Duodenal switch operation for pathologic transpyloric duodenogastric reflux

Functional, Diagnostic and Therapeutic Aspects of Bile

Bile is a unique body fluid synthesized in our liver. Enterohepatic circulation preserves bile in our body through its efficient synthesis, transport, absorption, and reuptake. Bile is the main excretory route for bile salts, bilirubin, and potentially harmful exogenous lipophilic substances. The primary way of eliminating cholesterol is bile. Although bile has many organic and inorganic contents, bile acid is the most physiologically active component. Bile acids have a multitude of critical physiologic functions in our body. These include emulsification of dietary fat, absorption of fat and fat-soluble vitamins, maintaining glucose, lipid, and energy homeostasis, sustenance of intestinal epithelial integrity and epithelial cell proliferation, reducing inflammation in the intestine, and prevention of enteric infection due to its antimicrobial properties. But bile acids can be harmful in certain altered conditions like cholecystectomy, terminal ileal disease or resection, cholestasis, duodenogastric bile reflux, duodenogastroesophageal bile reflux, and bile acid diarrhea. Bile acids can have malignant potentials as well. There are also important diagnostic and therapeutic roles of bile acid and bile acid modulation.

Large Buffering Effect of the Duodenal Bulb in Duodenal Switch: a Wireless pH-Metric Study

Introduction

Bariatric procedures result in massive weight loss, however, not without side effects. Gastric acid is known to cause marginal ulcers, situated in the small bowel just distal to the upper anastomosis. We have used the wireless BRAVO™ system to study the buffering effect of the duodenal bulb in duodenal switch (DS), a procedure in which the gastric sleeve produces a substantial amount of acid.

Methods

We placed a pre- and a postpyloric pH capsule in 15 DS-patients (seven men, 44 years, BMI 33) under endoscopic guidance and verified the correct location by fluoroscopy. Patients were asked to eat and drink at their leisure, and to register their meals for the next 24 h.

Results

All capsules but one could be successfully placed, without complications. Total registration time was 17.2 (1.3–24) hours prepyloric and 23.1 (1.2–24) hours postpyloric, with a corresponding pH of 2.66 (1.74–5.81) and 5.79 (4.75–7.58), p < 0.01. The difference in pH between the two locations was reduced from 3.55 before meals to 1.82 during meals, p < 0.01. Percentage of time with pH < 4 was 70.0 (19.9–92.0) and 13.0 (0.0–34.6) pre and postpylorically, demonstrating a large buffering effect.

Conclusion

By this wireless pH-metric technique, we could demonstrate that the duodenal bulb had a large buffering effect, thus counteracting the large amount of gastric acid passing into the small bowel after duodenal switch. This physiologic effect could explain the low incidence of stomal ulcers.

Correlation Between Bile Reflux Gastritis and Biliary Excreted Contrast Media in the Stomach

OBJECTIVE

This study aimed to evaluate the relationship between biliary excreted contrast media in the stomach and the presence of bile reflux gastritis.

METHODS

Consecutive 111 patients who underwent both gadoxetic acid-enhanced magnetic resonance cholangiography (gadoxetic MRC) and gastric endoscopy were included in this study. We performed a review of the gadoxetic-MRC image sets acquired 60 minutes after intravenous injection of contrast media and endoscopic images. We recorded amount of contrast media in the stomach. The sensitivity, specificity, and accuracy of duodenogastric bile reflux diagnosis were evaluated for the gadoxetic MRC. Statistical analysis was performed using the Fisher exact test and the linear-by-linear association test.

RESULTS

Among the 111 patients, 39 had 60-minute delayed images showing the presence of contrast media in the stomach. Of these 39 patients, 13 had bile reflux gastritis and 5 showed bile in the stomach without evidence of erythematous gastritis. Of the 72 patients who did not show contrast media in the stomach, none had bile reflux gastritis and 2 patients showed bile staining in the stomach without evidence of erythematous gastritis. Bile reflux gastritis was significantly more frequent in patients with contrast media in the stomach on gadoxetic MRC than in those without. Patients with high-grade extension of contrast media in the stomach had significantly frequent bile reflux gastritis than did those with low-grade extension.

CONCLUSION

Biliary excreted contrast media in the stomach on 60-minute delayed gadoxetic MRC has a correlation with the presence of bile reflux gastritis on endoscopic examination.

Postgastrectomy Syndromes and Nutritional Considerations Following Gastric Surgery

Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.

The Italian validation of the Montreal Global definition and classification of gastroesophageal reflux disease

BACKGROUND AND AIMS

Recently, a Global definition and a classification of gastroesophageal reflux disease (GERD) were developed by Montreal Consensus Group, composed of international expert gastroenterologists. Guidelines and consensus documents are, however, infrequently accepted and adopted at a local level. The aim of this study was to measure the acceptance of Montreal Global definition of GERD consensus document by specialists in a single country (Italy) and to measure the linguistic, scientific, and practical differences between the international consensus document and the Italian version.

METHODS

A 2-day meeting was held in June 2007 in Rome, Italy, attended by 147 Italian physicians who were experts in gastroenterology. They reviewed the individual original statements in their Italian translation and then voted on the statement using the scoring system used by the Montreal Consensus Group (6-point Likert scale). Voting was performed at baseline and after an analytical discussion on each statement, led by six internationally renowned experts. Consensus was defined as an agreement with a statement by at least two-thirds of the group. Results were compared with the Montreal statements.

RESULTS AND DISCUSSION

The level of consensus was already extremely high at the first vote (>90% with the two-thirds threshold). The level of agreement at the second vote increased slightly. The maximum variation between two votes was 33% (of increase from first to second round, 59-92%). The high level of agreement could be because of both the general acceptance of Montreal Consensus by scientific community, and the new scientific evidences published after the Montreal report, which fit with the original statements.

CONCLUSION

This study is the first national linguistic validation of the Montreal Global definition of GERD and is also proof of its scientific validity, based on the same methodology used to create the Montreal statements. It also suggests that evidence-based International disease classification systems can be applied to local settings after validation by local experts.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.