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Wang THH, Angeli TR, Beban G, Du P, Bianco F, Gibbons SJ, Windsor JA, Cheng LK, O’Grady G. Slow-wave coupling across a gastroduodenal anastomosis as a mechanism for postsurgical gastric dysfunction: evidence for a "gastrointestinal aberrant pathway". Am J Physiol Gastrointest Liver Physiol 2019; 317:G141-G146. [PMID: 31169993 PMCID: PMC6734376 DOI: 10.1152/ajpgi.00002.2019] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Postsurgical gastric dysfunction is common, but the mechanisms are varied and poorly understood. The pylorus normally acts as an electrical barrier isolating gastric and intestinal slow waves. In this report, we present an aberrant electrical conduction pathway arising between the stomach and small intestine, following pyloric excision and surgical anastomosis, as a novel disease mechanism. A patient was referred with postsurgical gastroparesis following antrectomy, gastroduodenostomy, and vagotomy for peptic ulceration. Scintigraphy confirmed markedly abnormal 4-h gastric retention. Symptoms included nausea, vomiting, postprandial distress, and reflux. Intraoperative, high-resolution electrical mapping was performed across the anastomosis immediately before revision gastrectomy, and the resected anastomosis underwent immunohistochemistry for interstitial cells of Cajal. Mapping revealed continuous, stable abnormal retrograde slow-wave propagation through the anastomosis, with slow conduction occurring at the scar (4.0 ± 0.1 cycles/min; 2.5 ± 0.6 mm/s; 0.26 ± 0.15 mV). Stable abnormal retrograde propagation continued into the gastric corpus with tachygastria (3.9 ± 0.2 cycles/min; 1.6 ± 0.5 mm/s; 0.19 ± 0.12 mV). Histology confirmed ingrowth of atypical ICC through the scar, defining an aberrant pathway enabling transanastomotic electrical conduction. In conclusion, a "gastrointestinal aberrant pathway" is presented as a novel proposed cause of postsurgical gastric dysfunction. The importance of aberrant anastomotic conduction in acute and long-term surgical recovery warrants further investigation.NEW & NOTEWORTHY High-resolution gastric electrical mapping was performed during revisional surgery in a patient with severe gastric dysfunction following antrectomy and gastroduodenostomy. The results revealed continuous propagation of slow waves from the duodenum to the stomach, through the old anastomotic scar, and resulting in retrograde-propagating tachygastria. Histology showed atypical interstitial cells of Cajal growth through the anastomotic scar. Based on these results, we propose a "gastrointestinal aberrant pathway" as a mechanism for postsurgical gastric dysfunction.
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Affiliation(s)
- Tim H.-H. Wang
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Timothy R. Angeli
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Grant Beban
- 3Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Peng Du
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Francesca Bianco
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota,5Departments of Medical and Surgical Sciences (DIMEC) and Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Simon J. Gibbons
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota
| | - John A. Windsor
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leo K. Cheng
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand,6Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Gregory O’Grady
- 1Department of Surgery, University of Auckland, Auckland, New Zealand,2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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