 3 months, and p = 0.045 at six months after the surgery.

Conclusion

Roux-en-Y duodenojejunal anastomosis appears to be superior to the classical gastrojejunal anastomosis while restoring patency of the gastrointestinal passage in the case of upper bowel obstruction.

Top Ten Tips Palliative Care Clinicians Should Know About Interventional Symptom Management Options When Caring for Patients with Gastrointestinal Malignancies

Patients diagnosed with advanced stages of gastrointestinal (GI) malignancies are often quite symptomatic, with symptoms primarily related to anatomic sites of obstruction. Endoscopic approaches to the palliation of GI malignancies have begun to overtake surgical approaches as first line in interventional management. We brought together a team of interventional gastroenterologists and palliative care experts to collate practical pearls for the types of endoscopic interventions used for symptom management in patients with GI malignancies. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians recognize common presentations of advanced GI malignancies, address interventional approaches to improve symptom burden, and improve the quality of shared decision making and goals-of-care discussions.

Effect of Mirtazapine on Gastric Emptying in Patients with Cancer-associated Anorexia

BACKGROUND/AIMS

The tetracyclic antidepressant mirtazapine is widely used in cancer patients suffering from anorexia. Although it is known to restore appetite, the exact mechanism remains unknown. The aim of the study was to evaluate if mirtazapine has any effect on gastric emptying in patients suffering from cancer-related anorexia.

MATERIALS AND METHODS

Solid-meal gastric-emptying study using radiolabeled meal was performed in 28 patients suffering from cancer anorexia once at baseline and repeated after 15 days of mirtazapine therapy.

RESULTS

At baseline, only 7 (25%) patients had normal gastric motility (emptying >70% at 3 h postingestion) whereas after treatment, 18 (64.2%) patients achieved this limit. Mean % gastric emptying increased from 55.2% ±21.0% to 68.9% ±21.3% (P < 0.001). Mean gastric emptying time (t_1/2) before intervention was 314.7 ± 421.0 min which decreased to 116.0 ± 106.7 min after intervention. Results were further analyzed by dividing the patients into two groups based on baseline gastric-emptying study. Group A (normal gastric emptying) consisted of seven patients, mean % gastric emptying at baseline and postintervention was 75.0% ±5.25% and 87.57% ±5.94%, respectively (P < 0.018). Group B (delayed gastric emptying) consisted of 21 patients, mean % gastric emptying at baseline and postintervention was 48.71% ±18.82% and 62.76% ±16.86%, respectively (P < 0.001).

CONCLUSION

Mirtazapine significantly improves gastric emptying in patients of prostate and breast cancer suffering from cancer-associated anorexia.

Malignancy-associated gastroparesis: an important and overlooked cause of chronic nausea and vomiting

A 69-year-old woman was referred to a gastroenterology clinic with a 1-year history of protracted nausea and postprandial vomiting. She had a background of gastro-oesophageal reflux disease, irritable bowel syndrome and chronic obstructive pulmonary disease with a significant smoking history. Her laboratory work-up including autoimmune screen, coeliac serology and synacthen test were unremarkable. Upper gastrointestinalendoscopy and CT imaging ruled out mucosal and obstructive causes. Gastric emptying studies demonstrated a delayed gastric emptying consistent with diagnosis of gastroparesis. Concurrently, she underwent a CT of the thorax for unresolved consolidation on her chest X-ray. This revealed a locally advanced primary lung carcinoma. In this context, with all other causes excluded, her gastroparesis was deemed to represent a paraneoplastic phenomenon. Gastroparesis is a frequent, under-recognised and important complication of cancer.

Pancreatoduodenectomy - preventing complications

Increased awareness of periampullary & pancreatic head cancers, and the accompanying improved outcomes following pancreatoduodenectomy (PD), has possibly led to an increase in patients seeking treatment for the same. While there has definitely been a reduction in morbidity rates following PD in the last few decades, this decline has not mirrored the drastic fall in mortality. Amongst the foremost in the factors responsible for this reduction in mortality is the standardization of surgical technique and development of dedicated teams to manage all aspects of this demanding procedure. This review intends to provide the reader with an overview of major complications following this major surgery and measures to prevent them based on the authors' experience.

Matched-pair analysis of postoperative morbidity and mortality for pancreaticogastrostomy and pancreaticojejunostomy using mattress sutures in soft pancreatic tissue remnants

BACKGROUND

After pancreaticoduodenectomy, the incidence of postoperative pancreatic fistula remains high, especially in patients with "soft" pancreatic tissue remnants. No "gold standard" surgical technique for pancreaticoenteric anastomosis has been established. This study aimed to compare the postoperative morbidity and mortality of pancreaticogastrostomy and pancreaticojejunostomy for "soft" pancreatic tissue remnants using modified mattress sutures.

METHODS

Seventy-five patients who had undergone pancreaticogastrostomy and 75 who had undergone pancreaticojejunostomy after pancreaticoduodenectomy between 2002 and 2008 were retrospectively compared using matched-pair analysis. A modified mattress suture technique was used for the pancreaticoenteric anastomosis. Patients with an underlying "hard" pancreatic tissue remnant, as in chronic pancreatitis, were excluded. Both groups were homogeneous for age, gender, and underlying disease. Postoperative morbidity, mortality, and preoperative and operative data were analyzed.

RESULTS

There were no significant differences between the groups for the incidence of postoperative pancreatic fistula (10.7% in both). Postoperative morbidity and mortality, median operation time, median length of hospital stay, intraoperative blood loss, and the amount of intraoperatively transfused erythrocyte concentrates also did not significantly differ between the groups. Patient age >65 years (P=0.017), operation time >350 minutes (P=0.001), and intraoperative transfusion of erythrocyte concentrates (P=0.038) were identified as risk factors for postoperative morbidity.

CONCLUSIONS

Our results showed no significant differences between the groups in the pancreaticogastrostomy and pancreaticojejunostomy anastomosis techniques using mattress sutures for "soft" pancreatic tissue remnants. In our experience, the mattress sutures are safe and simple to use, and pancreaticogastrostomy in particular is feasible and easy to learn, with good endoscopic accessibility to the anastomosis region. However, the location of the anastomosis and the surgical technique need to be individually evaluated to further reduce the incidence of postoperative pancreatic fistula.

Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial

OBJECTIVE

To study the effect of antecolic vs. retrocolic reconstruction on delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and to analyze factors which may be associated with post-PD DGE. DGE is a troublesome complication occurring in 30-40% of patients undergoing PD leading to increased postoperative morbidity. Many factors have been implicated in the pathogenesis of DGE. Among the various methods employed to reduce the incidence, recent reports have suggested that an antecolic reconstruction of gastro/duodenojejunostomy may decrease the incidence of DGE.

METHODS

Between Sep 2006 and Nov 2008, 95 patients requiring PD (for both malignant and benign conditions) were eligible for the study. Of these, 72 patients finally underwent a PD and were randomized to either a retrocolic or antecolic reconstruction of the gastro/duodenojejunostomy. All patients underwent the standard Whipple's or a pylorus preserving pancreaticoduodenectomy (PPPD), and the randomization was stratified according to the type of PD done. DGE was assessed clinically using the Johns Hopkins criteria (Yeo et al. in Ann Surg 218: 229-37, 1993). In patients suspected to have DGE, mechanical causes were excluded by imaging and/or endoscopy. Occurrence of DGE was the primary endpoint, whereas duration of hospital stay and occurrence of intra-abdominal complications were the secondary end points.

RESULTS

The antecolic and retrocolic groups were comparable with regard to patient demographics, diagnosis, and other preoperative, intraoperative, and postoperative factors. Overall, DGE occurred in 21 patients (30.9%). There was no significant difference in the incidence of DGE in the antecolic vs. the retrocolic group (34.4% vs. 27.8%; p = 0.6). On univariate analysis, older age, use of octreotide, and intra-abdominal complications were significantly associated with the occurrence of DGE; however, on a multivariate analysis, only age was found to be significant (p = 0.02). The mean postoperative stay was longer among patients who developed DGE (21.9 ± 9.3 days vs. 13 ± 6.9 days; p = 0.0001).

CONCLUSIONS

Delayed gastric emptying is a cause of significant morbidity and prolongs the duration of hospitalization following pancreaticoduodenectomy. The incidence of DGE does not appear to be related to the method of reconstruction (antecolic or retrocolic). Older age may be a risk factor for its occurrence.

Braun enteroenterostomy is associated with reduced delayed gastric emptying and early resumption of oral feeding following pancreaticoduodenectomy

BACKGROUND AND OBJECTIVES

Morbidity rates following pancreaticoduodenectomy (PD) remain high with delayed gastric emptying (DGE) and slow resumption of oral diet contributing to increased postoperative length of stay. A Braun enteroenterostomy has been shown to decrease bile reflux following gastric resection. We hypothesize that addition of Braun enteroenterostomy during PD would reduce the sequelae of DGE.

METHODS

From our PD database, patients were identified that underwent classic PD with partial gastrectomy from 2001 to 2006. All patients with reconstruction utilizing a single loop of jejunum at the University of Florida Shands Hospital were reviewed. Demographics, presenting signs and symptoms, pathologic diagnoses, and postoperative morbidity were compared in those patients undergoing reconstruction with an additional Braun enteroenterostomy (n = 70) to those not undergoing a Braun enteroenterostomy (n = 35).

RESULTS

Patients undergoing a Braun had NG tubes removed earlier (Braun: 2 days, no Braun: 3 days, P = 0.002) and no significant change in postoperative vomiting (Braun: 27%, no Braun: 37%, P = 0.37) or NG tube reinsertion rates (Braun: 17%, no Braun: 29%, P = 0.21). Median postoperative day with tolerance of oral liquids (Braun: 5, no Braun: 6, P = 0.01) and solid diets (Braun: 7, no Braun: 9, P = 0.01) were significantly sooner in the Braun group. DGE defined by two criteria including the inability to have oral intake by postoperative day 10 (Braun: 10%, no Braun: 26%, P < 0.05) and the international grading criteria (grades B and C, Braun: 7% vs. no Braun: 31%, P = 0.003) were significantly reduced in those undergoing the Braun procedure. In addition, the median length of stay (Braun: 10 days, no Braun: 12 days, P < 0.05) was significantly reduced in those undergoing the Braun procedure. The rate of pancreatic anastomotic failure was similar in the two groups (Braun: 17% vs. no Braun: 14%, P = 0.79). Median bile reflux was 0% in those undergoing a Braun.

CONCLUSIONS

The present study suggests that Braun enteroenterostomy can be safely performed in patients undergoing PD and may reduce the indicence of DGE and its sequelae. Further studies of Braun enteroenterostomy in larger randomized trials of patients undergoing PD are warranted.

Diagnostic and therapeutic approach to pancreatic cancer-associated gastroparesis: literature review and our experience

BACKGROUND

Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease.

OBJECTIVE

To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience.

METHODS

A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998-2005.

RESULTS

Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression.

CONCLUSIONS

We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.

Delayed gastric emptying in patients with caustic ingestion

INTRODUCTION

Patients with caustic ingestion may develop esophageal and/or gastric cicatrization.

OBJECTIVE

Scintigraphic assessment of liquid gastric emptying time in patients with caustic ingestion.

MATERIALS AND METHODS

Consecutive patients with caustic-induced esophageal cicatrization attending the gastroenterology clinic of our institute were studied (patients with age >or=60 years, earlier gastric surgery, vagotomy, peptic ulcer disease, diabetes, systemic sclerosis, and those on gastrointestinal motility-altering drugs were excluded). Gastric emptying time was assessed by radionuclide scintigraphy (ingestion of 200 ml mango juice containing of 18.5 MBq 99mTc sulfur colloid after an overnight fast by static imaging in anterior and posterior projections in supine posture at 10 min intervals each for 1 h). A time-activity curve was generated and gastric half-emptying time (GET 1/2) was calculated. Results were compared with GET 1/2 values estimated for normal individuals in our laboratory (mean+/-2 SD). The emptying study protocol for normal individuals was the same as in patients.

RESULTS

Twenty patients (males 10) median age 32 years, 16 with acid ingestion and four with alkali ingestion, were studied. No patient had symptoms suggestive of gastric outlet obstruction or gastroparesis. Eight patients had evidence of gastric cicatrization in the form of straightening of the lesser curvature and pulling of incisura and duodenal bulb medially and loss of parallelism between the fundus and left dome of diaphragm. Gastric distensibility was however normal in them. As compared with values for normal controls (25+/-9 min), GET 1/2 was significantly prolonged in the study group as a whole (53.2+/-27.77 min, P=0.000). No significant difference was observed between different age groups, sex, or type of caustic agent consumed. GET 1/2 differed in patients (n=10) with stricture involving lower-third of esophagus (72.2+/-27.67 min) when compared with those (n=10) who had a stricture involving upper and/or middle-third of esophagus (34.3+/-8.02 min, P=0.000). In the former, GET 1/2 was maximally prolonged in patients (n=6) with involvement of the lower esophagus and reduced stomach capacity (84.6+/-27.03 min), followed by patients (n=4) with lower esophageal involvement with normal stomach capacity (53.7+/-17.41 min), but the difference did not reach statistical significance (P=0.078). Patients (n=10) without lower esophageal involvement did not have statistically significant altered GET 1/2 compared with normal controls (P>0.05).

CONCLUSION

Our results show that patients with caustic ingestion have prolonged liquid gastric emptying even in the absence of any gastric symptoms.

Enteric autoantibodies and gut motility disorders

Increasing evidence suggests that a subset of gastrointestinal motility disorders is associated with the presence of circulating antibodies. These antibodies are directed against various molecular targets, the best known being anti-neuronal nuclear antibody (ANNA-1 or anti-Hu) associated with paraneoplastic motility disorders. There is also evidence that the presence of distinct autoantibody profiles is associated with non-paraneoplastic motility disorders. This review focuses on the types of antibodies associated with gastrointestinal motility disorders and the significance of these antibodies. Algorithms are suggested for the work-up and treatment of patients with circulating antibodies associated with gastrointestinal motility disorders.

Management of gastroparesis

Gastroparesis presents with nausea, vomiting, early satiety and abdominal discomfort, as well as a range of nongastrointestinal manifestations in association with delays in gastric emptying. The disorder may be a consequence of systemic illnesses, such as diabetes mellitus, occur as a complication of gastroesophageal surgery or develop in an idiopathic fashion and may mimic other disorders with normal gastric emptying. Some cases of idiopathic gastroparesis present after a viral infection. Management relies primarily on therapies that accelerate gastric emptying or reduce vomiting, although endoscopic or surgical options are available for refractory cases. Current research is focusing on the cellular and molecular mechanisms underlying development of delayed gastric emptying, as well as factors unrelated to motor dysfunction that may elicit some symptoms. Future pharmaceuticals will target the contractile and nonmotor defects via novel pathways. Novel electrical stimulation techniques will be employed either alone or in combination with medications.

Review article: gastroparesis

BACKGROUND

Gastroparesis is a chronic disorder caused by stomach pump failure and characterized by profound nausea, vomiting and epigastric pain. Most often, the cause is unapparent and of the known associations, diabetes is the most common. Diagnosis is usually made using an isotope-labelled test meal. Treatment is incremental and includes education, dietary support, prokinetic and antiemetic agents. There are novel approaches including gastric neurostimulation.

AIM

To review current concepts of gastric motor function, aetiology, investigation and treatment of gastroparesis.

METHODS

A systematic web-based review of the literature was undertaken using a lexicon of terms associated with gastroparesis.

RESULTS

There are few controlled studies of this condition. Little is known about causation or underlying nerve, muscle or pacemaker pathology. Idiopathic gastroparesis occurs most commonly in women and gastric emptying is often abnormal in diabetes. Isotopic gastric scintigraphy remains the gold standard investigation, but alternative tests are being developed. Treatment is multimodal and includes education, and nutritional support. There are no adequately powered controlled trials to support a particular drug regimen. In intractable gastroparesis, gastric neurostimulation appears to offer benefit.

CONCLUSION

Despite a significant progress in the past decade, further controlled trials are required into the therapeutic options available for treating this intriguing condition.

Gastroparesis: symptoms, evaluation, and treatment

Gastroparesis presents with gastrointestinal symptoms and nongastrointestinal manifestations in association with objective delays in gastric emptying. The condition may complicate several systemic disorders or may be idiopathic in nature. The diagnosis is made by directed evaluation to exclude organic diseases, which can mimic the clinical presentation of gastroparesis coupled with quantification of gastric emptying. Current therapies rely on dietary modifications, medications to stimulate gastric evacuation, and agents to reduce vomiting. Endoscopic and surgical options are increasingly used for cases refractory to medication treatment.

Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area

BACKGROUND & AIMS

Pancreatic cancer usually does not cause definitive symptoms until survival is severely compromised. Prevention and early detection are urgently needed. Our aim was to collect and analyze data in a population-based study on signs and symptoms of disease reported by patients with pancreatic cancer and control participants to contribute to earlier detection and better prognosis.

METHODS

A supplemental symptoms questionnaire was administered to 120 consecutive patients with pancreatic cancer who were part of a larger population-based case-control study conducted in the San Francisco Bay Area between 1994 and 2001. One hundred eighty age- and sex-matched population-based control participants also were queried about the same symptoms reported by at least 5% of patients with pancreatic cancer.

RESULTS

Most signs and symptoms occurred within 3 years before diagnosis with pancreatic cancer (cases) and interview (controls). Many signs and symptoms were more likely to have been reported by patients compared with control participants and included appetite loss (odds ratio [OR], 41; 95% confidence interval [CI], 14-120), pale stools (OR, 31; 95% CI, 7.3-134), abdominal pain (OR, 30; 95% CI, 9.1-101), jaundice (OR, 20; 95% CI, 8.0-49), unusual bloating (OR, 20; 95% CI, 5.9-67), unusual belching (OR, 17; 95% CI, 3.9-75), weight loss (OR, 12; 95% CI, 5.2-28), dark urine (OR, 10; 95% CI, 2.9-36), constipation (OR, 7.3; 95% CI, 2.0-26), diarrhea (OR, 5.6; 95% CI, 2.0-16), itching (OR, 5.0; 95% CI, 2.3-11), fatigue (OR, 3.8; 95% CI, 2.0-7.3), altered ability to sleep (OR, 2.9; 95% CI, 1.3-6.3), and unusual heartburn (OR, 2.3; 95% CI, 1.2-4.5).

CONCLUSIONS

Our results show that signs and symptoms likely to be indicators of pancreatic cancer occur substantially more often among patients with pancreatic cancer than among population-based controls. The large magnitude of the risk estimates indicate that common gastrointestinal symptoms may assist clinicians in earlier diagnosis of pancreatic cancer and perhaps affect survival.

Gastric phase 3 motility after pylorus-preserving pancreatoduodenectomy

OBJECTIVE

To analyze factors affecting the recovery course of phase 3 activity of the gastric migrating motor complex after pylorus-preserving pancreatoduodenectomy (PPPD) and investigate effects of the recovery of gastric phase 3 on gastric emptying after feeding.

SUMMARY BACKGROUND DATA

Whether early recovery of gastric phase 3 during fasting would predict early recovery of the fed-state gastric emptying function after PPPD has not been well documented.

METHODS

Manometric recording from the gastric antrum was repeated at a weekly interval until the first appearance of gastric phase 3 in 57 patients after PPPD. Twenty-three clinical parameters were assessed as possible factors affecting the recovery course of gastric phase 3 by simple and multiple regression analyses. A gastric emptying study after feeding of a test meal was performed by the acetaminophen method and the values were compared between patients with and without gastric phase 3 after PPPD.

RESULTS

The mean period before the first appearance of gastric phase 3 was 38 days. Among 23 parameters, only lymph node dissection along the hepatoduodenal ligament significantly delayed recovery of gastric phase 3 after PPPD by univariate and multivariate analyses. The presence or absence of gastric phase 3 in the early postoperative period did not influence gastric emptying after feeding in the intermediate period after PPPD.

CONCLUSIONS

Avoiding lymph node dissection along the hepatoduodenal ligament, if applicable, may contribute to early recovery of gastric phase 3 after PPPD. The recovery state of gastric phase 3 during fasting, however, is not necessarily consistent with the degree of improvement of gastric emptying after feeding.

Paraneoplastic gastrointestinal motor dysfunction: clinical and laboratory characteristics

OBJECTIVES

The aim of this study was to describe the clinical, manometric, and serological characteristics of 12 patients with paraneoplastic GI motor dysfunction and to assess the contributory role of diagnostic tests.

METHODS

Twelve patients diagnosed with malignant tumors and GI motor dysfunction were identified at the Mayo Clinic from 1985 to 1996.

RESULTS

Cancers identified were: nine small cell lung carcinoma (SCLC), one anaplastic lung adenocarcinoma, one retroperitoneal lymphoma, and one ovarian papillary serous adenocarcinoma. GI symptoms preceded the tumor diagnosis in all cases of SCLC (mean, -8.7 months, range, -1 to -24 months, n = 9). The diagnosis of a malignant tumor preceded the onset of GI symptoms in the three patients with other neoplasms (6, 12, and 24 months). Five of the nine patients found to have SCLC had no evidence of tumor on initial chest x-ray. One or more paraneoplastic autoantibodies were found in 10 of the 11 patients tested by autoimmune serology. Type 1 antineuronal nuclear antibody (ANNA-1 or anti-Hu) was detected in eight of the nine patients with SCLC (one patient was not tested). The patient with ovarian carcinoma had type 1 Purkinje cell cytoplasmic antibody (PCA-1 or anti-Yo). N-type calcium channel antibodies were found in one patient with SCLC, one with a retroperitoneal B cell lymphoma, and one with ovarian carcinoma. Gastric emptying was delayed in 89% (eight of nine tested) and 80% (four of five tested) had esophageal dysmotility. Autonomic reflex tests were abnormal in the seven patients tested.

CONCLUSIONS

The diagnosis of paraneoplastic GI motor dysfunction requires a high index of clinical suspicion. A panel of serological tests for paraneoplastic autoantibodies, scintigraphic gastric emptying, and esophageal manometry are useful as first-line screening tests. Seropositivity for ANNA-1, PCA-1, or N-type calcium channel-binding antibodies should prompt further evaluation for an underlying malignancy even when routine imaging studies are negative.

Diagnostic and therapeutic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all GI-related carcinomas. It usually presents late in its course. The clinical features are discussed, with emphasis on those that allow early detection of the disease, as well as a review of diagnostic methods and pre- and perioperative staging, which will allow the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance our therapeutic approach to this aggressive cancer.

AGA technical review on the epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma. American Gastroenterological Association

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee in March 1999 and by the AGA Governing Board in May 1999.

Diagnostic approach to pancreatic cancer

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all gastrointestinal-related carcinomas. It usually presents late in its course. In this article, the authors discuss the clinical features of pancreatic cancer, with emphasis on those that allow early detection of the disease. They also review diagnostic methods and preoperative and perioperative staging that allows the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance the therapeutic approach to this aggressive cancer.

Delayed gastric emptying after Billroth I pylorus-preserving pancreatoduodenectomy: effect of postoperative time and cisapride

OBJECTIVE

To study the recovery course of gastric emptying after Billroth I pylorus-preserving pancreatoduodenectomy (PPPD) and therapeutic effects of cisapride.

METHODS

To examine gastric emptying, acetaminophen was given, admixed in a pasty liquid meal, to 16 patients undergoing PPPD before surgery and at 1, 3, 6, 9, and 12 months after surgery. Cisapride was given orally to 10 patients before they received the acetaminophen regimen. Electrogastrography was performed at 2 weeks to 1 month after surgery in eight patients and at 6 to 12 months after surgery in seven patients.

RESULTS

Gastric emptying was delayed but returned to the preoperative level by 6 months after surgery. Pretreatment with cisapride accelerated gastric emptying during months 1 to 6 but not during months 6 to 12 after surgery. Electrogastrography frequently showed tachygastria 2 weeks to 1 month after surgery, but seldom 6 to 12 months after surgery.

CONCLUSIONS

After Billroth I PPPD, gastric emptying is delayed but recovers by 6 months after surgery. Tachygastria may play a part in the pathogenesis of delayed gastric emptying, but it can be treated with cisapride.

Gastroparesis after celiac plexus block

A 36-yr-old woman with metastatic mucinous cystadenocarcinoma of the pancreas underwent neurolytic celiac plexus block with 100% ethanol and 0.5% bupivacaine for intractable back pain. Several hours after the procedure she developed severe nausea and vomiting, which persisted for days despite cessation of opioid analgesics, and administration of intravenous metoclopramide and ondansetron. Both esophagogastroduodenoscopy and barium examination of the stomach and small intestine showed excess gastric fluid but no evidence of mechanical obstruction. A radionuclide study revealed delayed gastric emptying of solids. Treatment with oral cisapride 10 mg p.o. q.i.d. resulted in considerable symptomatic improvement. We document the first reported case of gastroparesis after celiac plexus block and discuss possible etiological mechanisms.

Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma

BACKGROUND

Management of the pancreatic stump after pancreaticoduodenectomy (PD) is still a matter of debate. Pancreaticojejunostomy (PJ) is used commonly but is associated with a significant incidence of pancreatic leaks. Pancreaticogastrostomy (PG) is an alternative that has been reported to be safer.

METHODS

The study is a retrospective analysis of all patients having PD for ampullary carcinoma in one surgical unit at All India Institute of Medical Sciences over 18 years, with PG being the only drainage procedure for the pancreatic stump.

RESULTS

Among 125 patients having PD for ampullary carcinoma, overall morbidity rate was 28%, mortality rate was 4.8%, with no cases of leakage from the pancreaticogastrostomy.

CONCLUSIONS

In world literature (including the current series), the leakage rate of PG is 2.5% (14 of 553) with only 2 deaths (2 of 14) due to leakage from PG. Our large experience and these data conclusively prove the safety of pancreaticogastrostomy, which should be the drainage procedure of choice for the pancreatic stump following pancreaticoduodenectomy.

Randomized trial of three types of gastrojejunostomy in unresectable periampullary cancer

BACKGROUND

A gastrojejunostomy with duodenal partition was designed to clarify whether so-called circulus vomiting exists and, if so, its clinical significance, by comparing it with two other types of gastrojejunostomy commonly used for gastric bypass in unresectable periampullary cancer.

METHODS

Forty-five patients with unresectable periampullary cancer complicated by gastric outlet obstruction (GOO) were recruited into this study between May 1992 and November 1995. They were randomized to receive one of the three types of gastrojejunostomy. The anastomosis in type I gastrojejunostomy was performed at the jejunum 20 cm distal to the ligament of Treitz. Type II was similar to type I except that in type II a duodenum partition was done by linear stapler 1 cm beyond the pylorus. Type III gastrojejunostomy was performed at the Roux-limb jejunum 60 cm distal to biliojejunostomy.

RESULTS

"Food reentry" was noted in three (21%) of the type I patients, as determined by upper gastrointestinal (UGI) study. Of the three, one patient had severe circulus vomiting, one had anorexia, and one had no major symptoms. When patients were evaluated immediately after oral diet intake resumed, the incidence (27%) of clinical GOO symptoms and mean value of gastric emptying time (GET1/2, 118.1 +/- 39.2 min) were significantly lower in type II patients than in types I and III patients. When evaluated I month after operation, the incidence (7% and 17%, respectively) of clinical symptoms of GOO and mean value of GET1/2 (42.0 +/- 23.0 and 35.6 +/- 5.4 min, respectively) were significantly lower in both type II and type III patients than in type I patients. The type II patients resumed oral diet after operation 3.5 days earlier than type I patients, p < 0.05.

CONCLUSIONS

Circulus vomiting induced by food reentry does exist if the gastrojejunostomy is performed as the type I gastrojejunostomy in this study. The newly designed type II gastrojejunostomy with duodenal partition is an easy, safe, and effective gastric bypass and avoids the problem of food reentry.

Case report: pancreatic cancer presenting with paraneoplastic gastroparesis

Delayed gastric emptying has been observed in some patients with histologically proved pancreatic cancer without evidence of obstruction. The case of a 73-year-old women who had signs and symptoms of delayed gastric emptying is described. Workup included a gastric emptying study that showed 95% retention of the radiolabeled test meal after 2 hours (normal result, <70%). Abdominal computed tomography showed findings consistent with a pancreatic mass. Indirect immunofluorescence study of the patient's serum showed staining of Purkinje cell nuclei and prompted further evaluation for malignant masses. No other cause for the patient's gastroparesis was found, including obstruction. This case illustrates how gastroparesis with no other apparent cause, particularly in elderly patients, may represent a paraneoplastic syndrome. Pancreatic cancer should be included in the list of occult carcinomas that can manifest in this manner.

Surgical palliation for pancreatic cancer: developments during the past two decades

Improvements in pancreatic imaging over the past 20 years have revolutionized the preoperative diagnosis and assessment of resectability in patients with suspected pancreatic cancer. This review highlights the resultant trends in the surgical treatment of ductal carcinoma of the pancreas, comparing series reported between 1981 and 1990 with those from the previous decade. Small but worthwhile gains have been achieved both in overall resection rate and in the survival rate from such resections. Nevertheless, 80 per cent or more of affected patients are still unsuitable for resection because of the extent of their disease. Laparotomy retains a crucial role in the management of carcinoma of the pancreatic head, although percutaneous and endoscopic stents provide a useful alternative for palliation of malignant obstructive jaundice in elderly patients or those with carcinomatosis. Operation provides the chance to confirm the nature and full extent of the tumour, to circumvent duodenal obstruction and to abolish pain, besides relieving jaundice without the need for tubes (with their potential to block). By contrast, operative treatment generally has much less to offer in patients with carcinoma of the pancreatic body, unless diagnosis and irresectability remain in doubt. In combination, radiotherapy and 5-fluorouracil may achieve more as adjuncts to palliative surgery than either agent alone. The increasing safety of pancreaticoduodenectomy raises the possibility of palliative resection in younger patients with limited but incurable disease.

Duodenal obstruction in advanced pancreatic carcinoma: how effective is gastroenterostomy in palliation?

Gastro-enterostomy produces variable and often disappointing results in the management of duodenal obstruction due to advanced pancreatic carcinoma. In a series of 51 patients who had palliative surgery for carcinoma of the pancreas five required a gastro-enterostomy. Three of these subsequently had difficulty with gastric emptying. The problem of gastro-enterostomy failure in palliation of pancreatic carcinoma is discussed.

Tumor-associated gastroparesis with esophageal carcinoma. Use of intravenous metoclopramide during radionuclide gastric emptying studies to predict clinical response

This case report describes a patient with esophageal carcinoma and tumor-associated gastroparesis. The radionuclide gastric emptying study diagnosed very delayed liquid and solid gastric emptying. Metoclopramide was administered intravenously during the study and was able to predict a good response to oral therapy.

Pylorus-preserving pancreatectomy: functional results

The pylorus-preserving technique is reported as improving the functional results of pancreatectomy but it is complicated in the early postoperative period by delayed recovery of gastric function in a proportion of patients. We have examined early and late gastrointestinal function in a prospective study of 16 patients having this procedure. The late results appear better than reported results for conventional Whipple resection and the delay in early recovery does not appear to have any late sequelae, provided that it does not require gastric bypass for relief.