Gastric emptying is accelerated following laparoscopic Nissen fundoplication

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Differential gastric emptiness according to preoperative stomach position in neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy

PURPOSE

We sometimes experienced prolonged delayed gastric emptying (DGE) in neurologically impaired patients undergoing laparoscopic fundoplication and gastrostomy. We explored the difference in the DGE rate according to the preoperative stomach position.

METHODS

Thirty-two neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy between 2015 and 2019 were classified into two groups based on stomach position: non-elevated stomach position (NESP) and elevated stomach position (ESP). Patients' characteristics, operative result and postoperative gastric emptying were reviewed.

RESULTS

The 11 ESP patients were significantly older than the 21 NESP patients (p < 0.05). The ESP patients had a significantly heavier body weight (BW) than the NESP patients (p < 0.05). The time taken (days) to reduce gastric drainage (days, below BW × 10 ml) in the NESP (4.3 ± 3.6) was significantly longer than that of ESP (1.3 ± 1.6) (p < 0.05). The time taken (days) to achieve full enteral nutrition in the NESP (14.1 ± 8.9) was significantly longer than that of the ESP patients (8.8 ± 3.1) (p < 0.05).

CONCLUSION

Elevated stomach position (ESP) patients archived full enteral nutrition earlier than NESP patients after laparoscopic fundoplication and gastrostomy. Stomach position correction might, therefore, be involved in the incidence of DGE.

Preoperative liquid gastric emptying rate does not predict outcome after fundoplication

AIM OF THE STUDY

Preoperative gastric emptying (GE) rate in patients with gastrointestinal reflux disease (GERD) was evaluated as a predictor of outcome after antireflux surgery.

METHODS AND PATIENTS

GE was assessed using radionuclide scintigraphy and a standardized meal with cow's milk. GE half time (T1/2), patient demographics and GERD symptoms including vomiting (>4days/week), retching (>4days/week), prolonged feeding time (>3h/day), and discomfort after meals were recorded pre- and postoperatively. A standardized follow-up included a 24-h pH-monitoring and an upper gastrointestinal contrast study. Of 74 patients undergoing Nissen fundoplication between 2003 and 2009, 35 underwent a preoperative GE study. The remaining 39 patients were not examined owing to volume intolerance, cow's milk intolerance or allergy, inability to lie still, or parents refusing participation.

MAIN RESULTS

Median age at fundoplication was 4.9 [range 1.1-15.4] years, and follow-up time was median 4.3 [1.9-8.9] years. GERD recurred in 7 (20%) patients. Preoperative T1/2 in the seven patients with recurrent GERD was median 45 [21-87] min compared to 44 [16-121] min in the 28 patients without recurrent GERD (p=0.92). There was no significant difference between the one third of patients with the slowest GE [T1/2 54-121min] and the remaining patients [T1/2 16-49min] regarding GERD recurrence or postoperative vomiting, retching, prolonged feeding time, or discomfort after meals.

CONCLUSION

Preoperative GE rate did not predict outcome after antireflux surgery, as slow GE was not associated with recurrent GERD or postoperative troublesome symptoms such as vomiting, retching, or meal discomfort.

New insights in gastroesophageal reflux, esophageal function and gastric emptying in relation to dysphagia before and after anti-reflux surgery in children

In children with gastroesophageal reflux (GER) disease refractory to pharmacological therapies, anti-reflux surgery (fundoplication) may be a treatment of last resort. The applicability of fundoplication has been hampered by the inability to predict which patient may benefit from surgery and which patient is likely to develop post-operative dysphagia. pH impedance measurement and conventional manometry are unable to predict dysphagia, while the role of gastric emptying remains poorly understood. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis (AIM) analysis, which relates bolus movement and pressure generation within the esophageal lumen.

Surgical management of pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) is common in the pediatric population. Most cases represent physiologic GER and as the lower esophageal sphincter (LES) matures and a solid diet is introduced, many of these patients (>65%) experience spontaneous resolution of symptoms by two years of age. Those who continue to have symptoms and develop complications such as failure to thrive, secondary respiratory disease, and others are classified as having gastroesophageal reflux disease (GERD). Goals of GERD treatment include the resolution of symptoms and prevention of complications. Treatment options to achieve these goals include dietary or behavioral modifications, pharmacologic intervention, and surgical therapy. This paper will review the clinical presentation of GERD and discuss options for surgical management and outcomes in these patients.

Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children

OBJECTIVES

To assess gastroesophageal reflux (GER), esophageal motility, and gastric emptying in children before and after laparoscopic fundoplication and to identify functional measures associated with postoperative dysphagia.

STUDY DESIGN

Combined impedance-manometry, 24-hour pH-impedance, and gastric-emptying breath tests were performed before and after laparoscopic anterior partial fundoplication. Impedance-manometry studies were analyzed with the use of conventional analysis methods and a novel automated impedance manometry (AIM) analysis.

RESULTS

Children with therapy resistent GER disease (n = 25) were assessed before fundoplication, of whom 10 (median age 6.4 years; range, 1.1-17.1 years; 7 male; 4 with neurologic impairment) underwent fundoplication. GER episodes reduced from 97 (69-172) to 66 (18-87)/24 hours (P = .012). Peristaltic contractions were unaltered. Complete lower esophageal sphincter relaxations decreased after fundoplication (92% [76%-100%] vs 65% [29%-91%], P = .038). Four (40%) patients developed postoperative dysphagia, which was transient in 2. In those patients, preoperative gastric emptying was delayed compared with patients without postoperative dysphagia, 96 minutes (71-104 minutes) versus 48 minutes (26-68 minutes), P = .032, and AIM analysis derived dysphagia risk index was greater (56 [15-105] vs 2 [2-6] P = .016). Two patients underwent a repeat fundoplication.

DISCUSSION

Fundoplication in children reduced GER without altering esophageal motility. Four patients who developed dysphagia demonstrated slower gastric emptying and greater dysplasia risk index preoperatively. AIM analysis may allow detection of subtle esophageal abnormalities potentially leading to postoperative dysphagia.

Nissen fundoplication in children with cerebral palsy: influence on rate of gastric emptying and postprandial symptoms in relation to protein source in caloric liquid meals

BACKGROUND & AIMS

The aim was to study the influence of Nissen fundoplication on rate of gastric emptying and postprandial symptoms in relation to protein source in liquid meals in children with cerebral palsy.

METHODS

Ten children with cerebral palsy and Nissen fundoplication and ten with cerebral palsy without Nissen fundoplication were studied. Patients had gastrostomy and received two meals, double-blinded, in random order, on separate days. Meals contained a standardised carbohydrate and fat base plus one of two protein modules (Meal A: 100% casein; Meal B: 40% casein/60% whey). The (13)C octanoic acid breath test was used to assess gastric emptying. Postprandial symptoms were recorded. Results are given as median.

RESULTS

For meal A and B, respectively, time until 50% of the meal had emptied (T1/2) was 110 in the Nissen fundoplication- and 181 min in the non-Nissen fundoplication group, (p = 0.35) and 50 and 85 min (p = 0.25). Seven in the Nissen fundoplication group reported postprandial symptoms to meal B, none in the non-Nissen fundoplication group (p < 0.01).

CONCLUSIONS

Compared with cerebral palsy-children without Nissen fundoplication, those with Nissen fundoplication have postprandial symptoms more frequently after receiving a rapid emptying meal. Gastric emptying alone, however, does not seem to explain the symptom occurrence. ClinicalTrials.gov: UUSKBK 28200706.

Comparison of upper gastrointestinal contrast studies and pH/impedance tests for the diagnosis of childhood gastro-oesophageal reflux

BACKGROUND

The upper gastrointestinal (UGI) contrast study is used in the assessment of children with gastro-oesophageal reflux (GOR) and for detection of structural anomalies. The pH study is more sensitive than the UGI study for the diagnosis of GOR. The pH study has been replaced by the pH/impedance test, which detects both acid and nonacid reflux.

OBJECTIVE

To compare the UGI contrast study with the pH/impedance test for the diagnosis of GOR in children.

MATERIALS AND METHODS

We retrospectively reviewed consecutive records of children investigated for GOR from October 2008 to February 2010, and compared the findings of UGI studies with those of pH/impedance tests.

RESULTS

The UGI studies revealed GOR in 116 of 579 children (20%). Of the children undergoing a UGI study, 66 also underwent a pH/impedance test. Using the pH/impedance tests as the reference for GOR, UGI had a sensitivity of 42.8% and a negative predictive value of 24%. There was no significant correlation (P > 0.05) between the reflux index and the number of reflux episodes in the pH/impedance tests and height of reflux in the UGI study. There were low incidences of malrotation (0.9%), hiatus hernia (1%) and delayed gastric emptying (0.4%).

CONCLUSION

The UGI study had low sensitivity for the diagnosis of GOR and low yield for the diagnosis of structural anomalies.

Pediatric gastroesophageal reflux disease

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.

Association of TCF7L2 allelic variations with gastric function, satiation, and GLP-1 levels

OBJECTIVE

Genetic variation in transcription factor 7-like 2 (TCF7L2), a regulator of proglucagon processing, is reproducibly associated with type 2 diabetes. GLP-1 alters gastric function and increases satiation.

HYPOTHESIS

Genetic variation in TCF7L2 is associated with satiation, gastric motor function, and GLP-1 concentrations.

METHODS

In 62 adults, a single nucleotide polymorphism (SNP) of TCF7L2 (rs7903146) was genotyped and associations with gastric emptying (GE) of solids and liquids, gastric volume (GV), and satiation (maximum tolerated volume and symptoms after nutrient drink test) were explored using a dominant genetic model, with gender and BMI as covariates. In 50 of the participants, we also measured plasma GLP-1 during fasting and after ingestion of a nutrient drink.

RESULTS

Presence of the T allele compared to CC genotype in rs7903146 SNP of the TCF7L2 gene was associated with reduced fasting GV (246.3 ± 11.4 mL for CC group, compared to 215.7 ± 11.4 mL for CT/TT group, p= 0.05) and accelerated GE t(1/2) of liquids (26.3 ± 2.0 minutes for CC compared to 17.7 ± 1.4 for CT/TT, p < 0.005). There was no significant association of rs7903146 SNP with GE of solids, gastric accommodation, satiation, fasting, or postprandial GLP-1.

CONCLUSION

Our data suggest TCF7L2 is associated with altered gastric functions that may predispose to obesity.

Proximal and overall gastric emptying of solids in patients with reduced gastric volume accommodation compared to matched controls

BACKGROUND

Interventions such as gastric surgery and erythromycin result in displacement of solids to the distal stomach and acceleration of overall and proximal gastric emptying. The effect of non-surgical impairment of gastric accommodation on gastric emptying is unclear. Non-surgical impairment of gastric accommodation is associated with accelerated gastric emptying.

AIM

To compare measurements of proximal and overall gastric emptying in patients with reduced postprandial gastric volume accommodation with the emptying rates in age- and gender-matched controls with normal postprandial gastric volume accommodation.

METHODS

We evaluated overall and proximal gastric emptying in nine patients with impaired gastric accommodation and age-equivalent and gender-matched controls. Gastric volumes and emptying were measured using validated SPECT and dual gamma camera scintigraphy, respectively. We compared group differences in overall and proximal gastric emptying t (1/2) by t test.

RESULTS

Patients with impaired postprandial gastric volume accommodation had greater fasting gastric volume. The proportion of food emptied from the proximal stomach immediately after meal ingestion was lower and t (1/2) of proximal gastric emptying correspondingly longer in the group with reduced postprandial gastric accommodation. In contrast, differences were not detected in overall gastric emptying in the two groups, and the ratio of overall to proximal gastric emptying t (1/2) was greater in the group with impaired volume accommodation.

CONCLUSIONS

Proximal stomach emptying is reduced in patients with impaired postprandial volume accommodation; this difference occurs predominantly during the time of meal ingestion. Compensatory mechanisms that result in normal overall gastric emptying require further elucidation.

Gastric emptying and antireflux surgery

PURPOSE

Absence of consistent data on the outcome of gastric emptying after fundoplication raises concerns about preoperative workup and surgical management. This study assessed how gastric emptying evolves after isolated fundoplication in order to determine whether a preoperative investigation and/or a concurrent gastric drainage procedure are justified.

METHODS

Eleven children with GERD underwent both pre- and post-operative gastric emptying scintigraphy. No gastric drainage procedures were added to fundoplication. Scintigraphy was performed according to a standardized protocol (labeled meal, 300 ml + 500 μCi (99m)Tc/m(2) bsa). Half-emptying time (t (1/2)), emptying rate and fractions of retention are expressed as the median followed by the [range]; statistical significance level was set at 5%.

RESULTS

Postoperative t (1/2) (min) showed a much smaller dispersion and was significantly lower than preoperative one (76 [56;101] vs. 107 [57;186], p = 0.04) with a variation of -48 [-105;19]; there was no individual correlation between pre- and post-operative measurements (r = 0.25). The proportion of patients with delayed gastric emptying (t (1/2) > 100) was significantly lower in the postoperative scintigraphy (9 vs. 55%, p = 0.03). The postoperative emptying rate (%/h) was significantly faster (35.1 [18.9;41.7] vs. 28.5 [16.3;38.7], p = 0.05). The retentions (%) at 30 and 60 min were similar; at 90 and 120 min were significantly lower after surgery (45 [35;54] and 32 [24;46] vs. 53 [33;78] and 41 [25;66], p = 0.03 and 0.05).

CONCLUSION

Gastric emptying accelerates significantly after fundoplication with a shift to normal values in the vast majority of patients. Scintigraphy does not predict the postoperative outcome. Therefore, concomitant drainage procedures seem unnecessary and preoperative gastric emptying study not useful.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery

BACKGROUND

An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery.

METHODS

A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal.

KEY RESULTS

Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed.

CONCLUSIONS & INFERENCES

Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.

Laparoscopic anterior hemifundoplication improves key symptoms without impact on GE in children with and children without neurodevelopmental delays

AIM

We investigated the impact of laparoscopic anterior hemifundoplication on gastric emptying (GE) and specific symptoms in children with and children without neurodevelopmental delays gastroesophageal reflux. Scintigraphic and ultrasonographic GE measurements were correlated.

PATIENTS AND METHODS

Twenty-six children (mean age 7 ± 6.1 years), of whom 14 were neurodevelopmentally delayed, were evaluated prospectively before 3 and 6 months after laparoscopic anterior hemifundoplication. All of the patients underwent clinical assessments, interviews, and 24-hour pH monitoring. Key symptoms were evaluated using a 5-point Likert scale. Gastric emptying was assessed by Tc-99m-DTPA-scintigraphy and ultrasonography.

RESULTS

All of the children had significant catch-up growth after fundoplication, which was more pronounced in the neurologically normal children (P < 0.05 vs impaired), in line with a decrease in the use of omeprazol (mean 0.93 ± 0.7 mg · kg(-1) · day(-1) before and 0.06 ± 0.18 mg · kg(-1) · day(-1) at 6 months after operation; P < 0.001). The 24-hour pH monitoring normalized in all of the children, and the mean severity of the key symptoms such as vomiting, choking, and pain was significantly reduced (P < 0.001). Scintigraphic GE parameters, such as the elimination rate/minute, gastric half-emptying time (t1/2), gastric residual activity (RA), and duration of the initial merging time, were not altered significantly by the operation (P > 0.05). Ultrasonographic evaluations confirmed these results [positive correlation with scintigraphy for t1/2 (P = 0.006) and RA (P = 0.01)]. The symptoms evolution and GE were uncorrelated (P > 0.01). There were no significant differences between children with and children without neurodevelopmental delays.

CONCLUSIONS

Laparoscopic anterior hemifundoplication achieves an excellent symptomatic outcome without affecting GE in children with and children without neurodevelopmental delays.