Effects of bile reflux and intragastric microflora changes on lesions of remnant gastric mucosa after gastric operation

Efficacy of transcatheter arterial embolization in treating nonvariceal gastric remnant bleeding: a retrospective 5-year study

BACKGROUND

Gastric remnant bleeding is a special case of upper gastrointestinal bleeding with certain specific disease characteristics, and some matters of transcatheter arterial embolization (TAE) for hemostasis need attention. In this study, we aimed to explore the clinical use of TAE in patients with nonvariceal gastric remnant bleeding and identify the factors influencing the clinical efficacy of these interventions.

METHODS

Data were retrospectively analyzed from 42 patients for whom angiography and embolization were performed but could not be treated endoscopically or had failed endoscopic management in our department between January 2018 and January 2023 due to nonvariceal gastric remnant bleeding. We investigated the relationship between the incidence of re-bleeding and the following variables: sex, age, pre-embolization gastroscopy/contrast-enhanced computer tomography, embolization method, aortography performance, use of endoscopic titanium clips, and the presence of collateral gastric-supplying arteries.

RESULTS

Forty-two patients underwent 47 interventional embolizations. Of these, 16 were positive for angiographic findings, and 26 were negative. Based on arteriography results, different embolic agents were selected, and the technical success rate was 100%. The incidence of postoperative re-bleeding was 19.1% (9/47), and the overall clinical success rate was 81.0% (34/42). Logistic regression analysis of the relationship between the incidence of early re-bleeding following embolization and the proportion of collateral gastric supply arteries revealed an odds ratio of 10.000 (p = 0.014).

CONCLUSIONS

Utilizing TAE for nonvariceal gastric remnant bleeding is safe and effective. The omission of collateral gastric-supplying arteries can lead to early re-bleeding following an intervention.

Laparoscopic subtotal gastrectomy in morbid obese patients: a valid option to laparoscopic gastric bypass in particular circumstances (prospective study)

BACKGROUND

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) without resection of the distal stomach is largely performed over the world for morbid obesity. Potential risk of gastric remnant carcinoma development has been suggested.

PURPOSE

To present the results obtained after LRYGB with resection of distal stomach.

METHOD

This prospective study includes 400 consecutive patients. The mean body weight was 105.9 ± 16.8 Kg (range 83-145 kg), and body mass index (BMI) was 38.5 ± 4.4 kg/m² (32.9-50.3). Postoperative morbid-mortality and follow-up were analyzed.

RESULTS

Operative time was 128.5 ± 18.7 min, hospital discharge occurred at 3rd postoperative day, postoperative complications occurred in 9.25%, early surgical complications were observed in 3% and medical complications 4%, late surgical complications occurred 2.25%, no mortality was observed. At 1 year follow-up, BMI was 25.3 ± 2.7 kg/m² with % of weight loss (%WL) of 84.6 + 19.1%. At five years follow-up very similar values were observed.

CONCLUSION

The results obtained after LRYGB with resection of distal stomach are similar to results published after non resection LRYGB regarding early and late results and can be indicated in high risk areas of gastric carcinoma.

Post-surgical gastrointestinal reflux disease: Status quo and treatment

Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.

Diffuse large B-cell lymphoma (DLBCL) in the bypassed stomach after obesity surgery

Laparoscopic Roux-en-Y gastric bypass is the most commonly performed surgical procedure for obesity and, consequently, post-operative patients are increasingly encountered by all specialties. This is a case of a patient presenting with abdominal pain, nausea and fever 9 months following gastric bypass surgery caused by diffuse large B-cell lymphoma (DLBCL) in the bypassed stomach. It demonstrates well that symptoms that may normally be considered 'red-flags' may not be as obvious or specific following an operation. The case also indicates the importance of considering diagnoses unrelated to surgery presenting in the post-operative period (especially when conventional investigation methods are not feasible), and the potential danger of assuming they are due to the operation alone; had this occurred in this patient then a malignancy may have been missed. This is only the second reported case of DLBCL in the bypassed stomach, and the third for lymphoma of any type.

Microbiota in the stomach: new insights

Bacteria are sparsely distributed in the stomach due to the gastric microbicidal barrier. Several innate defenses (low pH, migrating motor complex and the entero-salivary circulation of nitrate) as well as external factors (diet, Helicobacter pylori infection, proton pump inhibitors, antibiotics and stomach diseases) have been shown to influence significantly the microbiota composition in the stomach. In recent years new culture-independent technologies have allowed the investigation of the cross talk that occurs between hosts and stomach-associated microflora, which helps us to understand the role of gastric bacterial flora in the gastrointestinal microbiological system, both in physiological and pathological conditions. Here, we reviewed the literatures related to this topic and set the stage for future developments of the field.

Laparoscopic resectional gastric bypass in patients with morbid obesity: experience on 112 consecutive patients

INTRODUCTION

Gastric bypass, without gastric resection of the distal excluded stomach, is the surgical treatment more frequently performed for morbid obesity. Several postoperative complications related to the “in situ” distal stomach have been described, and few cases of undetected gastric carcinoma located in this segment of stomach have been published. In this paper, we present our early postoperative results in patients submitted to laparoscopic gastric bypass with resection of distal stomach in patients with morbid obesity.

METHODS

One hundred twelve consecutive patients were included in this study. The mean body weight was 112.15±5.1 (range 78–145), and BMI was 40.5±6.9 kg/m2 (32.9–50.3). Patients were submitted to resectional gastric bypass by laparoscopic approach. The operative time was 133.7±29.1 min (range 120–240).

RESULTS

Postoperative complications occurred in 12 patients (10.7%) without any mortality. Early complications were observed in 11 patients while one patient presented a late complication, four patients were re-hospitalized, three of them without operation and other four of them were re-operated due to early (three patients) or late complication (one patient). One hundred patients (89.2%) were discharged at fourth postoperative day, seven patients remained in hospital between 5 and 10 days, and four patients after the tenth day due to complications. Leaks were observed in three patients. The histological study of the resected specimen was normal in only 8.9%.

CONCLUSIONS

Laparoscopic resectional gastric bypass presents very similar results compared to classic gastric bypass, without significant increase of morbidity, mortality, early and late postoperative results, and therefore, it is an option for the surgical treatment of morbid obesity in countries with high risk of gastric carcinoma.

Bile acids and total bilirubin detection in saliva of patients submitted to gastric surgery and in particular to subtotal Billroth II resection

OBJECTIVE

The aim of our study was to detect bile acids and total bilirubin in saliva of gastrectomized patients, to confirm objectively presence of biliary laryngopharyngeal reflux and its relationship with laryngeal mucosa damage.

SUMMARY BACKGROUND DATA

Recently, it has been hypothesized that biliary-reflux may reach the upper aerodigestive tract and enhance development of laryngeal malignancies; nevertheless, the presence of duodenogastric contents in this region has never been revealed.

METHODS

We carried out a prospective observational case-control study on 52 patients (cases) previously submitted to gastric surgery, mainly to subtotal Billroth II resection, and on 51 healthy volunteers (controls). Patients were submitted to clinical interview, esophagogastroduodenal endoscopy, endoscopic laryngeal evaluation, and saliva collection. In all saliva samples, bile acids, total bilirubin, and pepsinogen II were assayed.

RESULTS

In cases, group bile acids levels were recorded in 17 of 52 (32.6%) patients, while in 35 of 52 (67.4%) they were undetectable. All controls were negative to bile acids. In positive cases to bile acids, we found a significant (P < 0.05) correlation between bile acids, total bilirubin, and pepsinogen II values and a significant (P < 0.05) higher prevalence of symptoms and findings of laryngeal damage and of previous laryngeal neoplastic lesions.

CONCLUSIONS

We found detectable levels of bile acids and total bilirubin in saliva of patients submitted to previous gastric surgery, prospecting an intriguing diagnostic role of this dosage in the study of biliary laryngopharyngeal reflux. We finally revealed a high incidence of laryngeal disorders in patients with positive bile acids in saliva.

[Gastrointestinal bleeding--concepts of surgical therapy in the upper gastrointestinal tract]

Bleeding of the upper gastrointestinal tract is the main symptom of a variety of possible conditions and still results in considerable mortality. Endoscopy is the first diagnostic modality, enabling rapid therapeutic intervention. In case of intractable or relapsing bleeding, surgery is often inevitable. However, emergency operations result in significantly higher mortality rates. Therefore the option of early elective surgical intervention should be considered for patients at increased risk of relapsing bleeding. If bleeding is symptomatic due to a complex underlying condition such as hemosuccus pancreaticus or hemobilia, angiography is now recognized as the definitive investigation. Angiographic hemostasis can be achieved in most cases. Due to the underlying condition, surgical management still remains the mainstay in treating these patients. This paper reviews surgical strategy in handling upper gastrointestinal bleeding.

Biliary laryngopharyngeal reflux: a new pathological entity

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent understanding of the harmful effects of gastric and duodenal agents on mucosa of the upper aerodigestive tract in patients with duodeno-gastro-esophageal reflux.

RECENT FINDINGS

The damaging action of duodeno-gastro-esophageal reflux on the gastro-esophageal mucosa and its potential etiological role in the development of many inflammatory and neoplastic patterns have been well documented in the literature. Recently, there has been increasing evidence that duodeno-gastro-esophageal reflux may also be related to several laryngeal disorders and clinical studies confirm that reflux after gastric resection may enhance the development of laryngeal malignancies. Finally, there have been experimental attempts to confirm that duodenal contents may contribute to inflammation and carcinogenesis in the pharynx or larynx, as it is known to do in the esophagus.

SUMMARY

The association between duodeno-gastro-esophageal reflux and laryngeal lesions is of great interest to otolaryngologists because it focuses attention on a new pathological entity that could be classified as biliary laryngopharyngeal reflux. This condition, as an acid one, seems to represent an important dangerous, endogenous risk factor involved in the pathogenesis of inflammatory, precancerous and neoplastic laryngeal lesions. For these reasons, particular attention is required in the future regarding the understanding of the local environment, individual susceptibility and clinical treatment. Finally, new antireflux therapy should be considered to control not only the acid gastric component of the refluxate but also the duodenal component.

Preventive effect of hydrotalcite on stress ulcer in rats after acute brain trauma

AIM: To study the role of bile reflux in the stress ulcer in rats after acute brain trauma, and to investigate the preventive role of Hydrotalcite (Talcid) to the stress ulcer.

METHODS: An animal model was established by Allen's method with modification. 128 male Wistar rats were divided randomly into four groups: Group I (n = 32): stress ulcer group, rats suffered from acute brain trauma without therapy; Group II (n = 32): normal control group, rats with sham operation; Group III (n = 32): Talcid group, rats suffered from acute brain trauma with Talcid administration; Group IV (n = 32): normal saline (NS) group, rats suffered from acute brain trauma with NS administration. Each group was divided into four subgroups of 1 h, 3 h, 6 h, and 24 h after the trauma (n = 8, for each subgroup). The rats in groups III and IV received Talcid and NS by gavage respectively before the operation for three days (Talcid: 500mg/kg.weight/day, NS: 1.5 mL/kg. weight/day). The bile acid concentration in the stomach and blood, the PH value and ulcer index (UI) were assayed, and the histology of gastric mucosa was analysed.

RESULTS: The concentration of gastric bile acid in group I was higher than that of group II at each time point (P <0.05, P <0.01); The damage of gastric mucosa was serious (P <0.05); and it showed a positive correlation between them (r = 0.05, P <0.01). But there was no difference in the blood bile acid and PH value. The histology showed corresponding changes. The concentration of gastric bile acid in group III was lower than that of group Ⅳ at each time point (P <0.01); The PH value at 1 h, 3 h, 6 h was higher but UI was lower at 6 h, 24 h in group III (P <0.01). There was a linear relationship between the gastric bile acid concentration or PH value and UI (r = 0.43, r = 0.52, P <0.01). The damage was ameliorated obviously in group III.

CONCLUSION: The bile reflux plays an important role in the stress ulcer after acute brain trauma. It shows a potential correlation between the extent of bile reflux and gastric mucosa damage. As a new combined bile acid drug, hydrotalcite can effectively prevent the occurrence of stress ulcer after acute brain trauma.