Calcium regulating hormones and bone mineral content in patients after subtotal gastrectomy

Vitamin D—The Nutritional Status of Post-Gastrectomy Gastric Cancer Patients—Systematic Review

Gastric cancer is a malignant neoplasm of the gastrointestinal tract, with one of the standard treatment methods remaining gastrectomy. The authors conducted a systemic review of the Medline and Embase databases concerning the serum vitamin D level in post-gastrectomy gastric cancer patients, regarding all articles published until 22 May 2022 according to the PRISMA guidelines. 18 studies with a total number of 908 gastric cancer survivors were included in the analysis. The initial rate of vitamin D deficiency in gastric cancer patients undergoing gastrectomy appears to be similar to the global population deficiency. In post-gastrectomy survivors, the level of 25(OH)D may remain stable or decrease, while the level of 1, 25(OH)₂D remains normal. Supplementation with vitamin D results in an improvement in its serum concentration and positively affects bone mineral density, which is gradually reduced in post-gastrectomy survivors. Combining vitamin D supplementation with calcium and bisphosphonates enables us to obtain better results than vitamin D and calcium only. The type of surgery influences the level of serum vitamin D and its metabolites, with total or partial gastrectomy and maintenance of the duodenal food passage remaining the most important factors. There is a strong need for randomized, controlled trials that would investigate this matter in the future.

A Gender Comparison of Bone Metabolic Changes After Gastric Cancer Surgery: A Prospective Observational Study

BACKGROUND/AIM

This study was designed to investigate gender-related differences in changes in bone metabolism after gastric cancer surgery.

PATIENTS AND METHODS

We prospectively recruited 47 patients (38 males and 9 females) who had early gastric cancer. The bone mineral density (BMD), serum levels of 1,25-dihydroxy vitamin D (1,25(OH)₂VD), 25-hydroxy vitamin D (25(OH)VD), and estradiol (E2) were measured before and after surgery.

RESULTS

BMD significantly decreased 12 months after surgery by median degrees of 3.4% and 3.9% in male and female patients, respectively (p<0.001 and p=0.023). There was no significant difference between both genders in the rate of change in BMD after surgery. The serum E2 level in male patients significantly increased by a median value of 22 pg/ml 12 months after gastrectomy (p=0.030). Both the serum 25(OH)VD and 1,25(OH)₂VD levels remained nearly within the normal range throughout the observation period in both male and female patients.

CONCLUSION

BMD significantly decreased within 12 months after gastrectomy in both male and female patients with gastric cancer, and there was no significant gender-related difference in the rate of change in BMD.

Metabolic bone disorders after gastrectomy: inevitable or preventable?

Some authors have suggested that a relationship exists between gastrectomy for gastric cancer and metabolic bone disorders. However, few studies have investigated metabolic bone disorders after gastrectomy for gastric cancer in detail. Thus, we reviewed the findings of our recent prospective study and those of other reports on this subject. Osteoporosis and osteomalacia have been observed after gastrectomy and appear to be caused by reduced food intake and absorption, and steatorrhea. Moreover, the incidence of fracture is high after gastrectomy, although subtotal or total gastrectomy and reconstruction for gastric cancer have not been identified as significant risk factors for decreased bone mineral density (BMD). Recently, we reported that the BMD decreased significantly within 12 months after gastrectomy for gastric cancer in both male and female patients, but there was no significant gender-related difference in the rate of change in BMD. More than 1 year after gastrectomy, the steep decrease in the BMD stabilized and normal levels of 1,25(OH)₂ vitamin D₃ were maintained, despite the lack of precursor for 1,25(OH)₂ vitamin D₃ synthesis after gastrectomy. Alendronate therapy might be effective and prevent postgastrectomy metabolic bone disorders; however, the optimal treatment and prevention strategy for this bone disorder has not been delineated.

Changes in bone metabolism after gastric cancer surgery in male patients: a prospective observational study

BACKGROUND

Several retrospective studies have shown that bone disorders occur after gastric cancer surgery. This study was designed to prospectively evaluate the changes in bone metabolism after gastrectomy for gastric cancer.

METHODS

We prospectively enrolled 39 men with early gastric cancer who underwent gastrectomy. We excluded women to avoid the effects of menopause. We employed dual energy X-ray absorptiometry (DEXA) to measure bone mineral density (BMD) of the lumbar spine. DEXA was performed before and 1 and 2 years after surgery. The serum levels of alkaline phosphatase (ALP), 1,25-dihydroxy vitamin D [1,25(OH)₂VD], 25-hydroxy vitamin D [25(OH)VD], and estradiol were measured before surgery and every 3 months until 2 years after surgery.

RESULTS

DEXA revealed that BMD significantly decreased by 0.036 ± 0.033 g/cm² 12 months after gastrectomy (P < 0.001) and by 0.046 ± 0.040 g/cm² 24 months after gastrectomy (P < 0.001). The serum ALP level significantly increased by 38.31 ± 103.8 IU/L 24 months after surgery (P = 0.013). The serum 25(OH)VD level significantly decreased by 4.88 ± 6.42 ng/ml 24 months after surgery (P < 0.001), whereas the serum 1,25(OH)₂VD levels were consistently in the normal range. The serum estradiol level significantly increased by 2.94 ± 7.49 pg/ml 12 months after gastrectomy (P = 0.035). A lower preoperative body mass index (BMI) significantly correlated with the reduction in BMD 12 months after surgery; the correlation coefficient was 0.37 (P = 0.025).

CONCLUSIONS

This study showed that a significant decrease in BMD was observed for up to 24 months after gastrectomy, not only 12 months.

Reconstruction method as an independent risk factor for postoperative bone mineral density loss in gastric cancer

BACKGROUND AND AIM

No study has compared the incidence of postoperative bone metabolic disorders between Billroth-I (B-I) and Roux-en-Y (R-Y) reconstructions after distal gastrectomy (DG) for gastric cancer (GC). In this study, we wished to examine the impact of reconstruction method on postoperative bone mineral density (BMD) loss.

METHODS

We investigated a total of 148 consecutive patients who underwent DG with B-I or R-Y reconstruction for stage I GC between 2008 and 2012. We retrospectively assessed the BMD data using computed tomography attenuation values of the first lumbar vertebra after surgery.

RESULTS

In multivariate analysis for the whole study series, R-Y reconstruction was identified as an independent risk factor for BMD loss after DG (P < 0.0001; OR = 5.60; 95% CI = 2.38-13.98). Propensity score match analysis was used to overcome bias because of the different covariates for the two groups; even though the 37 patients in the B-I group and the 37 patients in the R-Y group had no significant difference among characteristics, B-I reconstruction was validated to have superiority over R-Y reconstruction for preventing BMD loss in the first 3 years after DG. The cumulative hazard ratio of osteoporosis after gastrectomy was significantly higher in the R-Y group than in the B-I group (P = 0.0427).

CONCLUSIONS

Billroth-I reconstruction might be a preferable method for preventing BMD loss after gastrectomy in GC patients.

Vitamin D deficiency in patients operated on for gastric lymphoma

OBJECTIVE

To determine the nutritional status in patients treated for gastric non-Hodgkin's lymphoma (NHL).

MATERIAL AND METHODS

Patients treated during the period 1990-99 according to a protocol including primary gastric surgery for eligible patients were registered prospectively in successive patients. Those with aggressive lymphomas in stage IE-IIE underwent gastric surgery followed by CHOP-like chemotherapy. Patients with indolent lymphomas and localized disease did not receive any further treatment if the operation was considered radical; otherwise, they received local radiotherapy after surgery. Patients with advanced disease underwent gastric surgery only if there was a considerable risk of bleeding or perforation. Patients below the age of 80 years and in complete remission were offered a cross-sectional examination a median of 102 months later, including clinical examination with estimation of body mass index, upper endoscopy and blood tests (haemoglobin, ferritin, serum-Fe, total iron-binding capacity (TIBC), vitamin B(12), homocysteine, vitamin D status, parathyroid hormone (PTH), albumin and electrolytes).

RESULTS

Forty patients were identified, of whom 33 met for follow-up examination. Seventeen patients had a partial gastrectomy (PG), 9 a total gastrectomy (TG) and 7 patients were not operated on. The patients in the TG group had significant weight loss. Furthermore, the patients in the TG group had a lower storage iron content (s-ferritin and s-iron saturation), lower s-vitamin D, higher s-PTH and homocysteine than the other groups.

CONCLUSIONS

If surgery is necessary for gastric lymphomas, a PG should be performed when possible. The patients should receive dietary advice and be followed-up at least yearly for nutritional deficiencies. Regular intake of vitamin D and -B(12), calcium, folate and iron should be considered.

Different effect of antiulcer agents on rat cysteamine-induced duodenal ulcer after sialoadenectomy, but not gastrectomy

The focus was on salivary glands in cysteamine-induced duodenal ulcer and the different effects of antiulcer agents on cysteamine-induced duodenal ulcer in sialoadenectomized but not gastrectomized rats. We tested antiulcer agents on cysteamine-induced duodenal ulcer in rats (agents/kg i.p.) simultaneously with cysteamine 400 mg/kg s.c., rat killed 24 h thereafter subjected to no surgery (normal), to gastrectomy (24 h before) or sialoadenectomy, acute (24 h before) or chronic (21 days before). (i) Ulcerogenesis: cysteamine-induced duodenal ulcer had the same severity and incidence in normal, gastrectomized or acutely or chronically sialoadenectomized rats. (ii) Antiulcer effect under normal conditions or following gastrectomy: in normal or gastrectomized rats all agents tested, gastric pentadecapeptide BPC 157 [currently in clinical trials for inflammatory bowel disease (PL-10, PLD-116, PL-14736, Pliva) (10.0 microg or 10.0 ng), ranitidine (10 mg), atropine (10 mg), omeprazole (10 mg)] inhibited cysteamine-induced duodenal ulcers, acting through gastric acid-independent mechanisms. Following sialoadenectomy, acute or chronic: ranitidine, omeprazole and atropine were completely ineffective, while pentadecapeptide BPC 157 could protect. Thus, we found that contrary to stomach, salivary glands are implicated in cytoprotective agent activity (standard agents were ineffective after sialoadenectomy). Also, gastric pentadecapeptide BPC 157 was consistently associated with a cytoprotective effect, suggesting a beneficial activity distinctive from that of H2-receptor blockers, proton-pump inhibitors and anticholinergics; but probably replacing missing salivary glands factors.

Osteoporosis due to cancer treatment: pathogenesis and management

Many therapeutic regimens in cancer treatment carry the risk of causing or favoring the development of osteoporosis. Therapies in which hypogonadism may occur are most relevant in this respect. Prompt hormone replacement therapy is indicated in these patients. In patients in whom this is undesirable because of a hormone-dependent tumor, the risk of osteoporosis should be assessed by means of osteodensitometry, and prophylactic or therapeutic measures should be instituted if necessary. Early intervention improves outcome because osteoporosis therapy is most effective in preventing deterioration of bone mass. There remains much uncertainty in assessing the risk of combination chemotherapy with regard to the development of osteoporosis. Negative effects on the skeleton have, however, been demonstrated for individual drugs, such as methotrexate and ifosfamide. Negative effects of the tumor itself on bone metabolism may aggravate the degree of osteoporosis. Detailed data and long-term experience to assess the risk are urgently needed in this area and constitute an important research topic for the coming years and decades. This review discusses the most prevalent mechanisms of osteoporosis caused by cancer treatment and outlines therapeutic strategies for the prevention and treatment of therapy-induced bone loss.

Osteogenic effect of a gastric pentadecapeptide, BPC-157, on the healing of segmental bone defect in rabbits: a comparison with bone marrow and autologous cortical bone implantation

Gastrectomy often results in increased likelihood of osteoporosis, metabolic aberration, and risk of fracture, and there is a need for a gastric peptide with osteogenic activity. A novel stomach pentadecapeptide, BPC-157, improves wound and fracture healing in rats in addition to having an angiogenic effect. Therefore, in the present study, using a segmental osteoperiosteal bone defect (0.8 cm, in the middle of the left radius) that remained incompletely healed in all control rabbits for 6 weeks (assessed in 2 week intervals), pentadecapeptide BPC-157 was further studied (either percutaneously given locally [10 microg/kg body weight] into the bone defect, or applied intramuscularly [intermittently, at postoperative days 7, 9, 14, and 16 at 10 microg/kg body weight] or continuously [once per day, postoperative days 7-21 at 10 microg or 10 ng/kg body weight]). For comparison, rabbits percutaneously received locally autologous bone marrow (2 mL, postoperative day 7). As standard treatment, immediately after its formation, the bone defect was filled with an autologous cortical graft. Saline-treated (2 mL intramuscularly [i.m.] and 2 mL locally into the bone defect), injured animals were used as controls. Pentadecapeptide BPC-157 significantly improved the healing of segmental bone defects. For instance, upon radiographic assessment, the callus surface, microphotodensitometry, quantitative histomorphometry (10 microg/kg body weight i.m. for 14 days), or quantitative histomorphometry (10 ng/kg body weight i.m. for 14 days) the effect of pentadecapeptide BPC-157 was shown to correspond to improvement after local application of bone marrow or autologous cortical graft. Moreover, a comparison of the number of animals with unhealed defects (all controls) or healed defects (complete bony continuity across the defect site) showed that besides pentadecapeptide intramuscular application for 14 days (i.e., local application of bone marrow or autologous cortical graft), also following other pentadecapeptide BPC-157 regimens (local application, or intermittent intramuscular administration), the number of animals with healed defect was increased. Hopefully, in the light of the suggested stomach significance for bone homeostasis, the possible relevance of this pentadecapeptide BPC-157 effect (local or intramuscular effectiveness, lack of unwanted effects) could be a basis for methods of choice in the future management of healing impairment in humans, and requires further investigation.

The pharmacological properties of the novel peptide BPC 157 (PL-10)

The reported beneficial effects of the gastric mucosal derived pentadecapeptide BPC 157 (Gly Glu Pro Pro Pro Gly Lys Pro Ala Asp Asp Ala Gly Leu Val, M.W. 1419) on different organ lesions are reviewed. Apart from the effects on various gastrointestinal lesions, the potentially beneficial effect on pancreas, liver injuries, endothelium and heart damage, i.e. dysrhythmias following reoxygenation, and blood pressure, along with effect on experimental acute/chronic inflammation, wound and fracture (pseudoarthrosis) healing are described. It appears that these beneficial effects all together provide a particular network reflecting activity of a special peptidergic defence system. In support of this concept, it appears that there are interactions of this pentadecapeptide with many important systems (namely, dopamine-, NO-, prostaglandin-, somatosensory neurone-systems), that could provide a basis for the observed protective effects. Moreover, since disturbance of these systems' functions (i.e. dopamine-, NO-, somatosensory neuronal-system) which manifest either over-activity or as inhibition, may contribute to the multiple lesions in different organs. The reported evidence that this pentadecapeptide is able to counteract both their over-action, and their inhibition, may suggest this pentadecapeptide as a new, but most probably essential physiological defence system and that should be further investigated.

Calcium regulation and bone mass loss after total gastrectomy in pigs

OBJECTIVE

Total gastrectomy often results in postgastrectomy bone disease with decreased bone mass and increased fracture risk. To further elucidate the mechanisms of postgastrectomy bone disease, the authors investigated calcium metabolism and bone mineral density after total gastrectomy in pigs.

SUMMARY BACKGROUND DATA

Postgastrectomy bone disease can present as osteomalacia, osteoporosis in excess of normal aging, or a combination of both. The underlying mechanisms are insufficiently understood and need further investigation.

METHODS

Growing minipigs were gastrectomized and compared with fed-matched, sham-operated control p gs for 1 year. Calcium absorption, serum calcium, parathyroid hormone, 25-(OH)-vitamin D, 1,25-(OH)2-vitamin D, alkaline phosphatase, and computed tomography bone mineral density were measured in three monthly intervals.

RESULTS

Total gastrectomy resulted in impaired calcium absorption, reduced serum calcium and 25-(OH)-vitamin D, increased parathyroid hormone and 1,25-(OH)2-vitamin, and reduced bone mineral density compared with fed-matched, sham-operated control pigs.

CONCLUSIONS

The authors data indicate that a reduced serum calcium activates counter-regulatory mechanisms, resulting in calcium mobilization from the bone. Possibly, calcium and vitamin D supplementation after total gastrectomy might prevent postgastrectomy bone mass loss.