Synchronous electrogastrographic and manometric study of the stomach as an esophageal substitute

Assessment of Gastric Remnant Activity, Symptoms, and Quality of Life Following Gastric Bypass

INTRODUCTION

While most gastric bypass patients recover well, some experience long-term complications, including nausea, abdominal pain, food intolerance, and dumping. This study aimed to evaluate symptoms and quality of life (QoL) in association with the residual activity of the remnant stomach.

METHODS

Patients undergoing gastric bypass and conversion-to-bypass were recruited. The Gastric Alimetry® System (Auckland, NZ) was employed, comprising a high-resolution electrode array, wearable reader, and validated symptom logging app. The protocol comprised 30-min fasting baseline, a 218-kCal meal stimulus, and 4-h of post-prandial recordings. Symptoms and QoL were evaluated using validated questionnaires. Remnant gastric electrophysiology evaluation included frequency, BMI-adjusted amplitude, and Gastric Alimetry Rhythm Index (GA-RI, reflecting pacemaker stability), with comparison to validated reference intervals and matched controls.

RESULTS

Thirty-eight participants were recruited with mean time from bypass 46.8 ± 28.6 months. One-third of patients showed moderate to severe post-prandial symptoms, with patients' median PAGI-SYM 28 ± 19 vs controls 9 ± 17 (p < 0.01); PAGI-QOL 37 ± 31 vs 135 ± 22 (p < 0.0001). Remnant gastric function was markedly degraded shown by undetectable frequencies in 84% (vs 0% in controls) and low GA-RI (0.18 ± 0.08 vs 0.51 ± 0.22 in controls; p < 0.0001; reference range > 0.25). Impaired GA-RI and amplitude were correlated with worse PAGI-SYM and PAGI-QOL scores.

CONCLUSION

One-third of post-bypass patients suffered significant upper GI symptoms with reduced QoL. The bypassed remnant stomach shows highly deranged electrophysiology in-situ, reflecting disuse degeneration. These derangements correlated with QoL; however, causality is not implied by the present study.

Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying

Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.

Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage

BACKGROUND

The incidence of delayed gastric emptying (DGE) after esophagectomy is 10%-50%, which can interfere with postoperative recovery in the short-term and result in poor quality of life in the long term. Pyloric drainage is routinely performed to prevent DGE, but its role is highly controversial. The aim of this study was to report the rate of DGE after esophagectomy without pyloric drainage and to investigate its risk factors and the potential effect on recovery.

MATERIALS AND METHODS

Between January 2010 and January 2015, we analyzed 285 consecutive patients who received an esophagectomy without pyloric drainage. Possible correlations between the incidence of DGE and its potential risk factors were examined in univariate and multivariate analyses, respectively. The outcomes of DGE were reviewed with a follow-up of 3 mo.

RESULTS

The overall rate of DGE after esophagectomy was 18.2% (52/285). Among perioperative factors, gastric size (gastric tube versus the whole stomach) was the only significant factor affecting the incidence of DGE in the univariate analysis. The patients who received a whole stomach as an esophageal substitute were more likely to develop DGE than were patients with a gastric tube (13.2% versus 22.4%; P = 0.05). No independent risk factor for DGE was found in the multivariate analysis. The incidence of major postoperative complications, including anastomotic leak, respiratory complications, and cardiac complications, was also not significantly different between both groups, with or without DGE. Within 3 mo of follow-up, most patients could effectively manage their DGE through medication (39/52) or endoscopic pyloric dilation (12/52), with only one patient requiring surgical intervention.

CONCLUSIONS

In our study, the overall incidence of DGE is about 20% for patients undergoing esophagectomy without pyloric drainage. Compared with prior findings, this does not result in a significantly increased incidence of DGE. In patients with symptoms of DGE after esophagectomy, prokinetic agents and endoscopic balloon dilation of the pylorus can be effective, as indicated by the high success rate and lack of significant complications.

Thoracoscopic Implant of Neurostimulator for Delayed Gastric Conduit Emptying After Esophagectomy

BACKGROUND AND AIMS

Gastroparesis is a clinical syndrome characterized by delayed gastric emptying in the absence of mechanical outlet obstruction. Use of the denervated stomach as an esophageal substitute is a common cause of transient gastroparesis. Gastric electrostimulation through a thoracotomy approach has previously been reported to be effective in patients with medically refractory postesophagectomy gastroparesis. We report the first thoracoscopic implant of a gastric neurostimulator.

METHODS AND RESULTS

A 57-year-old woman underwent Ivor Lewis esophagectomy for early stage (T1N0) adenocarcinoma in 2007. She progressively developed progressive dysphagia, regurgitation, and a 29-kg weight loss. The barium swallow study and upper gastrointestinal endoscopy showed a dilated intrathoracic stomach without evidence of mechanical obstruction. Erythromycin and multiple endoscopic dilatations of the pylorus were unsuccessful, and eventually, a feeding jejunostomy was performed. At the time the patient was referred to our outpatient clinic, she was unable to eat and depended on total enteral nutrition. Computed tomography, endoscopy, and barium swallow study confirmed that there was no evidence of recurrent adenocarcinoma or mechanical gastric outlet obstruction. A gastric electrostimulator system (Enterra(®)) was implanted through a right thoracoscopic access and connected to the gastric conduit. At 6-month follow-up, there was a significant improvement of the total symptom score and quality of life.

CONCLUSIONS

Electrostimulation of the gastric conduit after esophagectomy can safely be performed through a thoracoscopic approach and may represent a reasonable therapeutic option in patients with symptomatic and medically refractory delayed gastric emptying.

Delayed gastric emptying after esophagectomy for malignancy

BACKGROUND

Controversy still exists about the need for pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. Although pyloric drainage may prevent postoperative delayed gastric emptying (DGE), it may also promote dumping syndrome and bile reflux. The aims of this study were to audit the incidence and management of DGE in patients without routine pyloric drainage after esophagectomy in a university medical center.

PATIENTS AND METHODS

From July 2006 to June 2012, data from 356 consecutive patients who underwent esophagectomy with a gastric conduit without pyloric drainage for esophageal or gastric cardia carcinoma were reviewed. Major observation parameters were the incidence, management, and outcomes of DGE.

RESULTS

Overall incidence of DGE was 15.7% (56 of 356). Early DGE developed in 26 patients, and late DGE developed in 30 patients. There were no differences in demographic and intraoperative data between the two groups with or without DGE. More DGE was documented in patients with an intra-right thoracic gastric conduit (P=.031). A higher incidence of postoperative pneumonia was observed in patients exhibiting early DGE, but without significance (P=.254). There were also no significant impacts on respiratory failure (P=.848) and anastomotic leakage (P=.257). There was an increased postoperative hospital stay with DGE, but without significance (P=.089). Endoscopic balloon dilatation of the pylorus was used to manage 33.9% of patients with DGE, yielding a 78.9% (15 of 19) success rate without complications. In 3 patients endoscopy showed the pylorus was open, and their symptoms improved over time. One patient with tumor-related DGE was treated by pyloric stent. The remaining patients were adequately treated with conservative management.

CONCLUSIONS

Omitting the operative drainage procedure does not lead to an increased frequency of DGE after esophagectomy with a gastric conduit. Many patients responded to conservative management, and endoscopic balloon pyloric dilatation can be effective in managing the DGE postoperatively.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.

A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy

OBJECTIVE

Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage.

METHODS

Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study.

RESULTS

No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet.

CONCLUSIONS

Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.