Role of vagal dysfunction in motility and transit disorders of jejunal Roux limb after Roux-en-Y gastrojejunostomy

Gastro-Intestinal Disorders and Micronutrient Deficiencies following Oncologic Esophagectomy and Gastrectomy

Primary surgical indications for the esophagus and stomach mainly involve cancer surgeries. In recent years, significant progress has been made in the field of esogastric surgery, driven by advancements in surgical techniques and improvements in perioperative care. The rate of resectability has increased, and surgical strategies have evolved to encompass a broader patient population. However, despite a reduction in postoperative mortality and morbidity, malnutrition remains a significant challenge after surgery, leading to weight loss, muscle mass reduction, and deficiencies in essential nutrients due to digestive complications. Malnutrition worsens quality of life and increases the risk of tumor recurrence, significantly affecting prognosis. Nevertheless, the nutritional consequences following surgery are frequently overlooked, mainly due to a lack of awareness regarding their long-term effects on patients who have undergone digestive surgery, extending beyond six months. Micronutrient deficiencies are frequently observed following both partial and total gastrectomy, as anticipated. Surprisingly, these deficiencies appear to be similarly prevalent in patients who have undergone esophagectomy with iron, vitamins A, B1, B12, D, and E deficiencies commonly observed in up to 78.3% of the patients. Recognizing the distinct consequences associated with each type of intervention underscores the importance of implementing preventive measures, early detection, and prompt management.

Roux Limb Motility in Gastric Bypass Patients with Chronic Abdominal Pain-Is There an Association to Prescribed Opioids?

BACKGROUND/AIM

A number of patients continue to suffer from chronic abdominal pain of unknown origin, which may also lead to a prolonged use of opioid analgesics. Symptoms of abdominal pain, nausea and vomiting in this patient group resemble the characteristics of the Roux stasis Syndrome. The aim was to elucidate relationships between chronic abdominal pain, Roux limb motor activity and opioid analgesics.

METHODS

Roux limb high-resolution manometry and ratings of abdominal pain and quality of life were analysed in 15 gastric bypass patients reporting abdominal pain of unknown origin. Effect of acute opiate administration (morphine i.v.) on fasting Roux limb motor activity was assessed in asymptomatic and morphine-naïve gastric bypass patients (n = 9) and compared with an untreated control group (n = 11).

RESULTS

In the symptomatic patient group, we found disturbed Roux limb motor patterns in 10 out of 15 examinations, but no signs of Roux stasis syndrome. A high prevalence of prescribed opioid analgesics as well as a high number of reoperations in this group. The worst quality of life and the highest number of pain-killing medications were observed among the patients with distal pacemaker activity in Roux limb. In the morphine-naïve and asymptomatic patients, morphine increased the muscular tone in the Roux limb during phase III-like motor activity. A majority of the RYGBP patients with chronic abdominal pain had a disturbed Roux limb fasting motility, and there was a high prevalence of prescribed opioid analgesics. In opiate-naïve RYGBP patients, acute morphine intravenously increased the muscular tone of the Roux limb.

Roux-en-Y limb motility after total gastrectomy

The Roux-en-Y stasis syndrome is a troublesome postgastrectomy syndrome. Although the era of gastric resection for peptic ulcer disease has almost come to an end, the increasing incidence of proximal gastric cancer and the outbreak of bariatric operations make the study of the motility of the Roux-en-Y limb (RYL) after gastric resection or gastroplasty very relevant.This study aims to evaluate the motility of the RYL after total gastrectomy using high-resolution manometry (HRM). We performed an HRM on 8 patients after total gastrectomy for proximal gastric cancer and Roux-en-Y reconstruction, 74 ± 111 months after the operation. At the time of the study, all patients were asymptomatic without evidence of cancer recurrence.Peristaltic waves were noticed at the RYL in 3 (37%) of the patients. The mean wave amplitude of the peristaltic waves was 63 ± 29 (37-94) mmHg and 83 ± 35 (42-104) mmHg at 3 and 7 cm below the esophagojejunal junction, respectively. Simultaneous waves were noticed in 6 (75%) of the patients in 80 ± 32 % (30-100) of the swallows of these patients. No patient presented with absence of motor activity detectable at the HRM. Our results show that: (1) esophageal motility is normal after total gastrectomy with Roux-en-Y reconstruction; (2) motor activity is always detectable at the proximal RYL, but peristalsis is abnormal in most patients; and (3) absence of peristalsis does not translate into symptoms.

Review article: the impact of bariatric surgery on gastrointestinal motility

BACKGROUND

Obesity is a major medical problem worldwide. Different treatment modalities have emerged to treat obese patients, but the best long-term results are achieved with bariatric surgery. Currently, the interventions most commonly performed are laparoscopic adjustable gastric banding (LAGB), Roux-en-Y- gastric bypass (RYGB) and sleeve gastrectomy.

AIM

To review the gastrointestinal motor complications associated with each of these types of bariatric interventions and the clinical implications of such complications.

METHODS

Search of medical database (PubMed) on English-language articles from January 1996 to March 2011. The search terms used were laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), roux-en-Y-gastric bypass (RYGB), using the AND operator with the terms: complications, motility, GERD, reflux, gastric emptying, esophagitis, dysphagia.

RESULTS

Of the three bariatric interventions reviewed, LAGB was the most studied. Most studies reported short follow-up, of ≤ 1 year. Oesophageal motor dysfunction is the most common motility complication following the bariatric interventions that were reviewed and is mainly observed after LAGB. Some data suggest that oesophageal motor function testing predicts development of post-operative symptoms and oesophageal dilation. RYGB offers protection from gastro-oesophageal reflux. Sleeve gastrectomy was the least studied and was associated with an acceleration of gastric emptying.

CONCLUSIONS

The effects of these interventions on GI motility should be considered when selecting patients for bariatric surgery. There is scant information regarding the overall effect of sleeve gastrectomy on gastro-oesophageal reflux patterns and oesophageal motility.

Reconstruction after gastrectomy: which technique is best?

Several reconstruction techniques are possible after gastrectomy. The best reconstruction is one, that maintains satisfactory nutritional status and quality of life while keeping postoperative morbidity as low as possible. The aim of this study was to describe the different reconstruction techniques that can be proposed after distal and total gastrectomy, heeding to the French guidelines on the use of mechanical sutures in these indications. We then conducted a review of randomized trials dealing with reconstruction techniques after distal and total gastrectomy. After distal gastrectomy, Roux-en-Y reconstruction seems superior to Billroth I and Billroth II reconstructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors. Otherwise, Billroth II should be preferred over Billroth I reconstruction because of lower postoperative morbidity and better oncologic margins. After total gastrectomy, Roux-en-Y reconstruction remains the easiest solution, with satisfactory functional results. Addition of a pouch reservoir after Roux-en-Y reconstruction seems to improve short-term functional outcome after total gastrectomy with better potential for nutritional intake. In the long-term, quality of life seems better mainly in patients with small-resected tumors associated with a good prognosis.

Efficacy of celiac branch preservation in Roux-en-y reconstruction after laparoscopy-assisted distal gastrectomy

BACKGROUND

The present study investigated the efficacy of preserving the celiac branch of the vagus nerve after laparoscopy-assisted distal gastrectomy (LADG) with Roux-en-Y (R-Y) reconstruction.

METHODS

Between January 2004 and September 2008, a total of 159 consecutive patients who underwent LADG for gastric carcinoma were classified into groups according to preservation of the celiac branch of the vagus nerve-preservation group (P-LADG; n = 70) and the resection group (R-LADG; n = 89). The parameters analyzed included patient and tumor characteristics, operative details, postoperative outcomes, and nutritional state. The endoscopic findings of the gastric remnant and lower esophagus were evaluated at 12 months postoperatively.

RESULTS

In regard to postoperative complications, no significant differences were found between groups. With R-LADG, 14 patients suffered from dumping syndrome (15.7%), compared with only 2 patients with P-LADG (2.9%; P = .007). The amount of meal consumption compared with the preoperative value and the rate of weight reduction at 12 months postoperatively did not differ significantly between groups. Endoscopic findings showed significantly more residue with P-LADG (34.3%) than with R-LADG (16.9%; P = .011).

CONCLUSION

The celiac branch is useful in regulating gastrointestinal motility by maintaining postoperative physiologic function. Celiac branch preservation seems to represent a feasible and beneficial method for LADG.

Myoelectric activity and motility of the Roux limb after cut or uncut Roux-en-Y gastrojejunostomy

AIM: To explore the mechanisms of uncut Roux-en-Y gastrojejunostomy, which is used to decrease the occurrence of Roux stasis syndrome.

METHODS: The changes of myoelectric activity, mechanic motility and interstitial cells of Cajal (ICC) of the Roux limb after cut or uncut Roux-en-Y gastrojejunostomy were observed.

RESULTS: When compared with the cut group, the amplitude (1.15 ± 0.15 mV vs 0.48 ± 0.06 mV, P < 0.05) and frequency (14.4 ± 1.9 cpm vs 9.5 ± 1.1 cpm, P < 0.01) of slow waves and the incidence (98.2% ± 10.4% vs 56.6% ± 6.4%, P < 0.05) and amplitude (0.58 ± 0.08 mV vs 0.23 ± 0.06 mV, P < 0.01) of spike potential of the Roux limb in the uncut group were significantly higher. The migrating myoelectric complexes (MMC) phase III duration in the uncut group was significantly prolonged (6.5 ± 1.1 min vs 4.4 ± 0.8 min, P < 0.05), while the MMC cycle obviously shortened (42.5 ± 6.8 vs 55.3 ± 8.2 min, P < 0.05). Both gastric emptying rate (65.5% ± 7.9% vs 49.3% ± 6.8%, P < 0.01) and intestinal impelling ratio (53.4% ± 7.4% vs 32.2% ± 5.4%, P < 0.01) in the uncut group were significantly increased. The contractile force index of the isolated jejunal segment in the uncut group was significantly higher (36.8 ± 5.1 vs 15.3 ± 2.2, P < 0.01), and the expression of c-kit mRNA was significantly increased in the uncut group (0.82 ± 0.11 vs 0.35 ± 0.06, P < 0.01).

CONCLUSION: Uncut Roux-en-Y gastrojejunostomy may lessen the effects of operation on myoelectric activity such as slow waves, spike potential, and MMC, decrease the impairment of gastrointestinal motility, and remarkably increase the expression of c-kit mRNA.

The vagus is inhibitory of the late postprandial insulin secretion in conscious pigs

The vagus is involved in the cephalic phase of insulin secretion but its role in the meal absorption phase of insulin release remains to be defined. The aim of this study was therefore to evaluate the role of the vagus in the early and the late meal absorption phases of insulin secretion. In six pigs, venous insulin profiles were compared in intact animals, after ventral or dorsal vagal trunk section, and after section of both vagal trunks (truncal vagotomy). Since gastric emptying could be modified by vagotomy, it was recorded concomitantly by gamma scintigraphy. Semi-solid (porridge) and liquid (glucose 10%) meals were tested. Truncal vagotomy significantly increased insulin release compare to intact animals after glucose (63.8%) and porridge (174.4%) meals in the early and the late absorption phases of insulin secretion, respectively. For the glucose meal, this effect could be explained by a vagally mediated change in gastric emptying rate, since insulin concentrations for a similar amount of nutrient propelled to the duodenum were not different in intact and truncal vagotomized animals. In contrast, after the porridge meal, truncal vagotomy was associated with a second, later occurring increase in circulating insulin, which could not be explained by changes in gastric emptying rate. These results demonstrate for the first time an inhibitory role of the vagus in the late meal absorption phase of insulin release.

Esvaziamento gástrico e jejunal proximal em ratos submetidos ou não à gastrectomia parcial com reconstrução do trânsito intestinal em Y de Roux ou a Billroth II

Estudou-se os efeitos da reconstrução gastrojejunal em Y de ROUX (YR) ou a BILLROTH II (BII) no esvaziamento gástrico (EG) e jejunal proximal de líquido nutriente. Constitui-se quatro grupos de dez ratos Wistar machos: simulado (grupo I), antrectomia em YR (grupo II), gastrectomia subtotal em YR (grupo III) e antrectomia a BII (grupo IV). O EG e jejunal proximal foram avaliados no sétimo dia de pós-operatório, 60 minutos após a introdução gástrica de ovo cru mexido marcado com Tc99m. Após esse tempo, retirou-se separadamente o estômago, intestino proximal e restante do intestino, seguindo-se da quantificação do radioisótopo presente em cada segmento, numa câmara de ionização. O EG foi mais rápido nos animais gastrectomizados do que naqueles sem gastrectomia (α < 0,05). O EG no grupo antrectomia em YR foi mais lento do que no grupo gastrectomia subtotal em YR (α < 0,05), mas não apresentou diferença significante com relação ao grupo antrectomia a BII. O esvaziamento da alça de ROUX (grupos TI e III) não mostrou diferença significante em relação ao da alça eferente de igual comprimento (grupo IV). Concluiu-se que o EG de liquido nutriente foi semelhante na antrectomia em YR ou a BII e que nas reconstruções em YR, foi mais rápido na gastrectomia subtotal do que na antrectomia.